A Country Doctor Writes:

“Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”          Florence Nightingale

Stephen Bloom became my patient almost ten years ago. He was an anxious fellow with high blood pressure and a less than perfect lipid profile. He also had borderline diabetes.

His previous doctor had told him he was a heart attack waiting to happen. “A walking time bomb” were the words Stephen remembered.

The doctor’s words had done little to bring about any change in Stephen’s lifestyle. When I met him, he was thirty pounds overweight with a blood pressure a good ten points over ideal, and his lipids were not quite controlled, but his biggest problem was his anxiety. He acted like every day was his last. He worried about what to eat, about which kind of physical activity was too much or too little, about side effects and about the cost of his medications.

Over the next several months we adjusted his medications and he actually lost a few pounds. I helped him figure out which foods raised his blood sugar the most and I encouraged him to make small changes in his eating patterns between each cholesterol test. But he was still on the verge of panic about his heart attack risk.

I had to work on his anxiety.

“Look at all the things you have been able to change. Your blood pressure is controlled, your weight is down, your blood sugars are normal and your cholesterol is so much better.”

I took a deep breath and added: “Right now, your biggest cardiac risk factor is your own stress and anxiety.”

He thought for a while, then seemed to relax and said “OK, that makes sense”.

I continued to see him every three months to monitor his progress, and he seemed to be more and more solid in his belief that he was doing everything he could to lower his heart attack risk. He seemed to enjoy life, and was an absolute rock when his wife, Donna, had a stroke.

Then, one day about a year ago, Stephen ended up in the emergency room with chest pain. His EKG was normal and his blood work didn’t show any sign of damage to his heart. I saw him in follow-up and ordered a nuclear stress test, which was normal.

From then on, Stephen’s anxiety was back. He often experienced chest pain when he got upset or when he couldn’t fall asleep at night, but never with physical exertion. I broached the subject of doing something more for his anxiety, but he said no, adding “I think my heart is starting to act up, it’s just not showing in the tests yet”.

All the courage he had gained and been able to maintain over the last ten years had suddenly escaped him, and he became more and more convinced that the good health he had enjoyed was sure to come to a cruel end at any moment. Unlike ten years ago, nothing I said made a difference this time.

I kept wondering, had I failed to reassure him, or was his fear and anxiety so deep, so miasmic, that he couldn’t be helped?

Shortly thereafter Stephen transferred his care to a doctor in the next town.

The other day I happened to see his sister, Gertrude. She told me Stephen was on all new medications and had to see Dr. Grimes for follow-ups at least every month because he was at such high risk for having a heart attack. Stephen never did anything without checking in with Dr. Grimes. In fact, she added, Dr. Grimes considered her brother to be “a walking time bomb”.

“I think I’ve tried every medication there is for my OCD”, Debbie Kurbitz said as she pulled out a large notebook from her canvas bag. “I’ve had reactions to all of them.”

Her record keeping was consistent with her diagnosis of obsessive-compulsive disorder. Listed on the pages of her notebook were the doctors she had seen, all the usual medications in our armamentarium they had prescribed and the particular side effects each drug had caused.

I already knew Debbie truly needed something done. She was struggling with rituals like counting everyday objects, words and even the steps she took.

It was clear that Debbie hadn’t done well with SSRI’s, the serotonin reuptake inhibitors we typically use for OCD. She had listed all the side effects I could think of off the top of my head. I concluded she must be very sensitive to these medications

“What doses of these did you try?”

She hadn’t listed the doses she had taken, but her recall was impeccable.

I looked at her list for a few moments before I spoke again.

“I think you might be helped by any one of these drugs, but in much lower doses than you tried before.”

“How much lower?”

“Well, I think Lexapro, escitalopram, would be worth trying again, but I would prescribe the liquid form and start you off with one milligram per day instead of ten, which is what you started with and didn’t tolerate.”

She raised her red eyebrows and put her chin in her hands.

“Take one milligram per day for three or four days. Then, if you don’t feel nauseous at all, go to two milligrams. If that agrees with you, go to three milligrams, but if you are the least bit nauseous, stay with that dose until you feel OK. Work your way up to no more than five milligram per day, and I’ll see you in two weeks.”

“OK…”, she said, but her green eyes almost seemed to roll back in disbelief.

Two weeks later those same green eyes were sparkling under her bushy red hair and eyebrows.

“I feel fine. Not a speck of stomach upset, and I’m not counting anymore!”

I smiled.

“How did you know this would work, or did you just guess?”

“I’ve been around. There are serotonin receptors in the stomach and they make you nauseous the first week on an SSRI like Lexapro. If you can get beyond the first week, you generally don’t have to worry about nausea unless you increase the dose.”

“But I only needed five milligrams…”

“Well, Lexapro has what we call a flat dose-response curve. Many people have the same effect from five as from twenty milligrams, just fewer side effects.”

“So a lot of people are taking higher doses than they need?”

“Possibly. When new drugs are introduced, the drug companies often look for a dose that is effective for the largest possible number of patients. Not everybody has serotonin receptors in their stomachs and brains as sensitive as yours. I suppose if you started everybody off at a very low dose, many people would get impatient and draw the conclusion that the drug wasn’t working and the drug company would lose a sale.”

“I can’t thank you enough. Now, do I still need to see the counselor you talked about?”

“I still think it would be worth your while.”

(The concept of prescribing the minimum effective dose goes back to Greek medicine, including Hippocrates. Many have interpreted his “First, do no harm” as a warning not to be heavy handed with medications.)

Eleanor Burrill reminded me Friday that she turns 90 next month. She has been a patient here as long as I remember, even though she lives in the next town and has to drive 20 miles to get here. We see her once a month or more, because she has to get her bloodwork done to regulate her blood thinner.

She has always been an inspiration because of her vivid intellect and never-ceasing curiosity about how things work, not just her blood sugar, pulse and blood pressure, which she diligently records every day in her monthly planner. Eleanor has a hunger for knowledge and even surfs the Internet. There, she also keeps in contact with her great-grandchildren.

She has always maintained a dignity and a certain distance. I have always thought of her as quite a lady.

She looked serious this time, and after we had taken care of her prescriptions, she told me:

“You know I’ll be ninety next month. I’m afraid I might be getting too old to be driving through moose country to come and see you, especially with winter coming…”

“I can understand that.”

“So I have made an appointment to see the new doctor at Tall Pines Medical Group at the end of next month. Believe me, it was not an easy decision, but I know it’s time. I wish you were closer.”

“You know, I think that’s a wise decision. It will be so much more convenient for you.”

“I didn’t want to hurt your feelings. You have been so good to me.”

“I don’t take this personally at all. You need to be practical and do what works best for you. I hope it works out well for you.”

We both got up from our chairs and shook hands. As I opened the exam room door for her and stepped aside to let her leave the room first, she turned back towards me.

“Thank you. I have a question, though.”

“Yes?”

“If I don’t feel comfortable with Dr. Selig, would you consider taking me back?”

“Of course I would!”

She smiled, turned away and made her way down the hall.

I should have hugged her.

This morning was a whirlwind of patients, paperwork and phone calls from specialists and home health nurses. It was also one of those mornings when nothing went the way I had hoped. Mr. Fielding’s liver biopsy results were nowhere to be found, Mr. Carlson’s CT scan had been done without intravenous contrast even though we had specifically ordered it with contrast, and Ms. Grondin who is on chronic narcotics for back pain had been seen playing Frisbee and doing the limbo at the county fair last weekend. At one point near the end of the morning I was starting to think that I was treading water and not really helping anybody.

My last patient before lunch was Joe Salvino. He was in for a blood pressure check and a refill of his pain medications. He has been talking about giving up his career because of his worsening neuropathy pain. He works more hours per week than I do and admits he can’t say no when his manager asks him to do more. He has researched Social Security Disability and he knows most people don’t get it the first time they apply, and nobody gets it unless they have been unable to work for a long time.

Joe’s blood pressure was finally under control with his expensive combination pill. He didn’t smell of cigarette smoke today. He told me he smokes well under a pack per day now. He still has high cholesterol, but we haven’t tackled that yet. Joe told me a while back he wasn’t ready, but today he told me he is eating better.

I gave him refills for his medications and even though we were running late, I got philosophical with him.

“It isn’t necessarily an all or nothing situation, Joe. Instead of going for disability you could work fewer hours. You don’t always have to be a good sport and make things work for others at your own expense. If you always play the hero, why would your boss not keep piling on more for you to do? ‘Give it to Joe, he never says no.’”

“I know…”

“If this boss won’t meet your needs, there may be others who would.”

“You’re right…”

“I’m not telling you to quit. I’m telling you that you have options, and that things can change. You need to figure out what you need and ask for it where you are or look for it somewhere else.”

I ended the visit by getting up from my chair and handing him the follow-up instructions for the receptionist. Finally, I shook his hand and said:

“I’ll see you in a month.”

His hand squeezed mine back long and hard and he looked straight at me and smiled.

“I like coming to see you. You give me hope.”

Stuart Green had lost his career as a lobsterman due to his bad back. His wife divorced him and he lost his boat and his home on the water. Land-locked and lame, he walked with a cane and had been on chronic narcotics for years.

When I first met him twenty years ago, he had just started seeing a psychiatrist. Stu told me he had hit rock bottom shortly before and there was nowhere to go now but up. His disability had gone through and that gave him health insurance and a steady if modest income.

His pain was partly mechanical with bone-on-bone grinding in his lower back, but also nerve related with relentless burning and weakness in his right leg.

His psychiatrist had him on a mood stabilizer and an antidepressant. These medications seemed to help his depression and also helped take the edge of the nerve pain.

I gave him a low dose of methadone, which did wonders for his pain. His spirits were clearly improved.

Two months into our acquaintance, he told me he had decided to restore his sister’s old boat, similar to the one he had given up, but much older. It now sat behind her barn on her farm near our clinic. He hoped to use it for charter some day.

Over the next few months, Stu got more and more involved with his restoration project. He would come in for his prescription refills regularly, but would never complain about his pain, even though he worked long hours. He had a purpose and seemed to thrive on it. He almost didn’t limp anymore.

I asked about his psychiatrist appointments. Stu told me Dr. Chasse was really helping him feel better about himself.

As winter drew nearer, Stu cancelled a couple of appointments and rescheduled them for bad weather days, so he could get more work done. He was working on the boat outside and was hurrying to get as much done as possible before the first snow.

The week of our first storm, Stu called the office three or four times to rearrange his appointment, but the day he was supposed to come in came and went with no sign of him.

The next day I had a call from the Deputy Sheriff, who had found him.

Weeks later the toxicology report showed that Stu had died from an overdose of methadone and his antidepressant. There was no trace in his blood of the mood stabilizer he had been prescribed.

(Up to 50% of bipolar patients attempt suicide, and 15-20% of people with bipolar illness die from completed suicide.)