A Country Doctor Writes:

The thought of writing about my experience as a doctor had been percolating for a couple of years before I started my blog and published my first post on April 28, 2008. I remember having a black notebook during our traditional New Year’s visit to Château Frontenac in Quebec. I was all dressed up in my tuxedo, waiting for the New Year’s dinner to begin and I finally hatched the title, A Country Doctor Writes. I didn’t know then if it was going to be a book or a blog or something else.

I didn’t get much more written in my little black book during that New Year’s holiday, and it took me almost a year and a half before I finally did it. I had some professional challenges that, in a way, made me think of my writing idea as a means to focus on the good and important aspects of being a doctor instead of some of the daily difficulties I had to navigate.

By November that year, I made the difficult decision to leave the practice where I had spent the bulk of my career up until that point. We ended up moving almost 200 miles north and I started over as a complete unknown at age 56. Talk of fodder for writing about being a doctor.

Up north, I quickly grew my practice and earned the trust of both patients and the medical community. Then, six years later, a new administrator in my old practice convinced me to return to my old position as medical director. But a divorce forced me to choose between going back to the job up north and the farm in Caribou, which was sitting there, empty and ready for horses, or to figure out how to start over “downstate” as we call the middle and southern parts of Maine.

Having worked in both parts of Maine as well as in Sweden, I have gathered more experiences than if I had stayed in one place. And it has made fictionalizing my clinical vignettes especially easy, beyond changing the names, ages and maybe even sexes in my case descriptions. Nobody knows where each particular patient was located. And now, so many years down the road, I don’t even remember for sure what the names were in all of the stories, which I have gathered since I graduated from medical school in 1979.

This summer, I will have been a doctor for 46 incredible years!

Every morning with my first big mug of coffee in bed with the dogs, I read the news on the BBC website, the New York Times, CNN and a Swedish compilation called Omni.

Over the years, I have written many blog posts inspired by medical news from the New York Times. Here is the latest article that really caught my attention, titled “Doctors told him he was going to die. Then AI saved his life”.

The article tells the story of how AI is now being used to scour old research papers for unexpected effects or side effects of medications that are now often both old and cheap, to indicate whether they may be worth trying for conditions beyond their original FDA approved indications.

The pharmaceutical companies are investing heavily in new treatments for common conditions, but not so much for rare conditions where the market is too small to ever recapture the cost of developing brand new drugs.

Here are a couple of quotes from the New York Times article:

In labs around the world, scientists are using A.I. to search among existing medicines for treatments that work for rare diseases. Drug repurposing, as it’s called, is not new, but the use of machine learning is speeding up the process — and could expand the treatment possibilities for people with rare diseases and few options.

Repurposing is fairly common in pharmaceuticals: Minoxidil, developed as a blood pressure medication, has been repurposed to treat hair loss. Viagra, originally marketed to treat a cardiac condition, is now used as an erectile dysfunction drug. Semaglutide, a diabetes drug, has become best known for its ability to help people lose weight.

https://acdw.substack.com/p/viagra-the-back-story

I put a hyperlink on the name Viagra to a video I made a while back about how that drug was discovered when there turned out to be a side effect of a new compound for pulmonary hypertension. I have also written about doxepin, a very old antidepressant that is possibly the most powerful antihistamine on the planet and a few other drugs with other uses. This kind of stuff fascinates me. I often say or write that drugs have personalities and if you really get to know them, you can almost predict where else they might be of use in our personal black bags of tricks. This is called “off label” use. It costs big money to go back to the FDA to get their approval for a new indication for a drug that is already or soon off patent and therefore inexpensive.

Doxepin, a Little Known Super Drug in My Personal Black Bag of Tricks

Other Super Drugs in My Personal Black Bag of Tricks

Beyond the Other Viagra: Curiosities in Off-Label Prescribing

I have never in my career seen tennis elbow in a tennis player. The proper name for this condition is lateral epicondylitis. There is also medial epicondylitis, nicknamed golfer’s elbow, and I haven’t seen that in a golfer either.

Still, it helps to have a folksy name for medical conditions when those names help people understand what it is or how it is caused.

In my case, I had it once before after a home improvement project. This time I’m pretty sure it was the combination of two thongs: First stall cleaning, putting manure, wet hay and shavings in the manure bucket with the pitchfork handle with my right hand and my left hand further down, making a backhand-like movement just like a tennis player. Second, I’ve been snow blowing. My Toro drives forward by itself but it doesn’t have a way to steer it except by holding on to the handle bars and making a twisting motion with my arms, pronation with one elbow and supination with the other, flirting with tennis elbow and golfer’s elbow on opposite arms.

Today, I also noticed for the first time that I have a swollen olecranon bursa on my left elbow, also sometimes called Popeye’s elbow or student’s elbow, supposedly caused by putting your flexed elbow on a desk or table too much. I didn’t think I did but I have it, a mild case where the fluid is not under pressure. No need for intervention. Same thing for my epicondylitis, take it a little easy for a while. I don’t dare to take ibuprofen with my acid reflux condition. Besides, I just don’t like to take pills…

Part of a Series

I happened to catch half an episode of a British show called Supersize vs Superskinny. In it, two people at opposite ends of the typical weight continuum swap diets for a period of time. Then, the heavier person gets to travel to the United States to visit someone even heavier than they are. The examples I saw were barely mobile because of their extreme obesity with other compounding, related complications like Charcot feet due to diabetes. After these emotional visits, the heavy British person returned with the determination to change their eating habits to avoid ending up like their new American acquaintances.

I wonder how much more money is poured into the development, production and marketing of the new obesity and diabetes drugs like Ozempic, Mounjaro and Wegovy compared to how much is spent on promotion of healthy eating habits. And, of course, also consider how much is spent on production and marketing of unhealthy foods in this country.

The path of least resistance for many Americans is to eat what is promoted, convenient and often less expensive than really healthy foods. It’s almost as if there exists a great conspiracy between the food industry and the pharmaceutical industry where one branch makes people sick and the other treats or counteracts the symptoms that are triggered by unhealthy types or quantities of food. And both are big, very big, businesses.

We don’t have a robust public health system in this country. The voices advocating reasonable portion sizes and healthful food choices are drowning in the barrage of marketing from the processed foods vendors.

Making healthy dietary and lifestyle choices is a true virtue in today’s America. It’s not like everybody is doing it, so you may feel like you are blazing your own path. It takes effort and requires both learning and discernment.

This dyad of “industries” where one is making people sick and the other is treating them is possibly an unstoppable symbiosis. But that doesn’t mean we can’t help those who really want to achieve better health naturally do so.

Here’s a piece I wrote in 2019:

“Let Food Be Thy Medicine and Medicine Be Thy Food”

From my Substack last summer

Walter Williams is a thin man with a mild demeanor. I met him in his home for a Medicare Wellness Visit. He was considering becoming a patient for primary care with us. He had a dramatic history of a couple of strokes with right sided paralysis lasting up to 24 hours without any remaining weakness. He also told me he had had several TIAs, transient ischemic attacks, between his strokes.

He lives in an area with minimal cell phone service and he has no internet in his home. He told me he’d had lots of CT scans that didn’t show anything. He didn’t think he’d had an MRI, but he was now scheduled for one because he had hearing loss in only one ear, which always makes you worry about an acoustic neuroma.

I asked him and his son to describe the spells to me. They always involved the right side of his body. The strokes involved the right side of his face as well as his right arm and leg and had lasted a day or more. The shorter spells usually involved only weakness of the right side of his face.

His neurological exam was normal except for numbness in his left 4th and 5th finger, which suggested that the ulnar release at the elbow he had several years ago had failed. He also had mild weakness in all the fingers of his left hand suggesting carpal tunnel syndrome.

“I’d like to get into the Maine Health InfoNet and look at all your hospitalizations, emergency room visits and x-rays you’ve had done. Then I’ll need to think about all this and come back to make a recommendation on what we should do next. Would that be all right with you”, I asked.

He agreed, and back home I pored over his big online dossier.

He had undergone two CT angiograms of the blood vessels in his neck and brain which were both normal. And two brain CTs were also normal. When his brain MRI then came in, it showed no acoustic neuroma and also no sign of a prior stroke.

It made no sense to me that someone could have several strokes with full recovery and TIAs with negative angiograms and brain MRI imaging. This had to be purely neurological and not vascular.

In my mind, this left only two options that could explain his symptoms, complicated migraine or some sort of seizures. I googled my question whether you could see paralysis during a seizure. The answer i found listed in my search was Todd paresis, something I had not heard of, but certainly matched his symptoms, multiple episodes of one-sided full or partial weakness lasting up to a few days and resolving completely on its own.

In follow-up I zeroed in on whether he’d experienced any kind of headache with his neurological episodes. He had , but not severe and only some of the time. As far as seizures went, most TIA and stroke-like episodes had occurred when he was alone, but his son had once or twice seen his father act a little spacey before the right sided facial weakness developed. He had certainly never had anything like a grand mal seizure. In my reading I saw that the seizure that precedes the paresis can sometimes be very subtle.

I explained my differential diagnosis to the two of them.

“The first time, when I was in the hospital in Boston, they put me on a seizure medicine, but I’m not sure why”, Walter said. “I took it for a few years but when my wife died and I moved up here, I stopped all my medications”.

“Why was that”, I asked.

“I went through a severe depression”, he answered.

“Did they do an EEG, where they put stickies and wires on your head, while you were in Massachusetts General”, I asked.

“No, I never had that done”, he answered.

I told him I’d like to order such a test and he agreed. It may be normal, and if so, I would probably still offer him a trial of seizure medications while we wait for a neurology consultation, which can take many months to get here in Maine.

I will also try to get the records from MGH to see if they made the diagnosis of Todd paresis on just the clinical history the way I am now considering, years later. A diagnosis made, lost and rediscovered?

(Why does this country have such fragmented medical records?)

This case was one of the first times I used my practice’s subscription to RubiconMD, a text based curbside consultation service with every imaginable specialty and subspecilty. Within less than an hour, I had my diagnosis confirmed and a solid treatment suggestion, the anti-seizure medicine Keppra (levetiracetam).

Curbside Consults by Subscription