A Country Doctor Writes:

On April 28, 2008 I hit the “Publish” button for the first time on “A Country Doctor Writes”. That post, “Cholesterol Guidelines and the Bachelor With Platform Shoes” is featured in the sidebar (or below, reading on a smartphone).

In the twelve years since then I have hit the Publish button 654 more times. Thinking back over all those words and the years that have passed, I especially value my clinical vignettes and glimpses into other people’s way of dealing with their illnesses and circumstances. I also notice how much I have written about what it means to be a physician and how I have evolved in my profession over the last 40 years (41 this summer).

As medicine has changed, I have also seen physicians change. I have seen distractions from our old focus of patients and their diseases multiply, and I have seen more and more burnout and disillusionment around me.

I have worked on my own feelings and attitudes because of the distractions in my own life. I love medicine and I have felt that this was my purpose in life since I was a very young child. When I don’t take time to reconnect with this sense of purpose I can feel my mental focus dragging my emotions away from the profound joy and satisfaction doctoring usually brings me.

For my twelve year anniversary, I decided to gather a sampling of pieces that illustrate the many aspects of doctoring I keep thinking about: The Fixer, The Hippocratic Apostle and The Guide through Life and Death.

Rather than reposting the pieces in their entirety, I decided to include a good size quote and a link to the original post, hoping this will give the essence of my observations without having to read too many words, for those with other things to spend their time on.

(Each title is a link to the original post)

Doctor Fix-It (2008)

Today I visited Ginny Leach. She lives by herself in an old trailer not far from our house. She is an ageless more or less shut-in woman.

A mild chaos erupted the moment I walked through Ginny’s front door. She was on the phone with her sister; I think they must call each other at least three times a day. Her only other contact seems to be the nuns from a nearby order; they help her out with chores and hand-me-downs. As I walked through the door, Ginny gestured to me, stretched the phone cord, and somehow her Slimline telephone fell to the floor and went dead on her. Ginny worried that her sister would assume something bad had happened.

Before I knew it, I was on my knees on the floor, examining the jack and the telephone…

The Apostolic Nature of Our Profession (2009)

I twice had a priest for a patient and I have been the personal physician of a handful of protestant ministers of various denominations. In each of these doctor-patient relationships I have found myself entering a ministerial role vis-à-vis my pastoral patient.

I have had reason to temper the hypochondriachal tendencies of one man of the cloth, and I have cautioned another that taking care of one’s body is a form of stewardship, and as such, just as important as taking care of one’s spiritual health. I have urged a minister to quit smoking and a priest to temper his sweet tooth.

Each time I have done one of those things I have been reminded of the apostolic nature of both our professions. People come to each of us, clergy or physician, with hearts and minds that are at least to some degree more open to hear what we have to say because of the office we hold, the cloaks we wear, that make our words somehow carry more weight than those of friends, relatives or family members.

Thank You, Father (2009)

I checked his heart and lungs without finding anything unusual, and then Mrs. McCann proceeded to expertly change his dressings, so I could inspect his diabetic ulcers.

“They’re coming along great”, I said, and added, “You are doing a superb job”.

“I do my best”, she answered, beaming.

I wrote some new prescriptions and we agreed on the timing of my next house call. She followed me to the door.

“Thank you, Father”, she said, and then quickly corrected herself.

“I mean, thank you, Doctor. Father Harris was here yesterday to see him.”

It struck me that Father Harris and I had come on similar errands, giving our blessing to the care and commitment we see in that house, neither one of us delivering much more than reassurance that the McCanns are doing their part and whatever happens next is in God’s hands.

The Counterintuitive Concept of Burnout Skills (2011)

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.” (Clair Burge)

The other night I suddenly realized I have always had the wrong perspective on how burnout occurs. It doesn’t happen to us, we bring it on ourselves.

One of our [reading] choices the other night was provocatively titled “Not Every Skill Is Profitable”. The subtitle was even more provocative: “In fact, some will just burn you out.” The writer referred to a South African blogger and businesswoman, Claire Burge, whose words in one instant changed my understanding of burnout:

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.”

I realize now that my strength as a tenacious problem-solver can be a burnout skill if I choose to take on problems that are ultimately unsolvable or go beyond my scope or authority as an employed primary care physician. When I can’t fix such problems, I feel frustrated and drained. My strengths as a diagnostician, communicator and motivator are my energizing skills. I need to use and cultivate them more in order not to risk burnout in my career.

A Samurai Physician’s Teachings (2013)

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference to archetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.

During the Ming dynasty, a prominent physician wrote:

“Premature death due to the hundred diseases is mostly connected to eating and drinking.” 

That quote still carries relevance today.

Something Extra (2016)

The pressures of time, the complexity of our patients’ needs and today’s documentation requirements can easily make a medical provider feel less than generous these days. We must counteract that in order to carry on as healers.

All day long, I am conscious of the time as I work my way through my long list of fifteen minute encounters. But I am also conscious of the fact that the more pressure I feel, the less empathic I can become, and the less effective I am in building and maintaining the relationships that lie at the root of my ability to care for my patients.

It is only because of those relationships that I am in any way able to tell a fellow human being what to do; it is that relationship that allows me to reassure someone in just a few words with only my demeanor and the tone in my voice.

I can only cover so many issues and help solve so many problems in fifteen minutes, and I have long been aware that some of those minutes need to be time spent nurturing the relationship that allows me to be my patient’s doctor, not just any doctor.

Be the Guide, Not the Hero (2018)

The dominating narratives present a flawed, insecure hero, who faces challenges while also reaching a higher level of insight, and he or she is supported by a guide who is older or wiser (Obi-Wan Kenobi or Yoda) but in no way competing with the fledging hero. These characters have been there, done that, and have nothing to prove. They are portrayed in ways that indicate they are supremely competent and yet almost self effacing. It is not their turn to shine.

That is a useful way for doctors to think of themselves. We must support our patients in their own pursuit of health and happiness. They must find out or choose for themselves. We can not make them do things that they don’t see or feel by themselves. And we have no right to expect that they will always follow our advice.

Our quality metrics can make us feel as if we are the main characters, or heroes in the story analogy, in our interactions with our patients. The results of our efforts can make us feel as if we are experiencing success or failure. This in turn can create job stress and burnout.

By adopting and staying in the role of Guide, physicians can preserve their stamina and enthusiasm for each and every patient encounter. We offer guidance, but every hero is free to choose whether or not to accept our words of wisdom.

Curiosity, Antidote to Burnout (2019)

I read an article on the BBC website that made me think again of my patient’s observation and how it fired up my curiosity. Titled “The secrets of the ‘high-potential’ personality”, it described curiosity as an antidote to burnout and one of several predictors of professional success that the authors claim to be better predictors than the Myers-Briggs Personality Types.

“Compared to our other mental traits, curiosity has been somewhat neglected by psychologists. Yet recent research shows that an inherent interest in new ideas brings many advantages to the workplace: it may mean that you are more creative and flexible in the procedures you use, help you to learn more easily, increases your overall job satisfaction and protects you from burnout.”

At the beginning of my day, my mind had been wandering back to New Year’s Eves away from the office, trudging through the snow in the Swedish countryside or dancing at Chateau Frontenac in Quebec.

As my workday ended, I wished my Suboxone group Happy New Year and thought about the literature search I wanted to do on my day off.

May I never lose my curiosity…

The Stages of a Man’s Life (2019)

Jungian psychologist Robert A. Johnson explains the difference between mood and feeling. Feeling is the ability to value and mood is being overtaken or possessed by a man’s inner feminine.

I am still working on reining in my tendency for moodiness on some levels, and I am working on letting go of my Americanized idea of “the pursuit of happiness”.

Johnson, as many other thinkers says that happiness is, linguistically and philosophically, living in the present, with “what happens”.

He references Alexis de Tocqueville:

“One cannot pursue happiness; if he does he obscures it. If he will proceed with the human task of life, the relocation of the center of gravity of the personality to something greater outside itself, happiness will be the outcome.”

Here I am, unpacking boxes, mending fences, cleaning stalls, reorganizing closets and cupboards; life is happening in a humble red farmhouse with peeling paint and a sagging front porch. It feels a lot like moving out to camp every summer when I was a young boy, before I started to think I had to be a knight and a dragon slayer…

To quote James Taylor, not for the first time:

“The secret of life is enjoying the passage of time. Any fool can do it. There ain’t nothing to it.”

Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.

When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.

The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.

The collection of requirements was called Meanaingful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.

For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.

I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:

Unbiased, Understanding, Unflappable, Unhurried

Like the software Meaningful Use items, these may be hard to attain, but especially in today’s healthcare environment, they seem worthy of striving for.

Unbiased: Able to fairly represent alternative approaches to allow patients to make up their own mind about their care.

Understanding: Able to listen to patients concerns and reflect back that you “get it” and will work to help address them.

Unflappable: Able to, in Osler’s words, maintain equanimity in the face of the challenges of medical practice.

Unhurried: Able to use time wisely, therapeutically, without frenzy, to make the most of the most valuable resource we all have.

Now, isn’t that more inspiring?

With the snow finally mostly gone here in northern Maine, I walked the perimeter of the horse pasture to inspect the fence this weekend. Down by the barn I felt warm in just my long sleeved shirt, but at the higher elevation there was a slight chill in the air. I quickened my steps and felt invigorated and inspired, thinking about my spring projects. It was my first walk in months, beyond just between the different outbuildings “down on the farm”.

Later that day, I came across a WSJ article about the health benefits and chemistry involved in this very basic but sometimes neglected human activity. It was an obvious reminder of how our bodies are made to do certain things, and how mostly sitting and hardly any walking isn’t good for us.

What we prob­a­bly don’t re­al­ize is that walk­ing can be a kind of a be­hav­ioral pre­ven­tive against de­pres­sion. It ben­e­fits us on many lev­els, phys­i­cal and psy­cho­log­i­cal. Walk­ing helps to pro­duce pro­tein mol­e­cules in mus­cle and brain that help re­pair wear and tear. These mus­cle and brain mol­e­cules—myokines and neu­rotrophic fac­tors, re­spec­tively—have been in­ten­sively stud­ied in re­cent years for their health ef­fects. We are dis­cov­er­ing that they act al­most as a kind of fer­til­izer that as­sists in the growth of cells and reg­u­la­tion of metabolism. They also re­duce cer­tain types of in­flam­ma­tion.

Ex­per­i­ments by the psy­chol­o­gists Mar­ily Opezzo and Daniel Schwartz of Stan­ford Uni­ver­sity have shown that walk­ing boosts cre­ativ­ity. They asked peo­ple to quickly come up with al­ter­na­tive uses for com­mon ob­jects, such as a pen. They found that peo­ple whom they got to walk be­fore com­ing up with al­ter­na­tive uses came up with al­most twice as many novel ideas as those who re­mained seated.

www.wsj.com/articles/why-walking-mattersnow-more-than-ever-11587182460

From other readings, I understand Aristotle did some of his best thinking and teaching while walking, and he founded the peripatetic school, which literally means walking around, in part because he was not a citizen of Athens and couldn’t own property there and instead used public places like the Lyceum for his teaching.

Other famous thinkers who practiced walking for creativity and inspiration are said to include Einstein, Asimov, Beethoven, Freud, Faulkner, Kafka, Hobbs, Descartes, Tolstoy, Hawthorne, Tchaikovsky, Darwin and Dickens, writes Rob Howard on Medium.

So, beyond the physical benefits of walking, we must not ignore its creative and spiritual benefits.

Over the last few weeks I have noticed that some of the worst worriers in my practice and many people with an emotional trauma history are actually becoming more focused on what they reasonably can and need to do during this pandemic and not spending much time thinking about seemingly far off what-if scenarios involving countless undefined other threats to our existence.

This reminds me of how I lost my fear of walking through the woods after dark going from my grandparents farm to our camp when I was a near-adolescent. One time I had a much younger and very frightened cousin with me and from that time on, I have felt no fear or anxiety myself on that walk.

Seeing the fear outside myself, I first somehow didn’t feel like I was alone with it and then, the more I saw it in my cousin, the less I felt it myself. I felt myself grew into the adult, protective role that was required of me to take on during that late evening walk.

Adrenaline flowing through our bodies can make us have a panic attack, but it can also give us the strength to lift a heavy object impinging a loved one or the courage to scare off a bear or mountain lion. Adrenaline needs a purpose, or it will paralyze us.

I wonder if other clinicians also have seen patients with a history of anxiety actually handling their condition better during this pandemic.

After my posts on telemedicine were published recently, (this one on Manly Wellness before the pandemic and this one after it erupted, on A Country Doctor Writes, then reblogged on The Healthcare Blog, KevinMD and many others), I have been asked about my views on telemedicine’s role in the future of primary care.

Things have changed quickly, and a bit chaotically, and there is a lot of experimentation happening right now in practices I work or speak with.

Before thinking about telemedicine in Primary Care, we need to agree on some sort of definition of primary care, because there are so many functions and services we lump together under that term.

Minor Illnesses

Many people think of primary care mostly as treating minor, episodic illnesses like colds, rashes, minor sprains and the like. This is an area that has attracted a lot of interest because it is easy money for the providers, since the visits tend to be quick and straightforward and such televisits are also attractive for the insurance companies if they can keep insured patients out of the emergency room. With the technical limitations of video quality and objective data such as heart rate and rhythm, I think this is an absolute growth area for telemedicine. However, with all the other forms but mostly here, fragmentation of care could become a complicated problem. To put it bluntly, if we still expect a medical professional or a health care organization to keep an eye on reports from various sources, such as hospital specialists, walk-in clinics or independent telemedicine providers, they are going to want to get paid for it.

Chronic Disease Management

In actuality, the bulk of the work we do in primary care is manage chronic diseases like diabetes, hypertension, heart disease, obesity, lipid problems, depression, fibromyalgia, asthma and COPD. Many of those conditions are well-suited for telemedicine, at least in between more in-depth periodic hands-on assessments, but a significant portion of patients who suffer from these chronic diseases either lack computer/Internet access or have difficulty using the technology. I still think this is a growth area for telemedicine and in the broadest sense this is really a science-based ”life coaching” in many cases. Here, a good data repository and continuity in the relationship between patient and provider are essential.

Referrals

Another function of primary care is making sure that patients who believe they need specialty care in fact do, and to facilitate appropriate referrals. So many people don’t know what specialty does what, and this division of labor varies even between counties within a state. A patient who needs allergy testing in northern Maine who asks for a referral could travel 200 miles to see an allergist or 20 to see an otolaryngologist who also does that. And where is a podiatrist a more appropriate referral than an orthopedic surgeon? Sometimes you need to physically examine the patient to know where to refer, but not always.

Public Health

Another area where telemedicine, in my opinion, has an obvious role is public health – one of my pet peeves as far as things that shouldn’t be the doctor’s responsibility. Once patients are set up for telemedicine, other people besides the medical providers can be involved: The practice can send health reminder messages via patient portals, provide screening and followups, patient education with nurses and other practice staff or even contracted off-site niche resources. Right now (here I go again…) primary care visits are bogged down with mandated public health issues that fit poorly in typical fifteen minute office visits.

Payment Reform – Don’t Revert

It is hard to imagine that we would return to the belief that in person visits will be the only way doctors deserve to get paid for what we do. I think the last several weeks have established in the public mind that medicine isn’t so different from other service industries that we shouldn’t use the available technology for the benefit and convenience of our customers.