A Country Doctor Writes:

This time of year the snowbirds return from their winter retreats in condominiums, trailer parks, relatives’ homes and motels far south of here – in Florida, Arizona, the Carolinas and other, warmer locales.

I have had many serious requests from patients to relocate with them to Florida for the winter months, so I could continue to provide medical care for them year-round.

Today I saw a patient, whose updated medical history made me seriously wonder what kind of cultural chasm exists between medicine in the two opposite corners of this country, or perhaps this is more about money than medical care.

My patient, a woman approaching seventy, had a colonoscopy done at Cityside Hospital last July for recurrent precancerous polyps. Our local gastroenterologist recommended another colonoscopy in three years. She has a history of heartburn that is quite well controlled on omeprazole, 20 mg daily. She had a small heart attack a few years ago, and takes cholesterol medication and blood pressure pills. She is physically active, quit smoking two years ago, and has no chest pain or shortness of breath whatsoever with even vigorous exercise. She has mild, chronic low back pain without any sciatica, and doesn’t ever take anything for pain.

During her time away she had no new symptoms, yet her winter physician put her through another colonoscopy only six months after her previous one, an upper endoscopy, a nuclear stress test, lumbar nerve conduction studies, an exhaustive battery of esoteric blood tests and even a comprehensive urine test for drugs of abuse. Medicare, her health insurance, must have paid well over $10,000 for these tests.

“So, how did you end up with all those tests?” I asked.

“I don’t know, Dr. Z. said I needed them. Actually, he didn’t tell me much,” she shrugged.

“And what did the tests show?” I had the upper and lower endoscopy report, the stress test and the urine drug screen. They were all normal, but I didn’t have anything on the nerve conduction studies. I also couldn’t find any diabetes-related tests.

“Well, the other tests were fine, I guess, but he said my back was a mess. All the nerves there are shot.”

“But you don’t have any new symptoms?”

“No, but he still prescribed this new medication, gabapentin….”

“Does it do anything for you?”

“I haven’t tried it yet.” She added: “Do you think I should?”

“Not if you don’t have pain going down the nerves in your legs.”

I leafed through the pages of printouts again.

“I don’t see any recent blood sugar results or cholesterol tests, did you have any done?”

“I must have,” she shrugged again.

In my mind, I weighed the cost of all the esoteric testing she had had over the winter and the cost of what she needed right now. Trying to retrieve more information from her winter physician in a timely fashion might or might not be possible.

I took out my fountain pen and ordered an inexpensive new set of routine blood tests to monitor her blood sugar, cholesterol, thyroid function, a complete blood count and a comprehensive metabolic profile. Perhaps this was a small duplication of effort, I wasn’t completely sure, but I needed to take care of the basics.

My middle-aged patient had all the risk factors for a heart attack: high blood pressure, borderline diabetes, high cholesterol, a strong family history and a sixty pack-year smoking habit.

His stress test was positive and the medications that were started in the hospital weren’t controlling his chest pains.

The cardiologist at Cityside Cardiovascular Consultants who took my call, Joe Altman, sounded tired. I have known him for over twenty-five years. He always impressed me by looking beyond just the acute problem of where a patient’s coronary blockage is and how to get rid of it.

Joe has the mindset of a generalist. He pays a great deal of attention to prevention and to each patient’s entire medical history. More than once he has contacted me to make sure I am taking care of a patient’s borderline thyroid function or some other problem most cardiologists wouldn’t concern themselves with. He has never recommended testing or interventions in a knee-jerk fashion, but always considered the patient’s entire case history. I have great respect for his conservative approach.

Joe, the senior member of his group, has seen younger cardiologists replace him in the catheterization laboratory. These days, he is often the one who takes calls from primary care doctors in the community who call with questions or urgent referrals.

“So, has he quit smoking yet?” was Joe’s first question after I finished my brief case presentation.

“He’s working on it, started bupropion today,” I answered.

“Better make sure he does… Well, I guess we’re obligated to cath him.” He paused for a moment, then sighed:

“I’ll tell’ya, I have less and less sympathy with the ones who keep smoking and come back here again and again to have us fix them up, and then go back and do the same thing all over again.”

I was taken aback a little by the emphatic frustration at the other end of the line, but not entirely surprised. Dr. Altman, probably ten years my senior and perhaps nearing retirement, must be looking back at his career. He must be thinking of all the expensive procedures that helped Cityside Cardiovascular Consultants build their magnificent new headquarters on the riverbank outside the city, yet wondering how it is that last-minute interventions seem so much more glamorous than the primary care and public health efforts to avoid and prevent heart disease in the first place.

He should have been a Family Practitioner, but I am grateful to have had him as my consultant cardiologist all these years.

Doug Leland is no stranger to back pain. After two failed back surgeries he is on long-acting narcotics in addition to high doses of seizure medications to dull the relentless nerve pain that burns day and night like an eternal fire deep inside his left leg.

A few weeks ago Doug went to the emergency room several days after slipping on his icy front steps. I read the report with some surprise. He had caught himself, and didn’t actually fall. He didn’t have broken ribs or any other serious injury, but was experiencing so much pain under his right shoulder blade that the ER doctor had decided to give him two intravenous injections of hydromorphone, a very strong, fast-acting opioid, plus high doses of a muscle relaxant and an anti-inflammatory medication.

When I saw him last week he was miserable. Every little movement of his upper body bothered him. His pain covered an area under his shoulder blade about the size of one of his large hands. Dead center in this area was an exquisitely sore spot with a palpable knot in the upper portion of his latissimus dorsi muscle. Even mild pressure on this tender spot caused a burning pain that radiated down the back of his right arm. This didn’t fit with the anatomy of any cervical or thoracic nerve.

I didn’t want to continue increasing his narcotics as they clearly weren’t providing him relief. With Doug’s ulcer history, he wasn’t a good candidate for continued anti-inflammatory drugs.

I decided to offer him something I haven’t done for a few years – a trigger point injection. They were common twenty years ago, but seem to have somewhat fallen out of fashion.

Doug was game: “Anything, Doc. Anything that might help, I’ll try it!

I mixed lidocaine and saline in a 3 cc syringe and attached a 25G 1½ inch needle. I localized the tender spot again and circled it with a ballpoint pen. I cleaned his skin with iodine and inserted the injection needle into the trigger point I had marked. I aspirated the syringe to make sure the needle wasn’t in a blood vessel.

“You’re in the right spot, Doc!” Doug groaned.

“Okay, Doug, here we go…” I told him.

A few minutes later Doug was moving his shoulders around, bending his back comfortably in all directions.

“The pain’s gone…”

“The Novocain is in the right spot, then,” I explained. “We’ll have to see if there is a lasting effect. Come back after the weekend and let me see how you’re doing.”

Doug came back, still smiling. There was a small area of tenderness several inches above where I had put the needle, but his pain was essentially gone. Doug was grateful.

“You’re a magician, Doc!”

“It’s an old trick I had almost forgotten,” I confessed.

“I’m sure glad you thought of it, Doc!”

That evening I thought more about trigger point injections. I don’t remember hearing about them in medical school or my internship in Sweden. I heard of them soon after I came to this country, thirty years ago.

I decided to do some research.

Trigger points were first described in 1942 by Janet Travell, MD. She became the personal physician to President John F Kennedy, who suffered from chronic back pain. Her first edition of “The Trigger Point Manual” was published in 1983 when I was a Family Practice resident here in the United States. I learned to inject trigger points in patients with myofascial syndrome in my residency, but this is not something all physicians learn today. Other modalities, from manual pressure to laser therapy, are now sometimes applied to trigger points.

Trigger points are thought to relate to dysfunctional end plates within the sympathetic nervous system. Acetylcholine levels and pH are thought to be important factors in myofascial pain.

The effect of trigger point injections can be reversed with naloxone, an opiate antidote. This suggests that the release of endorphins may be partly responsible for the effect of trigger point injections.

Very few articles have been published on this topic in recent years. There are few randomized controlled trials, and not all of them have found trigger point injections to be effective. One recent study found similar results for trigger point injections and acupuncture.

There are many similarities between trigger points and acupuncture points, but they have been viewed as very different in how they work. Trigger point injections, regardless of which chemical is used, are thought to cause physical changes at the injection site. Some clinicians even do “dry needling” of trigger points with the same results. The insertion of an acupuncture needle is generally thought to affect energy flow in predetermined meridians.

Intentional or accidental trigger point pressure can cause referred pain in other locations, similar to the correlation between acupuncture points and meridians. In fact, a 2006 study shows that of 255 trigger points with referred pain patterns described by Janet Travell and her collaborator, David Simons, 170 correspond to classic and 64 to newer acupuncture points and their meridians. This raises the question of whether the 70-year-old trigger point theory isn’t just Western medicine’s rediscovery of an ancient form of energy medicine. Doug’s pain pattern, radiating from the tip of she shoulder blade to the back of the arm, fits one described by Travell. It also closely follows one of the large acupuncture meridians.

What I did in the case of Doug Leland the other day may not just date back to 1942, but three or four thousand years.

“Tell me about the day you passed out,” I asked the middle-aged woman in Room 4 the other morning. “How did you feel?”

“We were up early, my husband and I, because Debbie – that’s our daughter – was coming home for Easter break. She’s on the dean’s list at Swartham College. She wants to be a civil engineer with a double in business administration. She’s so talented…”

“Were you feeling okay when you woke up?” I tried to redirect her.

“Well, Gordon looked at me kind of funny and asked if I was feeling all right…”

“Were you?”

“He didn’t think I looked well. Pasty, he said my face was… Pasty-looking!” She sighed. “I didn’t finish my toast or my bran flakes, and I usually gulp my breakfast before Gordon even gets back in the house with the morning paper.”

“Did you feel nauseous?”

“I didn’t throw up, if that’s what you mean. Gordon asked me the same thing. He felt my forehead and said I was clammy.”

“Then, what happened?”

“We got ready to go to the airport to pick Debbie up. On the way, I asked Gordon to stop at Dunkin’ Donuts and get me some Munchkins, but he was worried we’d be too late, so he talked me out of it.”

I started to be increasingly aware of the time.

“Do you remember the moments before you passed out? What did you feel?” I asked.

“I remember thinking it was hot in the luggage hall, and I remember Debbie talking about her new roommate. Then Gordon said he should have stopped for Munchkins after all, because we had had plenty of time and I was probably getting a low blood sugar…”

I changed my strategy and asked several more directed, yes-or-no questions. I formulated a plan for what kind of workup to do.

The rest of the day I kept thinking about that encounter. Over the years I have seen so many patients who don’t seem to be able to describe or even recognize their own feelings, but instead tell me what other people notice about how they appear to them. I have often wondered if there was a name and a psychological profile for people like that. They are a challenge to take a medical history from, but they must also be challenged themselves by never really knowing how or what they feel.

Last night after supper, my brother-in-law called from the west coast. While my wife talked with him, I Googled my question.

“Inability to describe own feelings, relying on other people’s description” I typed.

The third link on my search gave me the word I needed: “What is alexithymia?” The literal meaning of a-lexi-thymia is “lack of words (for) emotion”. I searched for “alexithymia” and a half-dozen articles completely captured my attention while my wife and her brother continued their telephone conversation.

What I read resonated with my own observations. Curiously, the first website I looked at had been posted or updated the day before my search and the original article by P.E. Sifneos, introducing the word and describing the phenomenon, was published in 1973 – the year before I started medical school. It took me this long to “discover” it myself!

Alexithymia is not classified as a disease in DSM-IV, the psychiatric book of diagnostic definitions. It is rather more like a personality type. What I found fascinating as I read along is the link between alexithymia and psychosomatic illness.

People with alexithymia can’t tell if their bodily sensations represent physical or emotional phenomena, because they have trouble registering their emotions. They are likely to look for physical illness as an explanation for sensations others may easily recognize as related to strong emotions. An extreme example from one of the websites I read was that a crying alexithymic might worry about having a blocked tear duct instead of registering their sadness. A person with little insight into how upset, sad or anxious he or she might be would not have any ability to judge whether they might feel bad, be it headache, chest pain or belly cramps, for emotional reasons.

One article suggested up to 10% of people have some degree of alexithymia.

Those impromptu few minutes on the computer made me a wiser clinician. I will be more tenderhearted with patients who have trouble describing their feelings in a fifteen-minute visit, and I will look harder for that trait in patients whose symptoms baffle me.

Talking with my wife on the phone at lunch today, I asked in my usual manner:

“Was there anything interesting in the mail?”

She hesitated for a moment before answering:

“There’s a letter from the Board of Medicine.”

My mind switched into a higher gear.

“A letter? Not a mass mailing?”

“No, it’s a regular, business-sized envelope.”

“Does my name look typed, or is it a mailing label?”

“It looks typed.”

I have had a couple of letters from the Board before. Many years ago two disgruntled patients complained about me. One wasn’t happy that I stopped prescribing pain pills, and another wanted me to provide care via email. Both times all I had to do was give my side of the story, and the complaint was dismissed without merit.

“Was this a letter about a complaint against me?” I thought to myself. I didn’t know if such letters came registered mail or not.

“Do you want me to open the letter?” my wife asked.

“No, save it for me to open when I get home.”

I had arranged to be off this afternoon in preparation for a weekend trip. A surprise April snowstorm thwarted our travel plans, so we had changed our plans to include a nice, early Friday dinner and a classic movie by the fireplace.

“Would the letter from the Board change the mood of our Friday evening and quiet weekend at home?” I wondered to myself. It had already made me feel a little uneasy the moment I heard about it. It could be a simple announcement of some type; it wasn’t necessarily something unpleasant, although I supposed it might be.

As a physician in America, I work very hard. I strive to do what is medically correct and also to take care of each patient’s need to understand and take responsibility for his or her condition. Sometimes when you read the headlines, it feels as if doctors are never safe from criticism and litigation for being humanly fallible.

“Was it my turn now to be called before the Board of Medicine because I had failed in someone’s eyes, or offended someone inadvertently? My mind wandered as I drove through town to do a few errands on my way home. “How bad could it be?” I tried not to worry.

It had already started snowing by the time I got home. The letter waited for me on the dining room table. I opened it quickly.

With a feeling of relief I read the first few words. The letter was addressed to all physicians with licenses coming up for renewal after May 1 this year:

“Written Exam Required at Renewal” it began.

When I renew my license next time, I will have to take an exam about the Board’s guidelines regarding Informed Consent.

One more hoop to jump through to prove myself worthy of continuing to practice medicine, nothing personal…