A Country Doctor Writes:

It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification

There are personal and executive coaches, wealth advisers, marketing experts, closet organizers and all kinds of people offering to help us run our lives.

In each of these fields, the expectation is that the provider of such services has his or her own “take” or perspective and offers advice that is individual, unique and as far removed from cookie cutter dogma as possible. Why pay for something generic that lots of people offer everywhere you turn?

So why is it, in this day of paying lip service to “personalized medicine”, genetic mapping, the human biome and psychoneuroimmunology that we expect our healthcare to be standardized and utterly predictable?

And why is it that we are so willing to fragment our care, using convenient care clinics, health apps, specialists who don’t communicate with each other and so on? Does anybody believe it makes sense to have your life coach tell you to have a latte if you feel like it because it makes you happy and your financial adviser scorn you for wasting money, never mind your health coach talking about all those unnecessary calories?

In today’s world, almost all knowledge and information is available, for free, instantly and from anywhere on the planet. But this has not eliminated our need for “experts”. It used to be that we paid experts for knowing the facts, but now we pay them for sorting and making sense of them, because there are too many facts and too much data out there to make anything self explanatory.

The information explosion of our era has brought with it an implosion and a near extinction of common sense.

The facts contradict each other:

Eggs are good for you and bad for you. Almost everybody should take aspirin and most people don’t need it. The bread of life is the bread of death. Low LDL is desirable, low LDL confers risk of disease.

I think there are way too many non-medical providers giving medical advice and way too few medical providers daring and taking the time to do it.

Our nation’s doctors are busily checking virtual boxes trying to randomly cover way too much ground instead of meeting their patients “where they are at”.

Kenny Lin, a fellow medical blogger, has a perfect name for his blog, “Common Sense Family Doctor”.

We don’t need more “Experts”. We need well trained, experienced professionals with common sense. Like Family Doctors.

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

Moving always involves pondering book titles as you pack and relocate your library. This weekend I did my last walk-in Saturday in Bucksport and back in Caribou sixteen hours after starting out I randomly opened a box that contained my prized Osler biography, signed by Cushing, and came across the 80-some page monograph “He” by Jungian psychologist Robert A. Johnson. I wrote about this book here six years ago.

I have a couple of copies of this little book and I keep coming back to it. First published in 1989, just before I started a four and a half year stint at Cutler Health Center at the University of Maine during my first exile from Bucksport, it describes the archetypical journey most men must undertake as they move through the stages of life, referencing literary names like the Fisher King, Parcifal, Don Quixote, Garamond, King Arthur and the knights around his table, the Holy Grail and the Grail Castle.

The essence of Johnson’s book is that males during adolescence have a profound (Holy) Grail experience, too powerful for them to remain in but then spend the bulk of their manhood hoping to find again. They finally learn that they were never that far from it; it is just a short way down the road and to the left, and this time, if they have learned their life lessons, they can enter the castle and remain there.

Central to the legend is that a simple man, a fool, needs to ask the simple question “whom does the Grail serve” in order for the wounded Fisher King to be healed. But Parsifal, who is such a person, heeded his mother’s advise “don’t ask too many questions” and missed his opportunity.

As I reread the book this time, a sunny Sunday morning over several mugs of coffee, I reflected on how much I have changed in the thirty years since I first read it.

One of the themes throughout the book, woven through the Grail legends, which exist in several cultures and languages, is man’s relationship to his inner feminine, one of the strong elements of Jungian psychology.

Johnson lists six basic relationships a man shares with the female world. All are useful, but they must not be confused with each other: His human mother, his mother complex, his mother archetype, his fair maiden (Jungian speak for inspiration), his flesh and blood wife or partner and Sofia, the goddess of wisdom.

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 reigning 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.”

(So much for “The Conversation”)

There are two versions of “The Conversation” we have with men: One is for teenage boys and it is about wet dreams, sexually transmitted disease, unwanted pregnancy and at one point also about testicular self-examinations. Those have now been edited out of the script, which makes sense to me since I have seen only three cases of that in forty years of practice, all but a couple of them diligently preaching that particular gospel.

The other one is with men of the age I now am, explaining, a few years ago, the benefits of blood tests (and, remember the rubber glove exam?) for prostate cancer screening and more lately the confusing intricacies of PSA blood tests.

For several years I’ve been spending a lot of time during physicals and wellness visits talking about the pros and cons of prostate cancer screening. I tell people you have to treat maybe 36 patients with prostate cancer to save one life. I tell patients that a recent long term study of men with early prostate cancer showed that 10 years into it only half of them had needed to do anything about the cancer. Still, many people want to be screened and I just encourage them not to panic if the result is abnormal.

A few weeks ago I got my first rejection of a Medicare PSA test for cancer screening purposes (ICD-10 diagnosis Z12.5, screening for prostate cancer).

My first, primitive, reaction was “here I have to spend all this time soft pedaling the news that PSA testing, which men (and doctors) were brainwashed into performing, is a general waste of time” and Medicare simply stops paying for it overnight without even telling me to save my breath.

Medicare will now only pay for PSA testing if you have the dribbles or something like that, not for screening for prostate cancer. On my iPhone I get notifications of all kinds of stupid things that don’t bother me a whole lot. Why couldn’t somebody tell me that Medicare no longer covers PSA for screening? Or maybe there’s an App or social network I’m not on?

Medical Quality is a fickle mistress, reminding me of the mythical Swedish “älva” (fairy), or is she just one of those random formations in the foggy mist I drove through on my way up from Bucksport to Caribou last night?

He did a double take as we passed on our small town sidewalk the other day.

“Hey Doc, I didn’t recognize you dressed like that, without your…”, he gestured to where my tie or stethoscope would have been. I was wearing a cafe-au-lait colored T-shirt and faded Levis.

“Did you hear about the appointment with the cardiologist yet”, I asked.

“It’s in two weeks”, he answered. “Tell me, Doc, how serious is this murmur?”

“Right now, not very, but you could end up needing a valve job some day, so you’ll need to have another echo done through your esophagus so they can get a better look at that noisy valve and then regular follow-ups”, noting silently to myself and I’ll never know how you make out now that I’m handing over your care to one of my partners.

He started thanking me for being his doctor for so many years, through so many illnesses, both life threatening final diagnoses and mere scares we had worked our way through.

Two years ago, almost to the day, I had a hunch that he might have a malignant kidney tumor, based on some nonspecific symptoms and an extremely elevated sedimentation rate.

In the end, he had something a bit less serious, and I was more relieved at him not having cancer than embarrassed about my inaccurate clinical hunch.

This time, he had been in for a routine checkup and as I listened to his heart I heard something new. He had a distinct early diastolic murmur. Soft systolic murmurs, between the first and second heart sound, are dime-a-dozen, but diastolic ones are fairly rare and his was fairly loud – what I ballparked as a 2-3/6 (more than a third of the maximum volume imaginable).

Systolic murmurs sound like Bipzzzt-Bip; diastolic ones sound like Bip-Bipzzzt. The diastolic murmur I knew the most about but haven’t diagnosed very often is mitral stenosis, usually caused by rheumatic fever. My patient had never had that as far as I knew and he had no symptoms of heart failure. I sent him for an echo and I got a call from the cardiologist who read it, praising me for my “excellent pick-up” of the murmur, which on the transthoracic echo indeed looked like at least a moderate if not severe mitral stenosis.

Being praised for my auscultation skills was nice, but I wasn’t pleased that my patient could be facing heart surgery in just a few years.

Early in our careers, doctors have a tendency to triumph over serious or rare diagnoses we make as we marvel over our newfound skills and the logical complexity of the human body.

At this stage of mine, I often feel sadness when a patient I care for, and care about, develops a symptom that signals the possibility of a serious disease.

If the diagnosis I think they might have is easily treatable with a good prognosis, I can triumph over my clinical hunches and diagnostic acumen. But if it is not, how can I feel proud about my skill at recognizing the distant footsteps of the grim reaper?