A Country Doctor Writes:

Over the years I have developed a friendship with our local small animal veterinarian. He has seen us through joys and sorrows with our cats and dogs and we have shared dinners and some family outings.

Inevitably, we have often ended up talking shop. Medicine is very much the same, whether your patients are adults, children or beagles. We have found that we do very much the same things for the same conditions, but we have a running competition about who has the toughest job.

Calvin C. Carruthers, DVM, C-3 for short, is a highly energetic and charismatic man. He insists his job is tougher than mine because pet owners in this part of the country tend to be less than forthcoming with medical history and useful information when their animals are ill. Calvin’s favorite patient complaint is “Dog Ain’t Right”. He tells me those three words are sometimes the only help he will get from an owner when diagnosing a sick dog. He doesn’t believe me when I tell him some of my patients don’t offer any more details than “I just don’t feel right, Doc”.

Calvin’s job is easier than mine in that he has developed a habit of often taking three and four day weekends and “signing out” to a vet in the next town over, about 20 miles away. He does the same thing when he goes on one or two longer vacations every year. We have accepted these inconveniences, because he is an excellent veterinary surgeon and a good friend. As of this fall, there will also be another veterinarian joining him, which will make his practice independent of call-sharing.

About two months ago our youngest beagle, thirteen-year-old Snickers, developed some swelling of her nose. We were concerned she might have a tooth abscess as Calvin had wanted to do a “dental” on her for some time. That was the week of the North American Lindy Hop festival, and Calvin and his wife were off somewhere in their spectator shoes, grooving to 1940’s music. His office answering machine directed us to the covering veterinarian, who after a fairly quick examination concluded that this seemed more allergic than infectious. We were relieved, but still wondered if this was the correct diagnosis.  

Snickers nose seemed to get better, but two weeks ago she acted a little lethargic and stopped eating. This time, Calvin was in Chicago at a veterinary convention and the young assistant veterinarian of the practice in the next town was the one on duty. He seemed baffled, and speculated Snickers might have had a stroke. He offered to do some bloodwork, but couldn’t get blood from her little legs. At that point we decided to bring the dog to the Emergency Veterinary Clinic in Capitol City.

The Emergency Clinic vet was sure she had a severe tooth infection with early sepsis, or blood poisoning. We agreed to start intravenous antibiotics and after the weekend we saw Calvin, who did the dental surgery last Tuesday morning.

Snickers’ recovery has been slow, but today we see a healthy appetite and a fair amount of tail wagging. She is still weak from her ordeal, but she is on the mend. We regret our delay in getting her teeth done in the first place and for wanting so much to believe the covering veterinarian, who thought Snickers’ swelling was harmless and would go away by itself.

Our seventeen-year-old, otherwise extremely youthful male beagle has started to act strange in recent months. He is drinking a lot of water, pants when we take him for a walk, and is showing a bit of a potbelly even though he has lost some weight. We took him to Calvin for an exam and some bloodwork. Stormy’s blood sugar and thyroid tests were normal and Calvin didn’t think there was any heart failure. Some of the liver tests were a little elevated, which could be transient or the beginning of something serious, so we didn’t have a diagnosis yet.

The other night I was reading from the book I got for my birthday, Harvey Cushing’s biography of Osler. My wife started talking about what might be the matter with Stormy. I closed my book and as we talked about the dog, my right hand came to rest as if I were pointing to the name Cushing on the cover. Suddenly she stopped talking and put her index finger near mine on the book.

“That’s it! Stormy might have Cushing’s! He’s panting, he’s got heat intolerance, increased thirst, potbelly and an elevated alkaline phosphatase. And remember he didn’t shed out this spring. Those are all symptoms of Cushing’s disease.”

My Nurse Practitioner wife may have figured it out first; I just knew the dog wasn’t right.

July is my birthday month. This year is one year past my halfway mark; a year ago I had lived half my life in Sweden and half in the United States.

Over the past few years my interest in medical history and the philosophy of medicine has deepened. It may be something every physician goes through at my age, or it may just be my way of dealing with the ever-quickening pace of change and the seeming loss of values in medicine today.

I recently bought Osler’s “The Evolution of Modern Medicine” and had been contemplating getting Harvey Cushing’s Pulitzer-prize winning biography of Osler. Somehow I never got around to buying it, and life got busy enough that I forgot about it.

My birthday came, and my wife gave me a small gift. “Your big gift didn’t come yet”, she said. In a remote, small town you do a fair amount of shopping through catalogs or the Internet. I waited for a week, and then, talking to my wife on the phone at lunch, she happened to be going down to the mailbox while we were on the cell phone.

“Your birthday gift came”, she said. “Wait while I open the package”. Next, I heard rustling of paper, followed by “Oh, wow”, after which she said nothing for a long time.

“You are going to be so pleased”, she said, but she wouldn’t tell me anything more. I had waited a week for my big birthday present, and now I had to wait until the end of the day.

After supper, I unwrapped two big packages that were obviously books. I, too, said “wow” when I opened the second one. The first one was Volume II of Cushing’s biography of Sir William Osler. The second package contained Volume I, signed by Harvey Cushing himself! The used-book dealer had not even listed the book as signed by the author.

Looking at the massive, two-volume work by the founder of modern neurosurgery, I was touched by how much time and effort must have gone into it and by the obvious respect Cushing had for Osler. I was struck by Osler’s wide-ranging interests, passion for medical education and commitment to the medical profession. I have struggled my entire career with finding a balance between seeing patients and feeding my soul by studying and creating. Clearly, the giants of modern medicine took time for other things, and that did not diminish the importance of their clinical work.

As I now sit here, a 57-year old physician who has spent the last 31 years in this profession, I hold in my hand a book about Osler, signed by the author, Harvey Cushing himself, in 1926. I feel a renewed commitment to my life’s work, the only profession I ever considered from the age of four.

I feel very fortunate, indeed.

Arthur Bloch has slowly been losing weight over the past six months. His thyroid function and all his routine labs are normal. He has had a chest x-ray, and he had a colonoscopy and an upper endoscopy a couple of years ago. He says his appetite isn’t what it used to be. He tells me he doesn’t have any trouble swallowing.

His Parkinson’s Disease is causing him to speak in a quiet, almost whispering voice, and his body movements and facial expressions are sparse. I have wondered if he might be depressed. He filled out a depression questionnaire a couple of months ago, and it was fairly unremarkable.

He and his wife, Zena, have had their share of health problems. Zena has become quite frail and has a mild dementia. Over the past few months, they have been set up with Meals on Wheels and homemaker services. Neither Arthur nor Zena drives anymore, and they are getting rides from the Senior Companion program. They usually come to each other’s appointment, in fact they seem inseparable and very devoted to each other.

Today, Arthur happened to be in alone. Zena was at the hairdresser’s. I reviewed his negative weight loss workup with him.

“I know why I am losing weight”, he declared. I looked quizzically at him. He continued:

“It’s the Meals on Wheels. Zena was always a wonderful cook and I ate like a king for fifty-two years, but with her dementia, she can’t cook anymore. She feels bad about it, but we have no other choice except Meals on Wheels. I don’t care for many of the meals, but I don’t want to say anything. That would just hurt her feelings. So I say I’m not hungry.”

“But you are hungry”, I concluded.

“Yes.” His eyes teared up.

“Can you get some desserts and instant breakfasts?”

“I suppose.”

The mystery of Arthur’s weight loss may be gone, but I am just as helpless with a diagnosis as I was without one.

Little Steven Pascal laughed out loud and pointed at my wife the first time he saw her. Initially, I didn’t understand why. She looked very respectable in her crisply ironed white lab coat, pink silk blouse, three-quarter length skirt and conservative black pumps; I thought she looked lovely.

“Look, Mommy”, he blurted out, “that doctor is a nurse”, to which his mother mumbled back something about both boys and girls becoming doctors.

Steven was more right than his mother, though; my wife isn’t a doctor, but a Nurse Practitioner. She no longer works in a medical office setting, but for ten years we worked side by side and she still enriches my professional life with her insights and advice.

I helped train my wife, who became a better clinician than I am. I also helped train one Nurse Practitioner who became Director of a Nurse Practitioner program at a nearby university and another NP who started her own practice for psychiatric patients with medical problems.

It is time I write about Nurse Practitioners. The subject came up briefly in my post “Time, Money and Midlevels”, which was also republished by KevinMD.

Nurse Practitioners have a Masters degree in Nursing, which generally is a six-year university education, and several years of clinical nursing experience.

Early on, Family Nurse Practitioners were a welcome addition to the primary care workforce in underserved communities when the new Medicare and Medicaid programs increased the number of eligible patients.

Over the years, Nurse Practitioners have found work in many other specialties, from dermatology to orthopedics, emergency medicine and inpatient care. Often, Family Nurse Practitioners were hired by specialist physicians and received on-the job specialty training. Even in states where NP’s can practice independently, Family Nurse Practitioners often choose to work as “physician extenders” in specialty areas under continued supervision by specialist physicians, who assume responsibility for the Nurse Practitioner’s work. This is basically how Physician Assistants work. In recent years there has been a backlash from the Nurse Practitioner credentialing bodies against this. They have insisted that NP’s stay within their scope of practice, based on their initial training, and not change specialties after graduation by working under the supervision of a physician in a different specialty.

The credentialing bodies for Nurse Practitioners offer Board Certification in nine different specialties. A Nurse Practitioner who wants to switch specialty would have to go back to school in order to qualify for board certification. While this strengthens the professional standing of Nurse Practitioners, it also limits their ability to take advantage of mentoring opportunities, change with the times and follow new trends in the job market. It may put seasoned NP’s at a disadvantage versus newly trained ones by not allowing them to be “grandfathered” into specialties they are already working within.

It has been said that physicians protect each other’s interests and tend to go easy on each other in licensing and credentialing matters. Many people I talk to say the opposite is true for nurses.

NP’s bring a nursing perspective to the practice of medicine. Patients who prefer a medical provider with a collaborative style, a focus on education and an interest in patient-centered medicine often seek them out. Not that all physicians are authoritarian, but that is a perception many patients have of us.

The quality of care delivered by NP’s in primary care has compared favorably to that of physicians. Critics say that is because NP’s tend to refer out their sickest patients. That is certainly true at every level of health care; there are always bigger clinics and more subspecialized specialists any one of us can refer our patients to. All clinicians need to do what Nurse Practitioners talk about – stay within their scope of practice.

Having worked with many Nurse Practitioners as well as osteopathic and allopathic physicians from dozens of countries, my belief is that education is only the minimum requirement to enter the healing professions. We are challenged to deliver our best in every patient encounter. The initials after our names don’t make our patients or their diseases more or less important. We are all healers.

A subspecialist at Cityside hospital once told one of my wife’s patients that she was in good hands with her choice of primary care provider:

“I trust her more than most of the doctors around here”.

That’s my wife, a Nurse Practitioner.

We often speak of the importance of continuity of care, but there is confusion about what this really means.

When I first joined our small clinic twenty-five years ago, continuity was the reason every medical group in the five town area had its own night-call roster. This way, patients who called after hours could reach a doctor from their own doctor’s office. Even if the covering physician didn’t know the patient, there was at least an illusion of familiarity. Continuity of care often motivated primary care doctors to do many procedures, which they nowadays may refer patients to specialists for.   Continuity of care was also the reason doctors traveled between their clinics and the hospital more than twenty miles away to care for hospitalized patients.

Over the years, some practices began sharing night call. Many primary care doctors stopped treating fractures and performing high-risk office procedures. The Hospitalist movement came to our area in the 1990’s. Many physicians stopped providing inpatient care, leaving this to specially trained, full time hospital doctors.

Many people lamented the loss of what they thought of as the old-fashioned country doctor, one who did everything and was always available. At the same time the level of sophistication in medicine made it harder for any single primary care doctor to deliver the same quality of care as a specialist in every area of medicine.

Family Medicine has struggled over the past twenty years to make peace with the new division of labor and what may look like a fragmentation of care. Family Physicians can and should be the glue that holds the fragments together. The latest name we use for this old concept is “Medical Home”.

Twenty-five years ago I had a chance encounter with another Family Physician in another community, much like my own newly adopted home town. I have seen his name now and then over the years, but we never met again after that day.

The other day I saw his name in JAMA, the Journal of the American Medical Association. He was the author of an inspiring essay about what real continuity of care is. He describes seeing a patient, who after a failed spine operation wanted to give up. Dr. David Loxterkamp knew the man from treating his aging mother and disease-stricken wife. He knew Bud had the resources to fight for his recovery, but he recognized that Bud was lost in what had happened to him. That knowledge, gained over years in the same community and through sharing in Bud’s family’s tragedies, helped Dr. Loxterkamp guide and motivate his patient to a full recovery.

Dr. Loxterkamp writes:

“Continuity of care is a pillar in the portico of primary care. But it promises more than customer satisfaction or improved health outcomes. When all we measure is the ratio of patient-physician continuity, we miss the point. The tragedy is not when others care for our patients, but when no one cares for them at all.”

“The purpose of continuity is to deepen our relationship with others, something that is utterly impossible if it never begins. It begins in every encounter where the patients feels known and – despite it – loved, or at least respected and cared for by another human being.”

“It cannot be enforced, taught or measured. It must be lived and experienced in the cross connections of real community. As physicians, we are chosen to witness the destruction wreaked by illness and age. Our challenge is to see the patient who has lost sight of himself. Thus, we are called to live where we serve, anchored against the currents of geographic mobility and “professional distance”. How else can we relocate those who have been dislodged from their identity?”

His words reflect my own experience and echo the words of Sir William Osler, the father of modern medicine, mentor to generations of physicians:

“Medicine is an art, not a trade, a calling, not a business, a calling in which your heart will be used equally as much as your head.”

“Recognize … the poetry of the commonplace, of the ordinary man, of the plain toil-worn woman with their loves and their joys, their sorrows and their griefs.”

“…gain the confidence of a patient and inspire him with hope.”

Continuity of care starts with caring.