A Country Doctor Writes:

It is the evening of Christmas Day. The day did not turn out the way I had planned. But I made it work. Those who follow me on Facebook know that I was one of the quarter million people in Maine who lost power Friday night.

Because I follow the weather, like most Mainers, I pulled my large, portable $1,300 generator out of my walk-in basement early Friday evening and connected it to the outlet outside. When, after several blips, the house finally turned dark, I just turned it on and manually switched from utility power to generator power for my little house and my Amish minibarn, infrared heater and all.

Christmas Eve, generator humming in the back yard, I fed the generator gasoline a few times, stashed more hay and water in the horse barn, made sure to replenish any water the horses drank, and went to town for a few extra groceries and to refill my gasoline tanks.

Some friends and neighbors didn’t fare as well as I did. Many don’t have generators. I could have installed a more permanent whole house germerator for $6,000 or more, but my portable unit runs everything electric on my little farm; I just have to fill’er up now and then. It is dual fuel, so maybe I’ll get a honking propane tank some day.

Feeling a little smug, I cherish the fact that for way under $2,000 I have what it takes to weather a storm like this without jeopardizing my horses or myself and my dogs. People around here spend much more than that on snowmobiles, ATVs and other toys. And then they freeze or have to check into a motel in situations like this one.

As Christmas Eve turned into night, it was obvious that I could not go to Bangor to celebrate Christmas Day with my children and grandchildren. I had to stay home with the animals and feed the generator. We were already planning for everyone to come up here for New Year’s so we will do another Christmas then.

Because I always think about Medicine, this incident made me again reflect on how, on the front lines, the practice of medicine is never predictable or straightforward. It is always full of surprises and obstacles that have to be creatively approached or circumvented. It always bothers me that the people who evaluate us have little or no understanding of the fact that primary care medicine is never predictable, that no two patients are ever the same, and the same patient may seem different on two different occasions.

Cookbooks are great learning tools, but show me a master chef who always follows a recipe.

I thought of watching a Christmas movie tonight, but I’m not yet feeling quite in the Christmas mood. Sitting by the fire, I instead decided to read from Pulitzer Prize winning Maine writer Richard Russo’s book, The Destiny Chief – Essays on Writing, Writers and Life.

In Getting Good, he writes:

Indeed, a good hint that you’ve entered the realm of art is that you immediately feel like giving up. You become overwhelmed by the astonishing complexity of the task, the sheer number of moving parts over which you have less – than – perfect control, the perversity of happenstance, the impossibility of predicting outcomes. In Life on the Mississippi, Twain describes learning to pilot a steamboat as an art because the river you steam up this week isn’t the same one you’ll navigate after a week of rains on your return trip. It’s still the Mississippi and eventually you’ll end up in New Orleans, not some unexpected city, but each trip is different because the river is. You have to know everything about it, know it without having to think, and be certain of your judgments, which will have to be made quickly on the basis of incomplete information, and at night you’ll have to do all this and more by feel. It would be nice if the river were a science because in the sciences there are controls, and if you’ve been careful your results can be replicated. What worked on Tuesday will work on Thursday, a claim that cannot always be made when what you hold in your hand is a paint brush or a camera or a pen. What was exactly right for your last painting will be completely wrong for this one. Creative people love to claim they know what works but in reality all they know is what worked. Fortunes are lost and hearts broken in that shift of tense.

Medicine, perhaps mostly in the muddy waters of primary care, is at least as much art as science. The number of variables is beyond at least today’s artificial intelligence to consider. Only a well educated and seasoned clinician has a fighting chance to do well by patients with messy histories, messy lives, multiple comorbidities and unclear genetic and epigenetic predictors of outcomes.

Once again, I find myself learning and borrowing from other disciplines as I muddle my way forward in the practice of primary care medicine.

Regular readers of this blog know that I have a sentimental streak in me. It often manifests itself at Christmas. As a Swede, I didn’t grow up with a Thanksgiving holiday, which is when many Americans take stock in where they are in life. For me, until I emigrated here in 1981, Christmas and the days leading up to New Year’s Eve was my week of introspection, reflection, gratitude and reorientation.

My most ambitious Christmas blog post was the 2011 one where I lifted phrases and sentences from the writings of Sir William Osler and created an imaginary Christmas letter to primary care doctors everywhere. I still like that one and it is getting views now, even without me promoting it.

My favorite one is probably the 2012 one harkening back to the Hebrew tradition of the Mezuzah, because it is about spaces being blessed and respected and about how we slow down for Holidays. Even though my circumstances have changed since I wrote it, I still cherish coming home to my little red farmhouse (lit up at sunset by timers in almost every room), where two horses and two Alabai dogs eagerly await me these darkest of days in northern Maine.

This year, as I have since I moved back to Caribou, alone, in 2019, I make a day trip to Bangor to celebrate Christmas Day with children and grandchildren. Then, for New Years, they join me in Caribou for Swedish Christmas food and Finnish fortune telling with molten soldering lead poured into ice cold water. The shape foretells your fortune for the coming year, a pre-Christian tradition.

One reflection I am making this Christmas season is the fact that next year I will be turning 70. I still remember when my father told me, on my fortieth birthday, that he couldn’t believe that he’d be turning 70 the following year. And I remember thinking to myself that he looked and acted like it.

I think people these days act younger than my parents generation. I am a lot more active physically than my dad was, and I’m a lot goofier, rolling around in the snow with my dogs and doing most things without power tools, taking myself a bit less seriously than men my age of the previous generation did.

My dad retired at 62, and here I am plugging along as I approach 70. I treasure every day of my life and I am looking forward to 2023.

In some ways, every year is a new beginning. For me, this year, it very much is.



A Christmas Message to All Physicians from Sir William Osler

Touching the Mezuzah

When I lived and worked in the Bucksport area, my best friend was the local veterinarian. Sometimes we talked about the difference between animal and human medicine. Animals can’t tell us how they feel, it’s up to us to read them and to know them.

I just had a situation with a horse that I am boarding, Emma‘s best friend. He stopped eating. Was it an early colic? Was it a tooth problem? Was it something orthopedic? Is it something passing or the beginning of a medical disaster?

Step number one, a dose of Banamine paste. This is a strong anti-inflammatory like a shot of Toradol for a human. Slight improvement, nothing dramatic. Phone call to the horse veterinarian: More anti-inflammatory drug, phenylbutazone, like a super ibuprofen. Maybe a little better, nibbled some hay. My thought as a physician playing vet: Maybe this is a primary G.I. problem? I have some leftover omeprazole in horse doses. I take 20 mg twice a day of the isomer esomeprazole, Nexium. The dose for a horse, that’s why they call it a horse dose, is 100 times as much. If nothing else you could protect him from G.I. side effect of his anti-inflammatory medicine.

Less than 24 hours later my guy is eating up a storm, fed him two suppers tonight.

Doctor playing vet.

This gruesome statistic speaks for itself. I love my adopted homeland, but there is a problem here. We have a problem that most countries on this planet don’t have.

Dustin had a history of seizures that were always mild and only happened at night. He took his medication faithfully. But a couple of months ago he had a bad one.

The emergency room workup showed that his phosphorous was critically low. They replenished it intravenously and his level normalized and stayed up.

My reading when I saw him in followup suggested that hypophosphatemia is sometimes transient without explanation, but sometimes related to vitamin D deficiency.

I prescribed vitamin D, which is something I rarely do because I’m very skeptical of D supplementation. I describe D levels as a lab test looking for a disease. Here in northern Maine all mental health professionals tell her patients to take vitamin D for seasonal affective disorder with no scientific backup.

So Dustin got his prescription for vitamin D and his phosphorus level stayed OK for a while but next thing I knew he was in the emergency room again with a seizure and a low phosphorus. I added a vitamin D level to the serum already in the lab and it had not budged at all.

I knew Dustin smoked a lot of weed and the emergency room pointed out the same thing. I realized that I should have been more aggressive with my dosing of his vitamin D but I just had a funny feeling that maybe there was a connection between marijuana use and low phosphorus.

I asked my esteemed colleague, Dr. Google. He instantly brought an article to my attention about a probable connection between marijuana use and low phosphorus.

So I cranked up Dustin’s vitamin D dose and gave him a printout of the article. “You might want to cut back on your marijuana use”, I suggested.

I guess I’m hedging my bets here between the low D and the high THC, and I’m open to other possibilities. The big message here, for what my CEO called a “late career physician”, is (and I’ve said it before): May I never lose my curiosity. (Although in the post below, it seemed like CBD oil did something good – always ask, always wonder, always question…)

Curiosity, Antidote to Burnout