A Country Doctor Writes:

Mrs. Blouin was new to our practice. Her previous doctor, in the next town up the road, had left the area just over a year ago. Her presenting complaint was “Wants Reclast infusion”.

Reclast is a once-yearly $1,200 intravenous infusion for osteoporosis, primarily for patients who cannot tolerate the older treatment alternatives.

I have many misgivings about osteoporosis treatment, and have not yet prescribed Reclast. It has a long list of drug interactions and side effects, and it is still very new.

It didn’t take me long to realize that there were other issues afflicting Mrs. Blouin. She was fatigued, her blood pressure was very high, she had no idea what her cholesterol was, and she had a foreboding family history of cancer and heart disease.

Dr. Greyson’s notes mentioned her blood pressure being up a bit, ongoing fatigue, breathing problems and several other symptoms. Reading through them, I wasn’t sure how osteoporosis came to be the predominant concern.

“How did you and Dr. Greyson come to focus on your bones?” I asked.

“I don’t know”, she answered. “I guess he thought they were really that bad.”

“It sounds like we need to look at the whole picture right now. You couldn’t get your infusion now anyway without some fresh bloodwork. We might as well see if we can find out why you’re tired, check you for anemia and thyroid problems. We could also check your cholesterol if you’d like. And I’d like to check your blood pressure one more time, since it’s higher today than it was last year at Dr. Geyson’s.”

I had moved the focus of our visit away from what Mrs. Blouin had come to see me for. So had Dr. Greyson, but in the opposite direction.

Physicians change the subject of patient visits all the time. Sometimes we do it because we feel there is a more pressing issue than the one a patient came to see us for, like correcting a high blood pressure or screening chronically ill patients for depression, which may be a barrier to achieving better health. Other times we may be guilty of shifting the attention away from a symptom we are unfamiliar or uncomfortable with in favor of something we find easier or more satisfying to deal with. Sometimes we may avoid or postpone issues that aren’t easily solved in a fifteen-minute-visit.

I sometimes hear patients say about other doctors: “He didn’t seem concerned about my symptoms”. Some people may say that about me too; I know I don’t pay as much attention to arthritis pain and old sports injuries as some patients might expect when they come in for physicals and have unmet screening needs for cancer and cardiovascular risk that I feel a need to cover in my half-hour with them.

But where do we draw the line? When is it fair to change the agenda for a patient visit and when is it not? When are we doing the right thing by steering our patients toward issues they may not have thought of as priorities, and when are we doing the wrong thing by not making them equal partners in their own health care?

I never did get my haircut for Christmas. The past few weeks, things seemed to be going at warp speed. Yesterday, my half-day at the office dragged on past two o’clock, and then there were two admissions, two 60-day reviews and several sick visits at the nursing home to take care of.

The week was interspersed with e-mails from my cousin in Sweden about his father. December 3^rd, at my own father’s funeral, R., his youngest brother, sat in his wheelchair in the center isle of the chapel. Afterwards, in the parish hall, he said “next time it will be my turn”. He felt a strange chill, but refused the black knitted throw his wife had brought with her.

Two weeks later, his doctor predicted he would be gone within hours. My cousin’s e-mails brought back memories of my own father’s passing. My father used to call me R., then correct himself when he realized I was his son, not his younger brother. I took it as a compliment, a sign that he sometimes saw me as a member of his own generation.

My uncle lingered on, and my cousin’s e-mails grew more philosophical. My replies contradicted their young doctor’s attempts at predicting the course of life’s biggest mystery.

Day by day, sometimes hour by hour, the messages told the story of my uncle’s changing neurologic condition and his family’s winding journey between extremes of hope and despair but inevitably away from the way things used to be.

As Christmas drew nearer, new snow fell outside while the family’s vigil continued. The e-mails arrived at a steady pace. My uncle’s breathing took on the familiar pattern I had listened to as I sat through long days and nights at my father’s bedside.

When the snowfall stopped and my uncle’s coma deepened, my cousin wrote metaphorically: “Fine flying weather, but no traveler yet.”

My day at work continued; there were so many things to take care of before we closed for the Holiday. Finally I arrived at home some time after seven o’clock with a couple of last-minute grocery items and a stack of Christmas cards from the office.

After a Swiss fondue and some Chianti we tried to watch a Bing Crosby movie, but we both kept nodding off, so we decided to postpone the movie until the next day.

Even though today was a Holiday, we woke up at five. Over coffee in bed I checked my e-mail. My cousin had written:

“The night flight departed at 0330 hours. The traveler disappeared with a broad smile on his face.”

I finished my coffee, got dressed and headed outside toward the barn with warm mash for the horse.

Walking across the yard, dimly lit by the almost full December moon, I paused to listen to the perfect silence of the Christmas Eve morning. I noticed the blinking lights of a small airplane moving across the sky. My eyes suddenly grew moist and I lost sight of the plane.

I thought of my cousin’s metaphor about his father’s passing, remembered my own father’s last breaths, and wondered if the two brothers had hoped to meet again. My father never spoke about what he really believed. 

The chill of the early morning crept inside my leather jacket and I hurried to get inside the barn door.

B. C. and his wife came in for his diabetes follow-up the other day. His blood pressure and blood sugar have been out of control for over six months now, but he has refused to try new blood pressure medications and he won’t consider insulin. He even hates pricking his fingers, so he had ordered a glucometer that uses blood samples from the forearm.

“I feel good”, he always says.

Even though we have seemed to be at a medical standstill, I have enjoyed our visits together. He has told me many things about the wildlife around here and he has helped me understand our male dog’s reactions to the wolves and coyotes that surround us.

“Here, this is for you”, he said as he handed me an oblong envelope. Inside was a Christmas card with a picture of the two of them – she in a long dress, he in a colorful costume with a bearskin draping his back and the bear’s head on top of his.

“That’s me in full regalia”, he said proudly.

His face in the picture was quite pale.

“How’d your face get that that white?” I asked, wondering if he was starting to feel poorly some of the time.

“Grease paint.”

I thanked them for the Christmas card and got down to business.

“Have you checked any blood sugars after meals?” I asked.

“No, my new machine hasn’t come yet, so I’ve only checked a few times, but my sugars are down”, he smiled.

The three readings he remembered were actually in a good range.

“Are you eating differently?”

He shook his head. “I eat about the same.”

“No, we got rid of all the junk food”, his wife corrected him. I noticed he had lost a few pounds.

“I went to he herb woman”, he said, “and she gave me a mixture of thirty-two herbs that I’m supposed to take with each meal. It tastes like salt, but there’s no salt in it. I’ve also been taking my cinnamon.

“And I’ve been reminding you about your pills”, his wife interjected.

He ignored her comment.

“Between that and the fenugreek my blood sugars have really come down and I feel great; I have so much more energy.”

“Well, I’ve got to hand it to you. I don’t know exactly how the stuff lowered your blood sugar, but it sounds like you should keep taking it.”

He grinned proudly and gave his wife a triumphant glance.

“But, just to be safe, I hope you’ll keep taking your regular pills, too. And watch the junk food, okay?”

“I will”, he said, rising from his chair.

“Merry Christmas my friend”, he said, offering his big hand in a firm shake.

“You too”, I said, “both of you.”

His wife, now standing behind him, looked into my eyes and silently formed the words with her mouth:

“Thank you.”

Mrs. Rizzo called the other day to ask if it was all right if she had half a glass of wine with dinner around the Holidays.

This time I knew enough to say no. A year ago I didn’t know her very well and made the mistake of leaving a vague answer via Autumn, my nurse, amounting to ‘Probably’.

Did I ever live to regret that! Just a few days after that initial query, the reports started coming in: Mrs. Rizzo was causing a ruckus at her seniors’ apartment complex; Mrs. Rizzo was verbally abusive with her husband; Mrs. Rizzo was making annoying phone calls to former acquaintances, who no longer wanted anything to do with her.

Last year’s binge lasted several weeks and took a great deal off effort and diplomacy to untangle myself from.

This year I returned the call myself. I made very sure to politely point out to Mrs. Rizzo that things didn’t go so well last year and that the half glass of wine had turned into far too many. I reminded her that she had said and done things back then that she later regretted. The fact that she now didn’t remember some of them also suggested that her brain was sensitive enough to alcohol that she seemed to have had some blackouts.

Hopefully this year’s firmer stand will help prevent another Holiday disaster at the Rizzo home.

My old friend Dr. David Duggans told me about a patient of his, who never used to touch alcohol at all until Dr. Duggans put the idea in his mind.

Old Sumner Tardif was a quiet man, who for two years had been grieving his wife. One day last winter Dr. Duggans suggested that Sumner do something about his “cabin fever” and get out of the house more, perhaps with the “boys” in his neighborhood.

Soon afterward, there were reports of Sumner buying drinks around the house at the Sports Bar several nights a week.

One snowy night last March Sumner skidded off the road on his way home from the Sports Bar. He hit his head badly enough to end up with twelve stitches and a concussion. The legal ramification of his episode of driving under the influence was a lengthy driving suspension.

Fortunately his neighbor up the road, Glenda Maas, took pity on him and offered to chauffeur him anywhere he needed to go. Widowed herself, she seemed to enjoy the company.

Soon, you saw the two of them not only at the grocery store and Wal-Mart, but occasionally also at Olga’s Restaurant and the Sports Bar.

Wouldn’t you know it – Sumner asked Glenda to marry him and they had a small wedding ceremony over Thanksgiving with Dr. Duggans as one of the guests of honor!

One of the first challenges I faced as a foreign doctor from an urban background practicing in a small town in this country was finding the right way to explain medical issues to my male patients. They were farmers and fishermen without much experience with illness, medications or medical procedures. Most of them came to see me reluctantly at their wives’ insistence.

Gradually, I found my voice and a style that has served me well over the years. As a Boy Scout and grandson of a farmer with more than an average interest in automobiles, I have found enough analogies from my own experience to be able to cross the cultural barriers I have encountered in my new homeland.

I may explain risk aversion by talking about why some men wear both a belt and suspenders. Heart attacks and angina are, obviously, related to plugged fuel lines. Beta blocker therapy is similar to shifting your manual transmission into fifth gear. Sudden discontinuation of beta blocker therapy is like releasing an inadvertently engaged emergency brake while driving with your gas pedal fully depressed. Untreated hypertension is like driving down the highway in third gear, and orthostatic hypotension is a lot like getting poor water pressure in an attic apartment.

Other, perhaps less obvious, analogies I have perfected over the years include the following:

Finasteride to slow progression of benign prostatic hypertrophy:

You buy a new car and the dealer sells you a rust proofing job. Five years later, your car is rust free. Is it because you paid extra for the rust proofing, or would the car have been OK anyway?

Why carotid artery stenosis up to 80% can be asymptomatic:

If you water your plants with a garden hose and compress the hose by 80%, the water will actually squirt faster and further than if you just stand there with a soft grip on the hose.

What to do when a test result and your judgment conflict:

When the terrain and the map disagree, follow the terrain.

Why some people with high cholesterol escape heart disease while others get more atherosclerosis than expected because of inflammation, as measured by C-reactive protein (CRP):

Some people’s arteries are like Teflon, nothing sticks, and other people’s arteries are like a scratched-up aluminum pan, everything sticks to the bottom.

Why skipping just one dose of your antihistamine can cause a major allergy flare-up:

If your townspeople are trying to discourage out-of-towners from stopping in and causing trouble at your local hangout and your strategy is to make the place look filled to capacity, be sure you get there as soon as they open, and don’t you all take a break at the same time, or the place will look empty and they’ll be sure to stop in.

Why some people can take an antibiotic several times before they get a rash from it:

Just because your neighbor’s pit bull doesn’t bite you the first time you see it, do you really know it won’t bite you the second time?

Our job as doctors is to meet our patients “where they’re at”, as people say around here. That’s not the English I learned in school, just like the explanations and analogies I use with my patients aren’t exactly the ones I learned at Europe’s second oldest university. But all the book knowledge in the world won’t help you be a better doctor if people don’t like or understand the way you speak.

Today, a nurse I work with at the nursing home gave me the nicest compliment. Her husband had, reluctantly, been in to see me a few weeks ago. She told me that her husband thought that now, for the first time ever, he had a doctor he could talk to – one that talked the way he did and laid things out plain and simple without putting on airs or making things complicated.

Comments like that always make my day, just like hearing that people forget I am a foreigner and “from away”.