A Country Doctor Writes:

Lester Croppe never did come back for his follow-up two months ago. He did show up this week, however, with a big frown on his perpetually tanned, furrowed face.

I immediately got the sense that Lester was upset or unhappy, although I wasn’t sure why.

“It’s been a while”, I said tentatively. “Last time we talked I gave you an insulin pen to start getting those blood sugars down….”

“Before you go any further, I need to tell you something”, he interrupted.

“Yes?” I said.

“I didn’t like what you said last time about me having to go on the needle.”

“I can understand that”, I offered.

“So I got mad and decided to do something about it.”

I glanced at his vital signs. His weight was down almost twenty pounds and his blood pressure was better than I’d seen it before. I asked:

“What did you do?”

“I gave up drinking beer, cut back on snacking and made my servings smaller than before”, he thundered.

“Looks like it paid off!” I said. “What kind of blood sugars are you getting now?”

“Nothing over 220, and my fasting readings are perfect.” His stern face broke into a contented smile. “I wanted to prove that I didn’t need insulin”, he said, triumphantly.

“And prove it you did! Congratulations….”

“Thank you”, he said, offering his enormous, calloused right hand in a firm handshake. “At first, I got mad at you, but then I knew it was really my diabetes I was mad at.”

I have known for several months that things were coming to an end between Helen and myself, and that I would probably have to be the one to actually end our relationship.

Helen’s medical condition is quite ordinary, but her reaction to it is unusual. She is convinced that she has some dreadful, yet undiagnosed disease. Years before she even became my patient she had been thoroughly evaluated and all the tests had been normal. A few more confirmatory tests reassured me, but not Helen.

She spiraled into a deeper state of panic about her symptoms and she started to call Autumn several times every week with new concerns, demanding that we drop everything and reevaluate her. She has refused to go to the emergency room when her symptoms have sounded dramatic on the phone, and she has refused to see my colleagues at the clinic when I have been too booked up to see her right away.

I tried to apply my usual strategy for working with anxious, doubtful patients. I gave her weekly double-length appointments in order to show her I was taking her seriously and wanted to address all her concerns. By seeing her often I hoped to decrease her panic between visits, but this made no difference. She has also resisted the notion that her symptoms may be worse when she feels anxious about them. She vehemently refuses to see our behavioral health specialist.

Our last several visits have followed the same pattern: I would ask about her symptoms, which always remain the same, then I would ask about her medication, which she never takes as prescribed. She would then tell me she has spoken with an acquaintance – a nurse, pharmacist or fellow sufferer of a similar condition. Inevitably, this other person has nothing good to say about my diagnosis or proposed treatment strategy.

Every time Helen has brought up the concerns raised by her friends, I have responded by reviewing how I arrived at her diagnosis, what the literature recommends for treatment, how the medications are dosed and how one monitors the condition and the treatment. Every time I have done this, Helen seems okay with my treatment plan, but by the next time I see her, the process starts all over again.

During last month’s visit, I put her chart aside and said to her:

“You really don’t seem comfortable with how I am handling your medical care.”

“Well, it’s just that – I mean, how do we know we’re on the right track?”

I remembered Rhonda Weston, who for almost a year kept saying she wasn’t feeling right. Her physical exam and all her medical tests were normal, until suddenly she developed the slightest lymph node swelling, which turned out to be non-Hodgkin’s lymphoma. Within two years she was dead, despite the best of treatment by Boston and local oncology specialists.

I went over Helen’s symptoms, the testing we had done, the diagnosis and differential diagnosis and my treatment recommendation, based on the literature I had reviewed and shared with Helen. I explained to her that after going over her history and evaluating every symptom she has told me about, there was no sign at this time of anything more dangerous going on. I reminded her that I always wanted to know if any of her symptoms changed, so I could evaluate them in the context of what we already knew.

“No test is perfect, Helen, and that’s why I’m always checking in with you to make sure there aren’t new symptoms or new findings that we need to consider. I am doing my very best to keep an eye on your condition.”

She concluded:

“I do trust that you’re doing your best, it’s just that I’m scared.”

“You’re scared that there’s something I’m missing?”

She nodded.

“What’s your biggest fear, your deepest fear?”

“I don’t know; just that I have something bad.”

I told her I understood, but that it wasn’t in her best interest to stay under my care when she had so many doubts. I suggested she look for another doctor, who might make her more comfortable than I could.

“No, I want to stay with you”, was her answer.

A few weeks ago Helen told me about a fourth cousin in Philadelphia, with the same symptoms, who suddenly ended up in a coma and on life support at a university hospital.

I knew I wasn’t going to break through her fear. I gave Helen the names of three or four doctors within easy driving distance who are accepting new patients. I told her I was sorry I hadn’t been able to help her more and that we really couldn’t go on like this. I gave her formal notice to find another doctor within 60 days.

I didn’t expect to feel relieved after doing this, but I had not anticipated how sad I would feel.

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.