A Country Doctor Writes:

Few things in primary care give patient and doctor mutual and instant gratification.

It’s been a while since I reduced a “nursemaids elbow” or a spontaneous shoulder dislocation other than my own, or a finger dislocation, but those all count.

I once wrote about curing deafness in a man with a movement disorder by flushing ear wax more or less on the run as he bobbed around the exam room. That was instantly rewarding and also both exhausting and exciting. Even more ordinary cases of cerumen impaction are rewarding to treat. I almost never let my medical assistants get the satisfaction, or the risk, associated with that procedure.

A few months ago a man came to my Saturday clinic with a plastic tip from his hearing aid lodged sideways deep inside his ear canal. With the help of my modern headlamp (I trained on the cartoonish forehead mirror ENT doctors used to sport) and a delicate long pair of forceps I was able to remove it and relieve the stranger’s suffering.

Often, I delight in asking a patient to make the shoulder movements that hurt them so much a few minutes earlier and now feeling no pain, confirming that my steroid-Xylocaine (Hurrah Sweden!) injection hit the right spot.

A few weeks ago I saw a patient for an unrelated problem, who had recently received a nerve block by a nurse practitioner to the minor occipital nerve. The patient had presented with severe pain on the side of her head and the shot gave instant relief. I had never heard of that injection, so I read up on it.

Wouldn’t you know it, the following week I saw a different woman with an excruciating pain on the left side of her head. The pain seemed to originate in the back of her head. She was tender on the scalp over her ear and even more so over the lesser occipital nerve. She agreed to an injection. It was instantly successful.

In medical school it was “see one, do one, teach one”. This time it was “read about it, then do it”. Now I’m ready to teach it, thanks to a clinician with fewer years of education, born well after I started medical school. I’ll happily learn from anyone who knows something I don’t.

A few weeks ago, I saw a patient with shortness of breath during my Saturday clinic. He had been short of breath for a few of weeks, and on a couple of occasions he had also experienced mild chest pain. He has known aortic stenosis, moderate according to his last echocardiogram two years ago.

My brain kicked into autopilot and I asked “have you fainted or passed out recently?” It was a flashback to medical school, where it seemed we were inundated with lists of threes.

For aortic stenosis, the triad of surgical indications for critical degrees was: Angina, synkope (remember I’m Swedish) and svikt, which is Swedish for failure, specifically congestive heart failure.

I’ve already written about a diagnosis right under my nose that I missed because the onset was so gradual: Dementia, urinary incontinence and gait disturbance, the diagnostic triad of normal pressure hydrocephalus.

A few months ago a crackerjack nurse practitioner came to me with the question: “What’s the syndrome with a droopy eyelid and a small pupil?”

“And a sunken-in eyeball?” I added.

“Yes!” She exclaimed.

“Horner’s Syndrome”, I proclaimed. “I still remember it from medical school and from a patient and my first Persian cat who both had sinus cancer.”

I don’t know why there are all these diagnostic triads out there, is it by some divine design or just because medical students can only retain short lists because of the multitude of diagnoses we have to memorize?

Where would we be without memorization? Sure, we could use computers to sift through endless lists of symptoms, most of which are red herrings, but there’s nothing quite as satisfying as knowing, in an instant, what the diagnosis is.

Wikipedia has a list of fifty clinical triads:

https://en.m.wikipedia.org/wiki/List_of_medical_triads_and_pentads

And, I almost forgot, last week I saw a patient with Reiter’s Syndrome, now called Reactive Arthritis: Persistent conjunctivitis, frequent urination and migrating arthritis that all began after a bout of severe diarrhea. She had already seen one other primary care clinician and her optometrist and both knew there was a bigger, overarching diagnosis behind her eye irritation. I was the one who nailed it.

One of the questions I was asked recently in an interview was something along the lines of could I say something about myself that few people know about.

The answer came to me fairly quickly.

After my military service, I applied to medical school. I had decided I wanted to go to Uppsala University. The Karolinska Institute was more famous, not the least because they pick the Nobel Prize winners in Medicine. But Uppsala is the second oldest university in the world, and the history behind it impressed me as the most classical medical education I could get.

In what now seems like a reckless thing to do, I only applied to Uppsala. It never occurred to me until after the deadline that it might have been wise to make a second and maybe even a third choice.

That fall semester I worked as a substitute teacher in my home town. I found myself one week in front of a room full of wide eyed second graders and the next facing one with bored and sullen fourteen year olds.

During those months I knew what I could do if Uppsala wouldn’t have me: I might become a teacher. I loved explaining things plainly and simply. I enjoyed presenting the hard to engage teenagers with an opening hook to gain their interest, or at least some degree of curiosity.

Today, again and again, day in and day out, I explain, challenge and engage patients in similar ways. As I often find myself pointing out, the word doctor is derived from “docere”, to teach.

So I got both jobs – a doctor, educated at the school of my choice, and a teacher for all ages, having to adapt my style and approach for a wide variety of patients, toddlers to centenarians.

It’s all the same, in a way. And I love it.

I chose doxycycline to treat Norman Starks Lyme disease. A week later he went to a walk-in clinic with sudden loss of hearing in his right ear. The PA who saw him suspected that the doxycycline had caused it and told him to stop the medication. Meanwhile, he needed at least one or two more weeks of antibiotics. He got amoxicillin.

When I saw Norman I asked what kind of exam they had done on him, he said “they just looked in my ears”.

“Did they do any kind of hearing test?” I asked.

He shook his head.

“Did they put a tuning fork on your head?”

“No”, he said quizzically.

I pulled my tuning fork from a plastic basket on the counter. I have one in every room.

“So how is your hearing now?” I asked.

“I think it’s a little better.”

“OK, tell me, if I put this tuning fork in the middle of your head like this, where do you hear it the loudest?”

Norman looked like he concentrated hard. He seemed confused.

“It’s louder in my right ear.”

“And which of these is louder, on the bone behind your ear or in the air in front of it?”

“Behind.”

I put the tuning fork away and sat down next to him.

“Your hearing is going to be fine. You can hurry it along by using some cortisone nose spray for a while. This is not nerve deafness, you’re just congested. And the doxycycline had nothing to do with it.”

I love low tech medicine.

And just the other day I saw a new diabetic who complained of blurry vision. After a split second of worry, I excused myself and got several sheets of dark paper, stapled them together and pierced a small hole in the center.

“Come with me, let’s check your vision”, I said.

We went down the hall and I asked him to look at the eye chart through the pinhole, one eye at a time.

“What’s the smallest line you can read?”

“D,E,F,P,O,T,E,C”, he read.

“Perfect. The lenses inside your eyes are just swollen from your high blood sugars. Hold off a little before seeing the eye doctor, and don’t order glasses until your blood sugars have settled down.”

Another early lesson all the way back from medical school.