A Country Doctor Writes:

Mrs. Carignan was in my schedule this morning for her one-month follow-up. Three months ago I had requested a psychiatric consultation for her, but I had not heard back about any appointment date from RPA, Rural Psychiatric Associates. They had lost both their regular doctors a year or two ago, and had been getting by with locum tenens physicians since then. I had referred Mrs. Carignan because I needed help with both diagnosis and treatment in her case. I was hoping the newly hired permanent psychiatrist could help her.

She had been hospitalized twice, once for a “breakdown” in her forties, and again about ten years ago for what sounded like a manic episode. Since then she had been on several mood stabilizers and a few antidepressants. When her old psychiatrist, Dr. Andrews, left the area, she stopped her medications.

Several months ago, she came to see me about her nerves. She was anxious and depressed, and on top of it was exhibiting symptoms of mild dementia.

My usual armamentarium of medications for someone like her proved useless, and I had finally convinced her she needed a psychiatric reevaluation. After the first month of waiting to hear back from RPA’s appointment staff I decided to put in for a Prior Authorization from Wellcare, her Medicare D prescription insurer, for a more expensive agent for refractory and bipolar depression.

My heart sank when I saw her name in my schedule this morning. There had been no word from Rural Psychiatric Associates and there, right in front inside her paper chart, was the fax we sent off to Wellcare more than a month ago. There was no indication of any reply in her chart. I searched our new electronic medical record. She had no clinical notes in it yet, nothing about any response from Wellcare, and there was nothing in the referral module about a psychiatric appointment.

I checked the time – five minutes into her allotted fifteen minute visit. I called Wellcare with some trepidation. This was likely to take time, but I felt I owed Mrs. Carignan this, since the system – actually three different systems – had failed her.

After only a minute or two on hold I told Wellcare’s customer service representative my errand:

“I am a physician. I faxed you a coverage request more than a month ago and have not had any response yet.”

She politely promised to put me in touch with someone who would be able to help me.

Two minutes later, a young man with a heavy accent offered to help me. I had to spell Mrs. Carignan’s name twice, and he double-checked her birthdate and policy number. He put me on hold and I listened to the same music I had already become familiar with.

“I apologize, Doctor, could you give me your patient’s birthdate and policy number again”, the young man said. I obliged, and he excused himself again. I glanced at the clock above my desk. Five minutes left of her visit, I noted with more than a little concern that I might not be able to do much for her today.

“I am sorry, Doctor, we have a client with the same name, different spelling and not quite the same birth date”, the young man announced when he finally came back on the line.

“This is her Social Security number…”, I offered.

“Let me look her up that way, then, Doctor. Would you mind holding for just one minute?”

I looked at the clock again. Two minutes left.

“Thanks for holding, Sir. I am sorry but we have no client with that Social Security number.”

“I see”, I said. “Well, I have already spent her entire appointment speaking with you on the phone. Thank you very much for looking into this. Good-bye.”

I grabbed her paper chart and my laptop and entered Room 1.

“I’m sorry to keep you waiting, Mrs. Carignan. I have just spent the last fifteen minutes talking to Wellcare, your prescription insurance, about that medication I wanted to prescribe for you. They claim they never heard of you.

“But I’ve been with them for years.”

“Let me call your pharmacy”, I said as I pulled out my cell phone.

A minute later Sandy, the new pharmacist at Williams’ Rexall answered my question:

“Wellcare is paying us just fine for her medications, but the policy number we have is different. It’s 596 0059.”

I wrote down the number, wondering when I would ever get the time to call them back.

Opening my laptop, I said:

“So we have no word from the psychiatry office and your insurance company don’t know who you are.”

She looked puzzled.

“Should I go on taking this”, she asked, reaching into her zippered toiletry bag with all her pill bottles. She produced a small bottle with an antidepressant I had not prescribed for her.

The name of the doctor on the bottle was Mary Meyerer, the new chief at Rural Psychiatric Associates. The fill-date of the prescription was almost three weeks ago.

“Oh, you did get an appointment with the psychiatrist!”

“Yes, and I’m going back next week again…”

“Great. I’m glad you finally got an appointment. You see, some specialists, particularly psychiatrists, don’t tell us when they make an appointment for someone we refer to them.”

“That seems silly…”

“Well, yes.” I paused. “At least you got in.” Looking quickly through her chart I added:

“I see it’s been a while since you had your bloodwork done for your cholesterol. Let me put an order in the computer for that…”

The task bar on my laptop informed me that I was 30 minutes behind, with two patients waiting in exam rooms and a third in the waiting room.

I must admit I had felt a little smug about my discovery of Elsa Bruegger’s faulty walker. It really seemed like a very logical explanation to her walking into walls all the time. As it happened, her new walker didn’t quite solve the problem. She continued to be off balance and sometimes did seem a bit unfocused, even downright sedated.

Looking back through her record, I came across a mildly elevated ammonia level a few months ago. I remember speaking with her psychiatrist back then about Elsa and a couple of other patients we share, whose routine ammonia levels were mildly elevated. Elsa had a standing order from the psychiatrist for ammonia levels every three months because of her valproic acid (Depakote) prescription for her mood disorder.

All my research has led me to the conclusion that ammonia levels are of little or no value in predicting whether patients on valproic acid are headed for trouble due to the drug’s unpredictable tendency to cause ammonia to build up within the central nervous system. I have come to understand that ammonia levels are only slightly helpful even in assessing a patient with coma or near coma; the correlation between brain levels and peripheral blood levels of the toxic ammonia relate poorly to each other because of how the blood-brain barrier works to keep the chemistries inside and outside the central nervous system separate. Many experts recommend against routine measurements of ammonia levels for this reason.

Watching Elsa fumble her way down the hall, I decided to order an ammonia level “just in case”. It came back elevated – twice as high as it had been ten weeks ago. Her liver function tests were normal.

I ordered her valproic acid stopped and made sure her psychiatrist got a copy of the lab report and my notes.

This week, Elsa is finally walking straight. She is attending her day program, says “good morning”, makes good eye contact and smiles. She also shows more of a temper, but nothing inappropriate.

Maybe this time I finally got it right.

“Elsa Bruegger has seemed a little unsteady in the morning lately”, the charge nurse told me at my boarding home rounds two weeks ago. “Her morning blood sugars have been a little low. Do you think we should cut back on her insulin?”

“Sounds reasonable”, I answered. Let me look at her chart.” Elsa is on valproic acid as a mood stabilizer and sees her psychiatrist every three months. Her drug level was just about due to be checked, so I ordered a fresh set of labwork and decreased the dose of her long-acting insulin.

We continued our stand-up rounds, going through dozens of reports and issues on the many residents who were not scheduled to be seen that day. I then did two admissions and saw a couple of patients for their scheduled visits.

The next time I went to the boarding home, I checked on the results of Elsa’s blood tests and reviewed her blood sugar log. Everything was well within range.

“How is she doing?” I asked.

“The girls still find her a little off balance now and then, especially in the morning.”

“Tell me again how long this has been going on…”

“Probably a month or a month and a half.”

“Any urinary symptoms? Anything else going on?” I flipped through the chart again. My eyes fell on some insurance paperwork. There, two months ago was a rejection letter for a Prior Authorization request for a brand-name drug Elsa had been taking for urinary frequency.

“Well, she’s incontinent sometimes, but that’s not new, and she has no dysuria. But we did have to switch her to that generic drug for her urine two months ago”, the charge nurse answered.

“Well, if she’s still incontinent, let’s stop the pill, because that could cause her to be dizzy”, I said, “so let me write the order for that.”

Yesterday I stopped in at the boarding home again to speak with the family of one of my patients. While standing at the nurses’ station I happened to see Elsa coming down the hall with her walker.

With every step Elsa took, she and the walker veered more and more to the right until she came to a stop with the right front wheel against the wall. She then lifted the walker toward the middle of the corridor and started walking again. Eight or ten steps later, she was back against the wall. She stopped and lifted the aluminum walker toward the middle of the corridor again and repeated the same procedure.

“Look”, I whispered to the nurse.

We watched as Elsa repeated her zigzag veer and correction half a dozen times until she came to the TV room half way down the hall. After she settled into her chair, I asked to borrow her walker. She seemed bemused.

I picked it up and spun the wheels, which rolled without any apparent resistance. I checked the length of its four legs and the tightness of all its bolts.

“Let me just take it for a spin”, I said. Elsa grinned as I started walking.

The moment I put even the slightest pressure over the front wheels, the walker started turning towards my right. I hit the wall just as fast as Elsa had. She giggled. The nurse sighed with her hands on her hips.

“Let’s get you a new walker!” I said as I returned the defective unit to Elsa. She smiled and nodded.

I didn’t know whether to feel good or bad about my diagnosis. It had taken more than two weeks, but really only took a minute to arrive at once I got on the right course.

In February 1995 I must have seemed overworked and headed for burnout. Clarine, my bed-bound patient who always encouraged me to write down my thoughts and experiences as a country doctor, gave me a copy of Thomas Moore’s 1992 bestseller “Care of the Soul”. She ran a small book editing and publishing business from her sickbed. Her vision was poor by then, but with the help of the adjustable settings on her computer, she could still do her work. When she inscribed the book with her thick fountain pen, she accidentally turned the book around and inscribed the back of it:

“With love and every good wish –

Preread & reviewed by

Clarine”.

Soul is not the same as spirit. While the spirit looks toward heaven, the soul has to do with our roots, the messy depths of our psyche. Thomas Moore explains that soul is in attachment, love and community; it is in food, music, art and experiences that touch our hearts.

In “Care of the Soul”, Moore points out that we cannot think ourselves out of the modern split between body and spirit, because “thinking is part of the problem”. He quotes fifteenth century writer Marsilio Ficino: “What we need is soul in the middle, holding together mind and body, ideas and life, spirituality and the world”. Moore goes on to say: “Care of the soul is not solving the puzzle of life; quite the opposite, it is an appreciation of the paradoxical mysteries that blend light and darkness into the grandeur of what human life and culture can be”.

I remember reading parts of the book, but hurriedly and not with an open mind. It sat in my bookcase for years, and I often glanced at the title on its spine.

In February 2007 my Nurse Practitioner wife and I registered for a Cape Cod summer seminar with Thomas Moore. We were working very hard, side-by-side, and we were feeling a bit stretched. We had a cleaning lady, who also did our grocery shopping, a laundry service, a lawn-mowing service and a handyman. Our spare time was occupied with dancing; in just four or five years we had become accomplished ballroom dancers. We took private lessons and practiced at least three nights a week and several hours every weekend in a rented studio. We used to joke that while we worked and danced, other people were living our life.

July 23^rd, just after we came home from a surprise retirement party for one of our dance instructors, where we had done a humorous tango exhibition, our 15 year-old German Shepherd got sick. She was a cancer survivor, and we made arrangements to have her seen at Angell Memorial Hospital in Boston on our way down to the Cape. The diagnosis and prognosis were grim; she had a grapefruit sized tumor in her chest.

That week in August, beginning four years ago today, turned our lives around. Our dog’s health failed rapidly, and my wife stayed with her in our rented cabin while I attended the Thomas Moore seminar. The topic was soulfulness in clinical practice and in one’s life. Moore took the principles from his book and put them in the context of being a clinician, a healer.

Back at the cabin we dragged the mattress off the bed and slept on the floor with our dog and our little Persian cat. I would update my wife on the day’s discussions and we worked on our assignments together.

In class, Moore showed a strobe-like black and white movie of C.G. Jung carving his inscriptions into a big rock at Bollingen. As the gentle waves of Obersee lapped against the shore, one of the fathers of modern psychiatry tirelessly and with great pride carved a stone when he could have written another book or lectured at foreign universities. Instead, he chose to do this, creating something that was important to him and could last for thousands of years. Were we, my wife and I, doing something really important to us or were we just working hard without purpose? We knew we had to get off the merry-go-round we had created for ourselves.

At the end of the week, Moore signed my old copy of his book – inside the front cover, which Clarine had inadvertently left blank when she gave it to me:

”Help us save the soul of the world.

Best Wishes,

Thomas Moore”.

Within weeks our dog died in her favorite spot in our kitchen. Two months later another Shepherd was given to us. He had been born July 23, the same day Callie got sick. Six months later my wife’s health caused her to leave her career as a Nurse Practitioner. We reassessed our priorities and vowed to take care of our own health the way we had always told our patients to.

I have developed an undeserved, strong bond with our recently adopted 23-year-old rescued white Arabian horse. She has made me the first human being in years that she dares to trust, because I ask nothing of her. I have read that Martin Buber, author of “Ich und Du” first became aware of the true nature of I-and-Thou relationships when he befriended a gray mare at age eleven.

Without all those other people running our life we are doing the soulful chores couples have done on small farms for countless generations – “chop wood, carry water”. We cook together and we read out loud after supper and talk about health, disease and doctoring. My wife studies other forms of healing and I write about my life as a country doctor. Dancing isn’t an exhibition sport for us anymore; we think of it as an expression of our love for each other.

Earlier this week a package came in the mail with my latest online purchase: Thomas Moore wrote a new book last year, “Care of the Soul in Medicine”. I opened the package eagerly, weighed the hardcover book carefully in my hands and reluctantly put it down on my desk. I haven’t had a chance to start reading it until this weekend.

How will I grow – as a man and as a physician – from his words this time?