A Country Doctor Writes:

Flanked by BE THE GUIDE, NOT THE HERO and IT PAYS TO PLAY DUMB SOMETIMES, most of the new chapters have titles starting with THE ART OF and appeared on A Country Doctor Writes after the publication of CONDITIONS and IN PRACTICE.

This small ebook with clinical vignettes reveals the inner workings of small town medical practice and the continual learning and exploration of a 40 year veteran who still loves practicing the Art of Medicine.

PREVIEW and buy on Amazon: https://www.amazon.com/dp/B095HT8LPP

Sometimes you learn about a disease just before you run into it for the first time. That has happened again and again in my career.

After I published my post about bot fly infections, a commenter asked if I had seen the larvae and suggested it might have been a case of Morgellons disease. I had never heard of that one, so I read up on it. Morgellons is a subtype of delusional parasitoses (DP), which can have many etiologies.

My own patient’s larvae were well documented by others and I think I saw them during our telemedicine visits.

A few days later I had reason to remember my impromptu research.

Gail is a woman in her forties with anxiety disorder and fibromyalgia. She came in with a concern about parasites under her skin and told me two of her girlfriends and her next door neighbor also had them.

Each one of them had seen several providers including the emergency room and basically had been told they might have scabies but probably didn’t. They had all tried and failed topical permethrin.

But Gail gave me a vivid description of all the teeny-tiny parasites she saw in the bottom of the tub after she bathed off the permethrin the morning after her treatment.

She also described, in excited and dramatic language, how scraping the skin where she saw a little black “thing” would make her suddenly itch or bleed some distance away. She used descriptions like “they get angry” and “they are clever”.

I looked and I looked. I took off my -10 diopter glasses and placed my eyeballs 4 inches from her skin, spotted with blemishes of different age and size. I saw nothing that looked like insects, burrows or bites.

I offered to do some skin scrapings. Gail was pleased. As I did it, I did see her unusually thin skin start bleeding very slightly half an inch away from my sampling here and there and she said, “see, they’re on the move”.

I submitted my sample and as I wait for the path report I am thinking about what to say next.

Here is what I have learned from UpToDate:

Delusional parasitosis can be associated with a host of psychiatric conditions but can also have its root cause in tingling sensations caused by medications, from ciprofloxacin to topiramate, amantadine, ketoconazole and many others. It can be related to diseases that cause paresthesias, from Lyme disease to restless leg syndrome (Ekbom’s disease, which can be linked to iron deficiency) to diabetes and many others.

Regarding Morgellons, which my commenter suggested, UpToDate writes:

Morgellons is a syndrome characterized by symptoms that appear to be identical to delusional infestation or very similar, but with the addition of the affected patient’s beliefs that inanimate objects (such as colored strings or fibers) were present in the lesion as well.

UpToDate and many other sites, including Wikipedia, point out that one (possibly increasing) common cause of delusional parasitosis, or formication, is methadone or cocaine abuse:

Some users also report formication: a feeling of a crawling sensation on the skin also known as “coke bugs“. These symptoms can last for weeks or, in some cases, months.

So now my question is: How do I tactfully explore if the cluster of cases in my community has anything to do with meth or coke when so many other things theoretically could cause these symptoms?

Words can be misleading. Medical terms work really well when shared between clinicians. But we can’t assume our patients speak the same language we do. If we “run with” whatever key words we pick up from our patient’s chief complaint, we can easily get lost chasing the wrong target.

Where I work, along the Canadian border, “Valley French” expressions tripped me up when I first arrived. The flu, or in French le flu (if that is how you spell it – I’ve never seen it in writing) is the word people use for diarrhea. Mal au cœur (heart pain) doesn’t mean angina or chest pain, but heartburn, a confusing expression in English, too.

But even if we are all English speaking, clinicians need to be careful not to assume common words mean the same to everyone.

I have seen many patients complain of anxiety, but not actually be worried about anything. A number of bipolar people have used the word anxiety when, in my personal vernacular, they are really describing pathological restlessness. I once had a patient complain of “nerves” but not have a worry in the world except for his hereditary essential tremor, which he assumed was a sign of untreated anxiety.

People often resist my labeling their symptom as chest pain, insisting that I am wrong about the location and the character of their discomfort. Instead, they might insist it is indigestion or prefer pressure, tightness or heaviness in their throat, epigastrium or even between their shoulder blades. “Chest pain is shorthand for all that”, I tell them.

I hear people use the word dizzy for a gnawing feeling in their epigastrium, and nauseous for a sense of early satiety after eating.

Even worse is when a patient attributes a symptom to the wrong organ or body part. It seems most people assume their kidneys to be much further down their back sides than they really are, so their “kidney pain” is really low back pain. This can be even more misleading if the patient claims to have a urinary infection and only when prompted for more history then says “because my kidneys hurt”, south of their anatomic location. Often this is entirely without urinary symptoms. Abdominal pain or pressure is also often self diagnosed as a UTI.

Most people want their hip joints to be where they might put their hands on their “hips”, the big body part in pear shaped people. I draw skeptical reactions when I tell them the hip joint is in the groin.

The other day I saw a 45 year old woman with a concern about burping incessantly for several weeks. She said she was hiding it the best she could. I asked her not to hide it, to “let it all out”. What I heard wasn’t burping, it was more of a hiccup. The workup and treatment is not the same, so it took me sitting with her for a while to know which way to go with her case.

We must avoid acting like bloodhounds in chasing the trail we are shown without taking in the surrounding territory. There may be something more obvious and important somewhere nearby.

The lesson I have learned is to use this three word question that should be a famous quote if it isn’t already:

“Tell me more!”

Today a patient told me a cancer doctor had told her husband that he only had a year to live. She was angry, because she felt that statement robbed her husband of hope and she knew well enough that doctors don’t always know a patient’s prognosis in such detail.

“Would you want to know if you only had a year to live”, she asked me.

I thought for a moment and then answered that I probably would want to know. I explained that I would want to make decisions and provisions because I live alone and am responsible for my animals. As I told her, I am well aware that if I dropped dead right now, things would be pretty chaotic for a while.

Two and a half years ago, I wrote a post titled Be the Doctor Each Patient Needs. In it I presumptuously coined the phrase I later put right on top of the sidebar of this blog:

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

I still believe we need to be incredibly sensitive to all the verbal and nonverbal clues our patients give us about what they need. In my 2018 post, I used the analogy of being like a chameleon. That’s not the same as being dishonest. It is a matter of knowing that your education and title give you an authority, an opportunity and an obligation to use your position of trust in your patient’s life to say things they need to hear in order to carry on or perhaps to take the first step in a new direction. We all wear the mantle of a superhero in a sense, and we can use this symbol for good. But that carries a responsibility to use our powers wisely.

We must strive to know our patients well enough to know what they need. Those things are seldom apparent from the medical record. They are subtle, subjective and often in some degree of flux through time and the course of life and disease.

The other day, a colleague who was scheduled to see a patient of mine I couldn’t accommodate in my schedule asked me if there was anything she should know before seeing this patient. What I did, in less than two minutes, was explain this person’s track record of resourcefulness, comprehension and follow-through.

Those qualities or capabilities in a patient must determine our behavior and care planning. I sometimes have a very full schedule because I think I know when I need to monitor each step in some patients’ treatment or they will get lost in terms of what to do and maybe even lost to followup entirely.

When I think about medicine being an art, I see the art in reading people and the art in applying basic treatment principles in an individualized way. This takes time to learn and hone, and it sometimes requires extra time in the patient encounter. My aim and my desire in practice is to automate and delegate the many mandated aspects of healthcare so I can focus on what only a treating physician can do: Pull together all the objective and subjective data, develop a treatment plan that makes sense for the patient and help them see the direction and steps needed to put that plan into action.

Another phrase I coined, perhaps equally presumptuous as the first one I quoted, and which I tried out on my boss a while ago (I can’t quite read the reaction I got) was “I’m an artist, not a bookkeeper”. I do believe that is what my patients need and are looking for.