A Country Doctor Writes:

Bibi and Dwight, both in their mid-sixties, always move as a unit. They have been married for forty years. Early on, they were athletic and adventurous, but over the past five or six years Dwight has developed macular degeneration and a fairly severe case of arthritis.

I have seen him once a year for a physical and usually no more. At his last two physicals, Bibi brought up her concern that Dwight was tired. She has always been present for his visits, even before his eyesight started to fail him. He always downplayed his fatigue and blamed it on his age.

This time I focused my exam on different causes for fatigue and ordered several blood tests. Bibi seemed pleased, but Dwight seemed distant and unengaged. I suspected he might be depressed about his arthritis and near blindness. We agreed to have a follow-up to go over the test results.

The only remarkable thing about his results was a borderline low thyroid function, which usually doesn’t cause any symptoms at that level.

As it happened, Bibi had her own appointment with one of my colleagues at the same time as Dwight came back to go over his test results.

After greeting him, I started:

“Well, Dwight, all your blood work looks fine…”

“I was sure it would”, he interrupted. “Listen, Doc, I know why I’m tired”, he said with a tone of frustration in his voice.

“I love Bibi, but she’s not like you or me”, he began whispering. “From the crack of dawn till way past anybody’s normal bedtime, we have to work. In the spring and summer it’s the gardens. We grow more vegetables than we could possibly eat. In the fall it’s the raking and the firewood. We are three years ahead on wood now. In the winter we dust and reorganize all her books and knickknacks. We never relax; we never sit down and talk. She always has to be busy. She’s wearing me out, Doc!”

He raised his arms in a gesture of exasperation.

“Help me, Doc!”

Just then, there was a knock on the exam room door. Autumn, my nurse, peeked in and said:

“I’ve got Bibi here, are you ready for her to join you?”

I glanced at Dwight. His eyes sank to the floor as he nodded.

“So, how is my boy?” Bibi said as she sat down next to Dwight while I quickly gathered my thoughts.

“Well, it’s nothing serious”, I said, “but Dwight has subclinical hypothyroidism, which is due to an autoimmune process in the thyroid. Some people get quite tired with that, more than you might expect from the thyroid numbers alone. Coupled with his arthritis, I expect Dwight to be more tired both physically and mentally than he was a few years ago.”

Both Bibi and Dwight had their eyes on me as I came to my concluding statement:

“I think with more rest built into his day, he should be good for many more years.”

As we said good-bye, his knotted hand squeezed mine quite hard for a person with arthritis.

Gwen and Dan Olsen were a handsome couple with a stunning blonde eight-year-old daughter, Trina. They had just moved to the town where I did my residency and over the course of their first six months there I saw all three of them for routine health care needs.

One day Gwen came in for nausea. She didn’t look well and I could see in her facial expression that something was dreadfully wrong. Thinking unplanned pregnancy and morning sickness, I glanced at her problem list, where her husband’s vasectomy was listed, in my own handwriting, as her method of contraception.

“I’m pregnant”, she burst out, tears suddenly streaming down her cheeks. I sat quietly for a while. She didn’t say anything.

“Dan had a …”, I started.

“He’s not the father”, Gwen said.

Wiping her tears she described how she had gone back to her parents for a visit, run into an old boyfriend and found herself doing the unthinkable.

“Does Dan know?” I asked.

She nodded.

“What do you want to do?” I didn’t say the A-word, but she understood.

“We’ve talked it over and we’re going through with the pregnancy as if it were Dan’s baby”, she began. “He’s promised me he will love us both just as much as if he were the father. We’ll just tell people the vasectomy must have failed.”

“Those things happen”, I said.

“Will you be my doctor for the pregnancy?” she asked.

“Of course”, I nodded.

“And please don’t put anything in my medical record about it not being Dan’s.”

“Of course”, I reassured her.

That fall I delivered a beautiful baby boy to two of the nicest, proudest parents I know. I was able to see him, his parents and his sister through two years of well baby visits, shots and minor childhood illnesses during the last two years of my residency.

Several years later I happened to run into the four Olsens again. Little Brad looked just like his mother.

Today I read in a journal that a large percentage of patients won’t tell their doctor sensitive information if they believe their information might be shared electronically with other doctors, hospitals or insurance companies.

Some things are better left off the record.

Two encounters today made me pause and reflect about what we really are doing to our patients and to the health care system.

The first one was a pharmaceutical representative in the clinic hallway. He tried to engage me in a conversation about the latest medication for overactive bladder.

“How much does it cost?” I asked innocently.

“It’s covered by most insurance companies”, he replied.

“I don’t care, I’d like to know what it costs”, I insisted.

“I don’t know”, he said.

“Even medications that are covered by insurance have a cost to somebody. In the end we all pay for medications. I never prescribe anything without knowing roughly what it costs, because I have a responsibility to my patients and to the system to know that and keep it in mind when I choose a medication.” I surprised myself a little with the emphatic tone in my voice. After all, didn’t I leave Sweden twenty-nine years ago because of being fed up with socialized medicine?

“I’ll have that information next time”, he said meekly.

“Never mind, I’ll get it online”, I said. One minute later, as he was packing up his laptop and his handouts I saw him again as I passed down the hall on my way to the next patient.

“$139 a month”, I told him.

“Oh”, he said sheepishly.

The second encounter  was a new patient visit. Mrs. Schmidt had just moved here from downstate to be closer to her daughter. A stylish woman in her mid-seventies, she had a fairly straightforward history and medication list. The only unusual thing I noted was that she was taking a combined estrogen-progesterone pill at her age. 

“What is the reason for your hormone treatment?” I asked. “Did you have trouble with hot flashes?”

“No, my doctor thought it would be good for my heart and my cholesterol”, she answered.

“Well, that was the thinking, but we now know that hormone replacement therapy can increase a woman’s risk for breast cancer, and doesn’t protect women from heart disease. It actually seems to increase the risk of strokes and heart attacks”, I said, not sure how she would take my disagreeing with her previous doctor.

“Well, then I’m happy to stop it”, she said. “I’m only taking half of a tablet anyway. 

“Great, one less medicine”, I concluded. I made a mental note of the fact that her doctor had continued to refill this prescription for seven years, even after the Women’s Health Initiative study found that such hormone treatment did the opposite of what the medical establishment had believed.

Postmenopausal hormone treatment has been around for fifty years, and many people saw estrogen as a wonder drug that promised prolonged youth and vitality. It is very humbling that it took half a century, longer than the careers of most physicians, to find the truth.

I often wonder which of today’s wonder drugs will ultimately be proven not only useless but actually harmful. There are a few I worry about.

Doris Delaney came from the next town. She had just turned sixty and she was worried. For two years she had suffered from chest pain after hard physical work and for the past month her attacks had been a little more frequent.

Her father had died from a heart attack at age 47. Her two brothers had bypass operations before age fifty. Her blood pressure was higher than ideal, even on medication. I flipped through the medical records that had come over on the fax machine and saw that her last LDL cholesterol, on medication, was too high for a high-risk patient.

“I looked on the Internet and I talked to my sister, who is a nurse in Houston. I think I’ve got angina and I’m worried I’ve got a blockage in one of my coronary arteries”, she said in her thick Texas accent.

I found a two-year-old stress test among the faxed pages and mumbled “I see you had a stress test a while back”.

“Yes, and the lady doctor who gave me the stress test told me to go home and take it really easy until I saw my Family Doctor, but he said the test came out okay”, she explained.

The first page of the stress test report was the interpretation of the Sestamibi®, or nuclear scan, where a radioactive tracer injected into the bloodstream shows how evenly the blood is distributed between various parts of the heart muscle at rest and with exercise. “Probably normal” was the conclusion rendered by the offsite cardiologist who interpreted the images. 

The second page was the report of what the physician saw when Doris did her treadmill exercise test. It said she had chest pain for several minutes at the end of the test and changes on her electro­cardiogram that were fairly typical for ischemia, decreased blood flow to the heart muscle.

“I know what happened”, I told her.

“A hundred years ago we would diagnose somebody with heart disease by listening to their story. Someone with your symptoms was said to have angina pectoris”, I explained.

“When I was in medical school we did EKG stress tests, and they were pretty good at identifying patients with partially blocked arteries. The EKG waveform changes when the heart muscle is stressed, because electricity travels differently through it.

The modern nuclear scan measures something a little different, not whether the muscle is feeling the lack of blood flow but how much blood we see in the picture going to each part of the heart. We think the nuclear test is more sensitive than the EKG, but I don’t know that it always is.

In your case you have symptoms that are very suspicious for having blocked arteries, and one part of your stress test was abnormal. Now you are having chest pain more often, and I want you to see a cardiologist as soon as possible. I think they will want to do a catheterization to look at your coronary arteries.

Today I need to give you a prescription for nitroglycerin, change your cholesterol medication and start you on one more blood pressure medication. These three things can make a difference right away.”

I had her wait in the room for a few minutes while I called the cardiology office at Cityside Hospital and spoke with Dr. Bronwen Wilkes about getting a fast-track consultation. It’s all set; her appointment is Monday.