A Country Doctor Writes:

You never knew me as a doctor. I was just a teenager when you were at the peak of your career. You would be 114 if you were alive today. But you represent something lasting, something archetypal, to me and to many of my colleagues – and also to patients who met you or heard about you.

You were passionate, caring, creative and daring.

Your were passionate about your calling as a doctor and about your principles. There was never any doubt about where you stood. Sometimes you had to process things, and many times your understanding and thinking evolved. But it was always a process grounded in your heart and soul, true to your nature.

You cared deeply for your patients. You often extended, gave of yourself, invested in them. They were not just clients or consumers of healthcare. They were your people.

Your creativity showed when you adopted new technologies to unique clinical scenarios, in your finding ways to reach closed minds or break through stalemates. Medicine was never cookbook in your practice, but an exploration of what you could do with whatever tools were available for you and your patients.

You were daring enough to speak up against injustice, closed mindedness, self pity or abuse. You took on hospital administrators and community leaders. You claimed and used the authority American physicians had in your day.

In some ways it seems being a doctor was easier in your era, but I’m not sure. Every age has its challenges. We have more treatments today to offer our patients. But I believe there is one tool we use much less than you did – ourselves.

You were fully engaged, fully invested. A doctor is what you were, who you were, through and through.

I don’t like to go to doctors, but if I had to, I’d want someone like you.

My wish is that I can be at least a little bit like you for the patients who choose me as their personal physician.

I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.

This is only today’s example of an interaction I didn’t have at my fingertips. I very often check Epocrates on my iPhone for interactions before prescribing, because – quite frankly – my EMR always gives me an entire screen of fine print idiotic kindergarten warnings nobody ever has time to read in a real clinical situation. (In my case provided by the otherwise decent makers of UpToDate.)

I keep coming back in my thoughts to, and blogging about, drug interactions. And every time I run into one that surprised me or caused harm, I think of the inherent, exponential risks of polypharmacy and the virtues of oligopharmacy.

One conclusion I have come to is that too often the benefit of our prescribed medication is actually too small to justify the drug. The way drugs are approved today is pretty much that they have to bring a 20% or so advantage over placebo for a certain outcome. Other than the drug versus placebo, all other factors are ignored or “controlled for”, which is easier said than done.

But this whole premise seems wrong to me: If pill A is 20% better than placebo at lowering blood pressure, but salt restriction, weight loss, exercise and stress reduction are twice as powerful as pill A, why are we so stuck on prescribing pill A? If a Mediterranean diet lowers cardiovascular risk as much as atorvastatin, why isn’t that a blockbuster/no-brainer intervention?

The health of our nation is not great, in spite of all the pills at our disposal. And the more pills we prescribe, the more we risk interactions: antidepressants and cholesterol pills with blood thinners, gout medicines with cholesterol pills, mood stabilizers with cardiac medications and on and on and on.

May we all take a step back and look at the big picture of what we are doing and where we are heading.

Donald W Light from the Harvard Center of Ethics wrote in 2014:

Few people know that new prescription drugs have a 1 in 5 chance of causing serious reactions after they have been approved. That is why expert physicians recommend not taking new drugs for at least five years unless patients have first tried better-established options, and have the need to do so.

Few know that systematic reviews of hospital charts found that even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients are given drugs that cause serious adverse reactions for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from drugs prescribed to them. This makes prescription drugs a major health risk, ranking 4th with stroke as a leading cause of death. The European Commission estimates that adverse reactions from prescription drugs cause 200,000 deaths; so together, about 328,000 patients in the U.S. and Europe die from prescription drugs each year. The FDA does not acknowledge these facts and instead gathers a small fraction of the cases.

There are obviously more recent statistics out there, but this piece struck me because it was published in a forum about ethics. Think about that for a moment: We are subjecting our patients to known and unknown risks of harm with every prescription we issue.

I’m a family doc. I do a little bit of everything. I’m good at psych. I often cure diabetes. I handle what comes my way with a few exceptions: I haven’t learned how to treat HIV or Hep C and I don’t feel comfortable about treating most cases of osteopenia and osteoporosis, because I’m still not convinced that something that happens to everybody at a predictable rate is a real disease.

I just posted about two Swedish psychiatrists who each developed a special interest in one disease. I’ll probably never make a name for myself through niche knowledge. I have, however, discovered a previously unclaimed clinical sign, which I would rather not be immortalized for: Multiple pinpoint underwear blood stains are usually caused by pediculosis pubis, “crabs”.

So, the only way I can get famous is probably by somehow connecting the dots between seemingly unrelated facets of medicine or life in general. I find this at least as intellectually stimulating as discovering something new.

One theme that has popped up many times in my writing is what doctors should be like: “Be the Guide, Not the Hero”, “Be the Doctor Each Patient Needs” (a little bit like a chameleon), “The Apostolic Nature of Our Profession” (part clergy and part disciple), “A Samurai Physician’s Teachings” (disciplined and simple), “If You Are a Doctor, Act Like One” (a role model), “I am Not InstaDoc, This is Not InstaMedicine” (a professional, not a robot), “If Not a Doctor, Then What?” (teacher) and the list could go on.

Here, I am shamelessly drawing attention to the second book in my A Country Doctor Writes series, IN PRACTICE – Starting, Growing and Staying in the Medical Profession.

Our role in medicine has changed dramatically since I graduated from medical school in 1979, partly by circumstance and partly by design. Patients’ views and expectations have evolved, the health care industry’s grip and control over us has tightened and our self image and career expectations have slipped. I never heard of physician burnout in the first decade of my career and now I hear or read that word every day, several times.

So, one of the purposes behind my writing is to “think out loud” about what it means to be a doctor, where this profession is headed and if that is what we want for ourselves. I love medicine and feel blessed to be practicing with passion and enthusiasm at my age. My hope is that I might help others see what I see in this role, in this profession, in this calling – not really as an “expert”, but more like a spokesperson.

The Swedish psychologist Erik Erikson’s 1950s theory on the stages of human development still informs mental health providers and physicians around the world. He distanced himself from Freud’s sexually focused theory and instead framed his development theory from a psychosocial viewpoint.

This month I have read about two Swedish psychiatrists in my morning paper, Dagens Nyheter: Stefan Krakowski and Peder Björling. Both work in clinics and both are pioneers in their own way.

Krakowski, is a researcher, columnist, author and senior psychiatrist with a background in general practice, occupational medicine and terrorism studies. He has deepened and championed our understanding of incels, involuntarily celibate young men who are sometimes linked to violence and hate crimes. He has applied his psychiatric expertise to in-depth interviews he conducted as an author and columnist. In his new book, INCEL, first published in Swedish and soon also available in English, he describes their tragic lives with tenderness and understanding.

Dagens Nyheter writes: Looking at right wing extremists or violent Islamists, they see themselves as a clear-sighted elite with an often grandiose view of themselves. This is not the case with incels. They see themselves as disadvantaged. The uniting factor is their rigid views of how women should be and behave.

The book is a description of what is called the male surplus, where men fall behind in education and in society; men who never had a partner, and who sometimes also don’t have any other natural social contact points. In the incel vernacular this is called NEET: Not in Education, Employment or Training. In a survey on an incel site, close to 70% say they view their being incels as permanent – that their loneliness will persist their entire lives.

Björling explains to Dagens Nyheter that narcissists are not simply selfish and evil, like sociopaths, but capable of empathy and emotions many people don’t give them credit for.

Like people who suffer from borderline personality disorder, the narcissist has difficulty managing relationships:

– But unlike people with borderline, who are preoccupied with the relationship to others, narcissists are more preoccupied with power and respect, with gaining recognition and praise, who is superior and inferior, respectively. They constantly have a need to emphasize and re-establish themselves, to be admired and respected, which gets in the way of their relationships. If the constant question for people with borderline is “are you still there for me?”, then the corresponding question for the narcissist is “do you respect me?”.

Narcissism is partly brought on by childhood experiences:

– If you throughout your upbringing suffered from a lack of trusting relationships, lack of feedback on yourself, if adults could not handle how you felt inside; for example, became stressed if you cried, it is not so strange that you have difficulty managing relationships as an adult. You find it difficult to understand and regulate your own feelings, you find it difficult to ask for help, get support from someone else or show yourself [as] weak.

Narcissists often seek power within a relationship but ultimately often strive to be viewed as good, loved or likable:

– If they feel at a disadvantage, are questioned, receive criticism from someone they feel dependent on and the self-image ends up in a state of shock, the narcissistic reaction is triggered. The closer the relationship is, the stronger the stress. The defense is then often to go to a powerful attack…

– At the same time, they may feel deep anxiety about being in a conflict, because the need to feel that “I am a good person” is so strong. The nightmare is that that bubble will burst. It can also be that they blame the other person for “You made me behave badly!”

It is estimated that 1% of the population suffers from narcissistic personality disorder, but many more have narcissistic features. Very few seek help for their narcissism but often present with depression, anxiety or psychosomatic problems like chronic pain.

Treatment trials at Björling’s clinic include work on self image, emotion regulation and impulsivity.

(Desperate times called for desperate measures.)

In the tech world, we have come to expect our devices to become outdated and obsolete very quickly. The biggest tech companies in the world didn’t even exist a few years ago. Bitcoin, a virtual currency which at least I can’t wrap my head around, seems to be more attractive than gold.

I get the sense most people embrace or at least accept the speed of change in tech.

But medical advances that occur rapidly are frightening to many people. Vaccine hesitancy, for example, involves concerns and characterizations like “unproven” and “guinea pigs”.

But can we as a society strive for and reward rapid progress in one area and reject it in another, especially if we feel threatened by outside forces or phenomena – be that a virus, climate change or the collapse of our economy’s infrastructure like supply chains and raw materials.

Tech has its own momentum, more driven by profit motives than altruistism or a desire just to make peoples lives better. Medicine clearly has profit as a driving force, but also a goal of improving life for people. Curing or mitigating disease must rank higher than making life more convenient.

But when a pandemic begins and its magnitude cannot be estimated, when the future of mankind and life on earth appear to be at stake – can we afford not to deploy the know-how and resources of medical science?

I am not an early adopter when it comes to drugs that claim to undo what people bring on themselves through their lifestyle choices. I’d rather nag them to do the non-drug things we know to be safe and effective. But facing a pandemic, what choice does mankind really have?

It seems easy now, a couple of years into the pandemic, to say that it isn’t as bad as it might have been. But we don’t know that for sure, we haven’t seen the end of it yet – the virus keeps mutating, in case anybody forgot.

You can’t stop innovation and we already live in a society where citizens are told to wear helmets, use seat belts, not drink and drive, not litter or pollute, not steal, rape or murder – and to get vaccinated before starting public school.

Freedom without concern for others is selfish. It breeds anarchy.