A Country Doctor Writes:

I have one patient in each of my clinics with a long history of relentless abdominal pain, mild constipation, poor appetite and general malaise. Neither one has any abnormality on any of the testing I or my colleagues at the clinic or in the nearest hospital have done: An alphabet soup of blood tests, CT scans, ultrasounds, endoscopies, gastric emptying studies and I don’t know what.

Each one of these older gentlemen usually comes in looking pale and gaunt, saying “I just don’t feel good, Doc”.

Now, one of them seems to be cured, within three days of starting a new prescription, intended to treat something else.

Hector Dunn happened to come in with a COPD exacerbation within a couple of months of his last one. I prescribed the usual steroid, but, because it hadn’t been too long since he had taken the usual Bactrim, I put him on doxycycline.

When I saw him in followup, my medical assistant warned me: “You’re not going to believe this, but Hector looks and feels like a million bucks”.

I knocked on the door of his exam room and entered.

He jumped out of his seat, grinned and gave me a strong, firm handshake.

“I feel better than I’ve felt in years after that last prescription. My breathing got better right away, but my stomach feels great, I don’t hurt anywhere and I have all kinds of energy. I’d say I feel the best I have felt in twenty years.”

His wife nodded and chimed in:

“The day after he started the doxycycline, he got rid of all kinds of gas over about 48 hours, and then he was like a new man.”

I sat quietly and took in the scene before my eyes and, just like with the patient I once had hat developed Parkinson’s disease under my nose and was diagnosed and treated by someone else, I suddenly saw Hector move his face while he talked, shift forward in his chair, make gestures with his hands, arms and shoulders as he provided more vivid and extraneous details about his colonic gas elimination. I had never seen him that lively; before that, he had always carried himself as if any extra effort or movement might cause him to crump.

“Could that antibiotic have gotten rid of some intestinal infection he had been carrying for years”, his wife asked, astutely.

“Absolutely”, I answered. “It’s called SIBO, or Small Intestine Bacterial Overgrowth. While we are supposed to have billions of bacteria in our large intestine, the small intestine should not have bacteria in it. Sometimes it does, and that can cause anything from diarrhea to chronic abdominal pain and bloating, and I now have to admit that may have been what Mr. Dunn has had for a long time now. There’s no handy test for it so sometimes we just guess and treat, but it had not occurred to me. Doxycycline isn’t the typical treatment for it, but it can work, and doxycycline also has some antiinflammatory properties, and SIBO may have elements of inflammation linked to it.”

“I don’t know what any of that really means, but I do know I feel good”, Hector concluded, rose from his chair and patted me on the shoulder. He seemed eager to get out of there, unlike other times when I was probably the one who wanted the visit to end because of my own helplessness.

“Now, I’ll need to hear if the belly pain comes back”, I said. If it does, we’ll have to decide if we’re going to use doxycycline again, or the stuff the books say might work even better. Let me know how you’re doing, okay?”

Later that day, I thought about my other patient, Percy Barr. What if he might respond to doxycycline, too? But he’s on warfarin, and there’s an interaction between those two drugs. I’d probably give him rifaximin. But he’s in Florida, as every other winter.

So in a twist of fate, I’m starting to look forward to him coming back, now that I have something different, new and promising to offer him.

Jeanette Brown had lost twenty pounds, and she was worried.

“I’m not trying”, she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:

A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.

That is exactly what happened to my mother some years ago, before she was diagnosed with the pancreatic cancer that took her life in less than two years.

Jeanette had a normal physical exam and all her bloodwork except for the sugar numbers was fine. Her review of systems was quite unremarkable as well, maybe a little fatigue.

“When people lose this much weight without trying, we usually do tests to rule out cancer, even if there’s no specific symptom to suggest that”, I explained. “In your case, being a former smoker, we need to check your lungs with a CT scan, and because of your Hepatitis C, even though your liver ultrasounds have been normal, we need a CT of your abdomen.”

I scrolled around in her chart. She was up to date on her mammogram and colonoscopy.

She was clearly worried.

“We’ll put in requests for the Prior Authorizations for these scans and let you know when they’re approved”, I said.

She looked puzzled.

“I have Martin’s Point Generations Advantage, that’s good insurance”, she said.

I sighed. “Well, it’s managed Medicare by a for profit company, like an HMO, and on the one hand they pay for physicals, unnecessary screening tests like carotid ultrasounds on people without bruits or symptoms, gym memberships and whatever, but on the other hand they don’t automatically pay for things like CT scans for weight loss.”

She looked incredulous.

“We’ll keep you posted”, I promised her.

Sure enough, a day or two later my referral coordinator came and told me:

I’ve just spent 45 minutes on the phone with these people and they’ve denied the CT scans.”

“Here we go again”, I answered her and thanked her.

I called Jeanette up and told her. “You’re due for your liver ultrasound pretty soon anyway, so we’ll do that, and we can get an x-ray of your lungs right here if we stress that you have a smoker’s cough. And, even though your thyroid test was normal six months ago, we can repeat that, plus I can run a test to make sure you’re still making your own insulin and not turning into a Type 1 diabetic.”

The chest film and extra bloodwork came back normal. But the liver ultrasound suggested a problem in the pancreas. A “pancreatic protocol CT” was suggested by the radiologist.

Martin’s Point approved the CT this time.

It showed calcifications in the pancreatic duct and an irregular appearance of the texture of the distal pancreas. Now the radiologist recommended an MRI evaluation of the pancreas and its ductwork.

Martin’s Point denied the MRI. After 45 minutes on the phone with my referral coordinator.

Medicare for all? That’s coming up a lot in the american health care debate these days.

Which kind, would be my question. The Lyndon Johnson kind or the Martin’s Point, Aetna, WellCare, Cigna, United Health kind?

I know the difference. I have a brand new red white and blue card in my own wallet.

And I’m probably breaking some obscure insurance gag rule right now. But this story happens every week in clinics like mine and it’s got to stop.

There is a lot of talk about team based care nowadays, and I have seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family.

But at the same time, there are so many decisions – judgement calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members.

I talk to patients all the time who ruminate, often at night, about the choices they made every day, and replay their conversations, reasoning and actions to the point of losing sleep and experiencing distresss.

I also know of a few clinicians who do the same thing.

I think there are a few fundamental tolerances clinicians must have:

One is tolerance of uncertainty. The other is a tolerance of being where the buck stops.

“Medicine is a science of uncertainty and an art of probability” is a famous quote by my hero, Sir William Osler, the “Father of Modern Medicine” and of bedside teaching.

This is a dichotomy: On one hand, the diagnostic possibilities in most cases are nearly endless, thus uncertainty, but at the same time, the major probabilities are usually pretty clear cut.

Our mission, should we chose to accept it (Mission: Impossible – in my case, the original series; I assume that quote is still relevant) is to embrace both the uncertainty and the need not to accept indecision.

In that moment, we are often alone.

The only way to balance these seemingly opposite notions is to acknowledge that no one can know for sure but the probability is…that is, being human and being fallible, but also possessing a certain amount of knowledge based confidence.

In my Swedish training, it was considered appropriate to consider and make a clinical decision based on “the odds”. In America, that isn’t always recognized. I agree you cannot completely skip over considering the probability of the esoteric, but how much weight do you give it?. If we don’t reign in the temptation to overestimate the odds of the esoteric, our health care will bankrupt us even faster than I imagined.

The kinds of decisions we usually need to make on our own are ones we have to live with and ones we cannot let ruin our sleep or our sanity:

Antibiotics or not? Hospital admission or not? Imaging or clinical diagnosis?

You do your best. It is all you can do. Without obsessing. Osler called that Aequanimity.