A Country Doctor Writes:

I sometimes tell patients “I work for the government”, but sometimes I say the opposite, “I work for you”.

Herein lies a dichotomy that is eating away at primary care in this country, like a slow growing cancer. I suspect everybody is aware of it, but it seems nobody has the inclination to deal with it.

2020 exposed how differently Americans view and prioritize things like personal freedom and public safety. We have also seen how vastly different perceptions of reality suddenly exist about what constitutes medical facts. Alternative facts and fake news are suddenly household concepts.

For years, American healthcare has paid lip service to ethnic and cultural sensitivity, as long as minority opinions or practices don’t clash too badly with the holy cows of western society. We tolerate circumcision in men, but not genital mutilation in women, for example. But we don’t even pay lip service to the majority’s right to direct their own healthcare.

Some people want to be screened for everything and some don’t. How heavy-handed should the healthcare system or individual providers be? If you buy a car and never bring it in for routine maintenance, isn’t that your personal choice, your personal freedom? Why should healthcare be completely different?

In bread and butter primary care, we are squeezed every day between patients’ requests for healthcare and the American quasi-religious medical quality dogma. The possibly well-meaning principles were set forth by CMS, the Center for Medicare and Medicaid Services, and turned into business opportunities for private health insurers and the many middlemen of the healthcare industry.

We disagree on whether mask wearing decreases the spread of the coronavirus and whether, even if it does, you can legally mandate it.

Yet medical providers have been routinely measured and financially rewarded for things like recommending aspirin use in middle aged people until it turned out that was faulty science. We have been mandated to do all kinds of things that have nothing to do with why people come to see us, because Uncle Sam (in the broadest sense of America’s paternalistic healthcare system) knows best what people need.

A patient smokes, feels depressed, has an elevated blood pressure and hasn’t had a screening colonoscopy. They also have this gnawing pain in the belly that six months later will turn out to be an inoperable pancreatic cancer. I can get 4 quality brownie points for clicking EMR boxes for smoking cessation counseling, scoring degree of depression and suggesting a behavioral health referral, advising salt and alcohol restriction and arranging for a blood pressure followup as well as referring my patient for a screening colonoscopy.

But there are no quality parameters or incentives for paying attention to this patient’s main concern, “Chief Complaint”, for making an early and correct diagnosis and saving the patient’s life.

Medical providers are disincentivized from listening to their patients because the screening opportunities have become the dominating purpose of primary care in the eyes of those in power.

People with new symptoms may have long waits to see their primary care providers, who are overburdened with screening and housekeeping duties. Doctors went to medical school, residencies and fellowships to learn how to diagnose and treat disease. We were never selected for or trained for the bookkeeping duties that are becoming the bulk of our work.

So much of what we do could be done by others, even digitally and remotely. It’s a new year in a shaken-up healthcare system in a shaken-up nation. It’s time to think about what we really need doctors to do.

I’ve always had a sentimental streak in me. To the extent I make resolutions this time of year, they have tended to be about being a better human being, and never about changing health or work habits or aiming for specific achievements. I had plenty of those thoughts, but they never came up at New Year’s.

This year in particular, I think a lot about gratitude and abundance: gratitude for the wonderful life I have lived and the good fortune I have had, and abundance as a frame of mind—focusing on what is instead of what isn’t.

If the past few years have taught me anything, it is that you never know what to expect. People change, careers change, death and illness happen around us, close by and far away.

My world is smaller than it was in my middle age. I have fewer distractions and I spend more time thinking at the same time as I have ended up doing more manual labor, for lack of a better word.

My promise to myself this year is to live richly in the moment, treasuring every day for what it is and do a little less thinking and a little more feeling. As I look back over my life, I know I am missing some details but I have powerful recollections of my feelings: I remember vividly the way I felt when I held my infant children for the first time or saw my mother for the last time. I remember how I felt the first and the last time I left Sweden.

I promise myself to feel grateful for the abundant peace and beauty in my immediate surroundings and the unconditional love from my animals. I promise myself to never expect others to behave or treat me in any certain way, but to always feel good will toward them. I treasure the affection of my children and grandchildren, but I don’t demand it or think I always deserve it.

After the Nor’easter

I promise myself to cultivate grace in my day, in my home and in my heart. I promise myself never to be greedy, not for material riches, not for love or attention, and not for more days or years in this life than my fair measure.

Yes, I fulfilled my dream of being a country doctor, and yes, I am a published writer. Yes, I raised two children, and yes, I have been able to embrace two cultures.

Now, I have no bucket list, as some people call it. I am happy exactly where I am, with exactly what I am doing. I wouldn’t trade it for anything.

I promise myself not to wish for what isn’t. Because what is suits me perfectly. I have arrived exactly where I am supposed to be: I read about Maine’s Swedish Colony in a Stockholm newspaper 40 years ago, just when I was starting out in medicine. And here I am today, after several twists and turns that eventually brought me here, then away and then back here again.

A little over 6 months ago, I declared I would post very little on this blog and focus my writing on books and other platforms where I would not be tied to a self imposed editorial calendar.

As my regular readers soon noticed, I kept writing and posting here at well over half my regular rate. I did write some articles for other platforms and I did compile two books, but I came to understand how much I enjoy the immediacy of posting my work as soon as it is finished—waiting for an editor to accept and publish my work was much harder than I had anticipated. I still work that way to a degree, but I missed being able to share my writing in real time.

So, know that I have not ended up putting A Country Doctor Writes to rest, just know that I post when I have something to share. I know that my regular readers are quick to read my work because they subscribe via email or WordPress or follow me on LinkedIn, Facebook or Twitter.

I do enjoy the freedom of not promising myself a set number or frequency of postings. I had developed an all-or-nothing view of my blogging that wasn’t at all necessary. It’s a little bit like my dietary habits. Let me explain:

As a child, I was a picky and squeamish eater. I could eat meat as long as it wasn’t recognizable as an animal part, such as a chicken drumstick or a piece of steak with its obvious muscle texture. Approaching my teens, I didn’t want to be viewed as a picky eater, so I decided to call myself a vegetarian, but I eventually decided to simply eat what I wanted and not worry about how to explain or justify my preferences.

So here we are. I write when I have something to say. But when there is snow to shovel, animals to take care of or family matters that occupy my mind, I go silent without worrying. Nobody will suffer from my periodic radio silences and nobody will set their alarm clock according to my writing habits.

I was being a little obsessive-compulsive about the whole thing. And now I have gradually given myself permission to go with the flow—of life, of waxing and waning inspiration and inconsistent degrees of ambition.

But I have come to realize that having my own “platform” is a very liberating feeling. I was just being a little hard on myself in my view of what that platform should look like.

Three years ago, I wrote about the Dunning-Kruger effect, the phenomenon that makes beginners overestimate their abilities.

Fellow physician blogger Niran Al-Agba and Rebekah Bernard, MD are now on a crusade against Nurse Practitioners and Physician Assistants. They are implying that perhaps those professionals are more dangerous than doctors because of the Dunning-Kruger effect.

A beginner is a beginner, regardless of educational level, and even after years in practice there are strong clinicians and weak clinicians. I have seen Physician Assistants and Nurse Practitioners deliver better care than physicians.

The indisputable fact is that we have people with different educational levels delivering health care in this country. It gets us nowhere to argue an end to what used to be called midlevel practitioners. Instead, we need to face the facts that sometimes the wrong people are admitted to NP or PA school and once there, are often given the wrong messages during their training. And, possibly more important, sometimes the wrong staff category are placed in the wrong professional setting.

Diagnosing and treating common symptoms like abdominal pain, cough or headache are the hardest and most treacherous things we do in medicine. It takes more to do that than to do a routine physical, annual wellness visit or diabetes followup.

But what do many clinics do? They have their senior clinicians do the chronic care and their junior or less educated clinicians work the frontline triage functions.

I wrote about this six years ago in a two part essay titled It’s Time We Talk: Why Should Doctors Treat the Well and Nurses the Sick? (Part One and Part Two.)

There, I’ve said it again: Teach humility and put the right people in the right position in health care!

Near New Sweden, Maine – just like the old country…

Growing up in Sweden without a Thanksgiving holiday, Christmas has been a time for me to reflect on where I am and where I have been and New Year’s is when I look forward.

I have written different kinds of Christmas reflections before: sometimes in jest, asking Santa for a better EMR; sometimes filled with compassion for physicians or patients who struggle during the holidays. I have also borrowed original sentences from Osler’s writings to imagine how he would address physicians in the present time.

This year, with the pandemic changing both medicine and so many aspects of life in general, and with a gut wrenching political battle that threatens to erupt in anarchy or civil war within the next few weeks or months, my thoughts run deep toward the soul of medicine, the purpose of being a good doctor, even being a good human being.

We live in ideological silos, protected from dissenting opinions. News is not news if it is unpopular. Fake news and fake science are concepts that seemed marginal before but have now entered the mainstream.

As a physician, I serve whoever comes to see me to the best of my ability. But this year I have had to pay extra attention to the fact that so many people have already made up their minds about the nature and severity of the pandemic we are living with. If they don’t believe the country’s top experts, they are not likely to believe in me. Still, I try to gently state that we are still trying to figure this thing out and until we do, it’s better to be cautious.

I am starting to read about what some are now calling the Fourth Wave of the pandemic, the mental health crisis this winter may see in the wake of the physical illness we are surrounded by.

With this raging pandemic and the pandemonium it has created in our personal lives and the lives of those around us, we as doctors need to keep our priorities straight:

• A physician’s mission is to ease suffering.

• We save lives when we can.

• But sometimes, all we can do is help inevitable death happen with dignity and without unnecessary suffering.

• Because we have seen suffering and death in our work, our words of experience and our empathy can help others.

• We are all mental health workers in the eyes of our patients.

• We must work hard to the best of our abilities.

• But we cannot sacrifice our own health in the process.

• We must put our own oxygen mask on first, as during in-flight emergencies.

• We must accept that bad things happen in spite of our efforts.

• We must accept that in life, there is no light without darkness, no joy without sorrow, and no good without evil.

• We must recognize that we need to make every day count, because time, and life itself, is a finite resource.

Life is certainly messy, confusing and unpredictable. And while scientists and politicians may be using their brains for thinking of ways out of the situation the world is now in, the rest of us, doctors on the frontlines, are hunkering down in our shrunken worlds – reconnecting with the soulful, inconsistent underpinnings of who we really are but were perhaps too busy to really think about, recommitting to easing suffering, one patient at a time.

Remember Hippocrates: “Ars longa, vita brevis, occasio praeceps, experimentum periculosum, iudicium difficile” — “Life is short, the art is long, opportunity fleeting, experiment treacherous, judgment difficult.”