A Country Doctor Writes:

An Early and Late Career Collaboration

See Dr Lilian White’s post at

https://learningmedicine.substack.com/

I was trained in allopathic medicine, which is sometimes referred as Western medicine. The Greek word implies treatment with the opposite of what causes our patient’s suffering. It was coined by Samuel Hahnemann, the father of homeopathy. Homeopathy means treating like with like, giving very small doses of substances that in higher doses could cause the very symptoms our patient has.

There was intense competition between the two practice philosophies. At one point in the United States, the homeopaths seemed to have the upper hand. They even formed their American Institute of Homeopathy in 1844, three years before we got our American Medical Association off the ground.

Eventually, allopathic medicine became the leading practice in this country and homeopathy became sidelined. But here and there, homeopathic principles made their way into Western medicine. Robert Koch developed tuberculin in 1820, an extract of the TB bacillus, and tried it in hopes of curing TB, starting with very small doses. That ultimately didn’t work well enough, but tuberculin became a way to test for exposure to TB. Vaccines introduce miniscule doses of parts of viruses or weakened forms of viruses to prevent disease. Allergy shots are made with “homeopathic” doses of the very substances people are allergic to. And even in behavioral health and psychiatry, we widely practice desensitization for phobias. There, too, we use miniscule pictures of what a patient may be afraid of, starting with a picture of a stick figure of a very small dog far away, for example. So, none of us allopathically trained doctors can say that it is always wrong to treat, or at least prevent, disease or suffering according to the principle of treating like with like.

Another practice of medicine originated with Andrew Taylor Still in 1874. He called it osteopathic medicine. Trained as an MD, he looked for alternative ways to prevent and treat disease. He took Hippocrates view that all parts of the body are interconnected and viewed the musculoskeletal system as fundamental in that regard. Osteopathic means suffering of the bones. Physical manipulation of the musculoskeletal system is paired with an emphasis on prevention and wellness, which are an ever-increasing part of what allopathic physicians also practice. And as far as connection between body parts and their influence on each other, the P6 acupressure point near the wrist and its relation to nausea and vomiting is fairly well accepted, for example.

And, speaking of interconnectedness between body parts, we now have concepts like psychoneuroimmunology, PNI, “a discipline that has evolved in the last 40 years to study the relationship between immunity, the endocrine system, and the central and peripheral nervous systems”.

This brings me to the term “placebo effect”, which we use as a derogatory way of explaining why patients can appear to get better from therapies we don’t believe in. For example, homeopathy is probably only that according to many allopaths.

But, what if our bodies have a much greater ability to heal than we ever imagined, now that we even know some of the mechanisms behind that? What if a harmless homeopathic dose of a substance with a suggestive name can trigger a positive chain reaction of psychoneuroimmunological events in our bodies? Compare that with the nocebo effect of having to list all the possible side effects of the medicines that we allopaths prescribe – and many of them have very real risks. Ortega and others wrote in 2022:

The placebo effect can be defined as the improvement of symptoms in a patient after the administration of an innocuous substance in a context that induces expectations regarding its effects. During recent years, it has been discovered that the placebo response not only has neurobiological functions on analgesia, but that it is also capable of generating effects on the immune and endocrine systems. The possible integration of changes in different systems of the organism could favor the well-being of the individuals and go hand in hand with conventional treatment for multiple diseases. In this sense, classic conditioning and setting expectations stand out as psychological mechanisms implicated in the placebo effect. Recent advances in neuroimaging studies suggest a relationship between the placebo response and the opioid, cannabinoid, and monoaminergic systems. Likewise, a possible immune response conditioned by the placebo effect has been reported. There is evidence of immune suppression conditioned through the insular cortex and the amygdala, with noradrenalin as the responsible neurotransmitter.

So, I think we could borrow from other schools of thought in order to better help our patients. And I absolutely think the allopathic healthcare “system” has made it harder and harder for us to promote healing because of the bureaucratic and regulatory requirements it imposes on us. They make it harder for us to live up to one of my personal favorite concepts – when the doctor is the treatment.

When the Doctor is the Treatment

When the sun set this afternoon, it had been one of the shortest stretches of daylight hours in my life – since I moved to this country at age 28, that is. In Caribou, Maine we had about 8 1/2 hours of daylight today. In Uppsala, Sweden, today only had just under six hours of daylight. Sunrise there was at 8:50 am.

I was born at 2:30 in the afternoon on July 18 near Stockholm. That day the sun set around 9:45 pm – 7 hours and 15 minutes of daylight on a day I got a late start.

No wonder we Swedes burn a lot of candles in the winter. Our ancestors did, and they created rituals around them, from the four Advent candles to Saint Lucia with candles in her hair to lots of little live candles in the Christmas tree. That particular ritual now involves electric lights, thank goodness.

Between the darkness and the cold of winter, in Sweden and Maine both, everything seems a little harder to do. I remember when I had manual transmissions in my cars, it was sometimes very difficult to move the stick shift because of the viscosity of the transmission fluid in cold weather.

My own gear shifting is a little sluggish this time of year. I feel like winding down as it gets dark around four in the afternoon. I do get less done around the house and am more likely to just watch a show or movie on my big screen, listen to music, read or write in my library/media room.

I do think back over the year that has passed and think about the year to come. I do try to show up for my Suboxone patients extra meetings to help them get through the holidays. And I always put my thoughts down on this platform every year.

I have wrangled Sir William Osler’s words into a Christmas message for today’s frontline physicians, I have incorporated the Hebrew Mezuzah as a concept for myself and I have written about my shrinking world during the pandemic.

Since my divorce and my move back to Caribou almost five years ago, I have found new rhythms and new traditions for Christmas and New Years, but this year looks like it will be different because of the work schedules of everyone involved. A little bit like the pandemic, my world may seem smaller for a while. But there will be other times to get together as a large extended family.

This year I am making plans for some more ambitious home improvement projects I’ve been thinking about ever since I moved back to my little farm. I have to finish some remaining trim work in my library and more than one person has told me I should dust off my guitar (literally) and make music again.

I guess one conclusion here is that things don’t always turn out exactly as we have planned. That’s certainly no news to me. But that doesn’t mean we can’t do something enjoyable and meaningful no matter where we are, no matter who is missing in that particular moment and no matter what new things we might end up doing instead of what we did last year.

Quality in medicine is a moving target. I have reflected and written about this topic many times, perhaps most recently in March of this year. When I was medical Director in Bucksport, Maine, I did not allow the use of numeric pain scales for the simple reason that frame of mind influences perception, and even though opiates are often effective as anxiolytics and antidepressants, there are safer treatment options. It is ironic that it takes so long for medical evidence to be adopted into practice (17 years average), and then when it comes to quality metrics there is another delay on top of that. Well, anyway, I was just informed that pain assessments for Medicare patients’ quality scoring is about to be “retired“ with the beginning of the new year. Thank goodness.

Of course, we still need to deal with patients who have pain, but assessing pain is not straightforward, much less numeric. We need to understand the significance, the symbolism and the psychological components of what people view as pain. Narrative medicine, if you will.

Mandatory Pain Assessments Are Such a Pain

My power company, which stretches in a thin strip from northernmost Maine to the area around Bar Harbor, Maine, has 164,000 customers. This morning 30 minutes after my morning coffee brewed automatically, I lost power along with 68,000 other customers.. By 11 PM only 7300 customers are without power so they did a good job restoring the grid after a terrible overnight wind storm.

Both my little farm up here and the saltwater farm I bought near Bar Harbor have been plagued with power outages. Here I have the largest portable generator, you can buy and down there we invested in a standby automatic generator.

I woke up to darkness this morning thinking I need to get out there and get the generator going to get some coffee, but my coffee had already been made so I could relax and drink my 1st cup before starting the generator.

It keeps you humble to be subject to the elements because you’re living in the northern extremes or near the coastal weather systems.

Here is a post I wrote about loss of power in my very first year of blogging.

There was an interesting thread in the conversation during the weekly Suboxone clinic I participate in remotely as the prescribing doctor. The behavioral health team leads the group and I see patients individually in a Zoom “breakout room” via my iPhone on a little tripod/selfie stick from my kitchen table or my home office/library.

I usually have a chance to listen to at least some of the check-ins before my individual meetings start. Like many groups we start with a check-in and end up with takeaway and homework. I often catch the end of that part of the meeting after I see my patients. After the participants leave, the behavioralists and I go over how everyone is doing. We also touch on what themes came up in the conversation.

Being Dependent on Recovery came up this week. It is common to develop addictive behaviors toward something different when you are treated for opiate addiction. Some people gravitate toward drinking, for example. We also see food addiction and increased use of tobacco or marijuana.

The new concept was that the recovery work in itself can become such a strong focus that others may view it as a dependence, or even an addiction. This is not just a clever play with words. I think it is a natural tendency for some people to create principles and rituals that support, strengthen and sustain their recovery. Others may see that as too exaggerated or unnecessary, but gravitating toward another substitute for the opiates is certainly no healthier.

So the original concept from the group discussion, dependence on the recovery process, is fine with me. The way we use the words dependence and addiction are that people with a dependence function normally but could suffer in some fashion if they don’t have what they are dependent on. Not all dependence is bad. We all need oxygen, for example, and some people with bad lungs need supplemental oxygen. Addiction involves behaviors that ultimately harm the person who uses the substance or people around them. Being extra enthusiastic about your recovery doesn’t hurt anybody in my opinion – it could even be life saving.

This brings me back to something I published in 2008, a condition (because everything humans do seems to need a medical description or diagnosis) called orthorexia nervosa. This is where people adopt extremely healthy lifestyles. Their lives may be more complicated because of the high standards they set for themselves, but we are all on our own journey, so I say to each his own. Extra healthy habits that bring a person joy and not suffering (fretting about not measuring up) have my blessing.

Orthorexia Nervosa – Too Much of a Good Thing