A Country Doctor Writes:

“I made myself a hypodermic injection of a triple dose of morphia and sank down on the couch in my consulting-room….I told her I was all right, all I wanted was twenty-four hours’ sleep, she was not to disturb me unless the house was on fire.”
– Axel Munthe, MD, The Story of San Michele (1929)

When people in this country mention the opioid epidemic, most of the time it is in the context of addiction with its ensuing criminality and social deprivation, and the focus is on opioids’ medical complications like withdrawal, overdose and death.

But that is only one of the opioid epidemics we have. Far greater is the epidemic of largely compliant patients who take their modest three or four daily doses of opiates for pain that was originally described as physical, but which in many cases is at least as much psychological – not imagined, in fact often quite severe, but nevertheless without a physical explanation or available cure.

Stimulation of opioid mu-receptors in the central nervous system induces euphoria more reliably than it reduces pain. In fact low dose opiates have been shown to sometimes lower pain thresholds but at the same time allowing dissociation from the pain experience.

People who smoked opium in antiquity didn’t all have intractable pain to begin with; many had miserable lives, just like many of my countrymen today with health problems, low income, poor education, lacking social supports and limited prospects for even a sustainable future in a job market they cannot even begin to qualify for.

Most physicians have or know of patients who have remained on the same moderate or low doses of opioids for many years and never failed a pill count or a urine test. They show no addictive behaviors, but without their prescriptions they function less well. We are still tapering most of them down or off their pain medications because that is what we do these days in response to the more famous opioid epidemic and in an effort to have fewer opioids, legal ones, that is, in circulation.

Ronald is a 57 year old patient of mine with a bad back, diabetic neuropathy and generalized anxiety disorder. He has been off his 5 mg oxycodone-acetaminophen (paracetamol) pills for two years now, takes pregabalin for his neuropathy and escitalopram for his anxiety with a low dose diazepam as needed. Since he came off his pain pills, his anxiety has been almost paralyzing. Social stressors, like a move to a different neighborhood, sent him into a frenzy. Then he fractured several ribs moving his washer and dryer up the icy front steps of his new home. The emergency room gave him just a couple of days worth of his old pain pills.

“It was amazing”, he explained to me, “I felt a warm wave travel through my body and it was like I was being hugged and everything felt all right, like I didn’t have a single thing to worry about in the whole world, even my nerve pain seemed like it didn’t bother me even though it was still there.”

Next, he asked if he could stay on them, “just three a day”.

I shook my head no.

He has his three other pills that don’t work as well. But at least they’re not opiates.

I still sometimes get messages from patients without known chronic illnesses who want “routine blood work” and “routine physicals”. This terrible set of medical myths just won’t go away. It is even getting promoted by well-meaning but misinformed employee wellness programs.

In spite of all the talk about evidence based medicine, patients and colleagues all around me are clinging to the antiquated misperception that disproven rituals like digital rectal and testicular exams, clinical and self administered breast exams, annual lipid profiles, PSA tests, EKGs and 20-item chemistry profiles have anything to do with good health and longevity.

A dozen years ago I started offering instead an “Annual Health Review”, a brief opportunity to talk about each patient’s individual risk factors, based on family history, personal metrics and lifestyle. I also did a symptom inventory or review of systems. But I did not check their sodium or vitamin D levels, their back molars or the lint between their toes.

That sounds a little like the new Medicare Annual Wellness Visit, but that one rigidly demands that every patient gets screened for exactly the same items (risking non-payment if a single thing is missed). The AWV is cluttered by more or less mandated silly, medically unproven items like baseline EKGs and visual acuity by means of the Norman Rockwell style eye chart (seniors need their intraocular pressures measured; even the DMV checks their acuity, at no extra cost).

The canned Routine Physical, no longer recommended by the US Public Health Service Taskforce on Prevention, is a relic from a bygone era. These days, when people can send out for their own personalized genetic profiles, their family doctors are stubbornly treating everyone according to the same yardsticks and protocols.

This costly ritual consumes more than half of the working hours of some doctors: Thirty minutes per patient times the “ideal” panel size of 1,500-2,000 patients amounts to 750-1,000 hours of a normal 2,000 hour year. Consequently we see our patients go to walk-in care or, worse, the emergency room when they get a cut, a headache, bronchitis or the flu, so we can keep doing all those physicals.

It’s just after six o’clock on a Sunday morning in December. The barn animals have fresh hay and warm water. My wife and the dogs are asleep. The cats are gathered around me as I sit down to write. One of them has jumped up in my lap and is pawing and clawing my jeans.

The fire is roaring in the wood stove but the 1790 room is still cold. I have read the morning news on my iPad. Our house is quiet, always; we don’t have a television or a radio. We have more time to think that way.

I do a lot of thinking these days, even though I put in long hours at work. During my commute to and from the clinic and during the long winter evenings I have plenty of time to think about my role as a doctor at this age, in this place and in these times.

I never wanted to do anything else, and I never want it to end. I cringe when I hear things like the commenter on my blog who wrote “I am sick of it and intend to retire as soon as I am able”. What a shame, what a waste. Kings, Presidents, Supreme Court Justices, Popes and Archbishops don’t usually retire “as soon as they are able”.

In some fields, age and wisdom are valued, especially the combination of the two. In many areas of medicine, at least in this country, doctors aren’t feeling valued at any age or skill level. Many feel like pawns or cogs in big, corporate schemes.

We have allowed ourselves to be devalued, and we as a profession have lost our clarity of vision, our sense of calling. Because of how unappreciated and squeezed we feel, we are at risk of losing our love for mankind, without which we will completely lose our professional purpose. We are thinking too much about production and quality metrics and losing sight of our apostolic and archetypal role in the lives of the patients we serve.

We are too distracted these days; we are practicing medicine with our minds, but not always with our hearts. We need to remember why we are in this profession and we need to stop feeling sorry for ourselves.

Victims of psychological domestic abuse undervalue themselves, overestimate the power of their tormentors and underestimate their own options. They stay in abusive situations sometimes because they don’t see clearly what is happening to them. They become physically isolated and feel shame, isolation and loneliness.

Professional burnout has many similarities with these facets of domestic abuse. But doctors are not really as tortured and trapped as abused spouses. Some of us just feel and act that way. We have one of the most meaningful jobs in the world. What a shame that so many of us want to get out of it while they are still able to do it.

Others have thought and written many wise words, not so often spoken today, about finding meaning in work:

“No man needs sympathy because he has to work, because he has a burden to carry. Far and away the best prize that life offers is the chance to work hard at work worth doing.”
― Theodore Roosevelt

“The purpose of life is not to be happy. It is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well.”
― Ralph Waldo Emerson

A small taste of these ideas is what I wish for those of my colleagues who are unhappy this Christmas.