A Country Doctor Writes:

A couple of years ago I saw a young man with pain in his lower right abdomen. I sent him for an urgent CT scan with a “wet read” to check for appendicitis.

It was afternoon and things were crazy at the office. I forgot all about the pending CT report. I have learned this about myself: I am efficient because I have the ability to hyperfocus, but that has made me dependent on my support staff to see the big picture of my schedule or pending, unfinished tasks.

The next morning there was a fax from Cityside with a lengthy explanation saying he had an epiploic appendagitis, and it went on to explain that this is a harmless and self limited condition.

I did some reading. These appendages are little fat bumps that run along the outside of the colon. They can undergo torsion, or twisting, and become acutely inflamed. This condition is found in up to 7% of patients suspected of having appendicitis and 1% of patients with suspected diverticulitis.

I had never heard of appendagitis, and I wondered how certain the distinction was between this harmless and the other potentially lethal -itis was.

Checking with the patient, he was in more pain and more nauseous than the day before.

I suggested going to the ER just to make sure. I just didn’t feel comfortable trusting a CT and a diagnosis I had never heard of. I imagine this is a result of training before CT scans were in use and then not rubbing elbows enough with major surgery to be aware of the finer distinctions of the differential diagnosis in acute abdomens already too sick for the primary care office.

The ER report from Cityside was gracious in its description of why my young patient was there. He got an anti inflammatory medication and some pain pills and went home reassured. He was still uncomfortable when we called him a day later, but feeling better.

The other day I saw a young woman who had been to Mountainview Hospital for left lower quadrant abdominal pain.

She had a history of diverticulosis, and at her young age had already had a CT proven episode of acute diverticulitis a few years earlier. This time, the CT showed a sigmoid epiploic appendagitis with no evidence of diverticulitis. The ER doctor prescribed antibiotics that would have been appropriate if she had diverticulitis.

I saw her two days after the emergency room visit. She was feeling a bit better. Her exam was benign and I explained to her that she didn’t really need the antibiotic. But I also told her it was a rare condition that I had not heard of in my first 35 years of practice. I told her the Mountainview ER doc probably hadn’t seen a case before either, or didn’t trust the CT.

My patient was happy to stop her antibiotics and happy that her diverticular disease was not the cause of her symptoms.

You’re never too old to learn.

I guess I’m American enough, after spending ten more years here than in Sweden, to start to get a little philosophical at Thanksgiving. I spent my first Thanksgiving in this country not far from where the Pilgrims landed at Plymouth Rock, as an exchange student with a Jewish family, three houses down from an African American family in an otherwise white Anglo Saxon distant suburb of Boston.

I, too, was a pilgrim of sorts when I decided to move here. I was smitten by the sense of freedom and optimism in this country, and by the belief that hard work almost always paid off.

Because many of the specialists I started referring to when I first came to this area have now retired, I can vaguely picture the end of my own tenure, but I hope to have twenty more years in the profession that was my dream since age four.

I am thankful for the schooling I received and for the mentors that guided my progress through my early years of practice. I am thankful for the opportunity to knock on an exam room door twenty times a day and say “how can I help you today” to twenty fellow human beings. I am thankful that most of the time my advice is well received and I am humbled that so many patients have remained loyal to me for so many years.

I am thankful that I have been able to stay focused on the essence of doctoring and have had so few feelings of burnout after 38 years of being a physician.

I am thankful that I have always landed on my feet when life has seemed to trip me up. And I am thankful that I have so far been blessed with good health.

As I reflect on my own fortune, I can’t help but grieve over how many people I meet that don’t have the optimism, faith and enthusiasm I first encountered when I came to this country. My adopted homeland is a very different place from when I started my Senior year in 1971 and my Family Practice residency in 1981.

I don’t think it’s just because I’m older that I have to do a lot more life counseling with people who are losing their faith in their own future. And at the same time the health care system is squeezing the agenda of my patient visits with more and more demands that challenge my ability to really connect with my patients and help them carry on with their lives.

So, for the next twenty years or however long I have left, may I never lose my own faith in the power of the doctor-patient relationship or my gratitude for the opportunity I have been given to cure sometimes, treat often and comfort always.

The woman’s legs were so swollen that the indentation from my thumb squeeze was as deep as half my thumb. Her belly looked pregnant at sixty plus years but a recent ultrasound had shown no fluid and no change in size or texture of her already enlarged liver.

“There may be something else going on, I said. “Have you had any chest pain lately?”

“Well, yes, three weeks ago I had a pain here”, she said, pointing to her left upper chest. “It lasted three days, and I kept waking up and going back to sleep, hoping it would go away.”

“Has your breathing been worse since then?”

“Yes, but I thought it was because my belly got bigger.”

Her EKG showed q-waves in leads III and aVF, new since last winter, a sign of a possible old inferior myocardial infarction.

“It never occurred to me that it could have been a heart attack“, she said. “I should have known better.”

I have found that few people volunteer that they have had serious chest pain, so I ask at every visit with anybody who is at risk. Why is there so much denial about this?

“I didn’t want it to be my heart.” Her classic comment summarized my recurring observation.

I thought of a post I wrote four years ago, called Twenty Questions:

Adrian Bell didn’t look dehydrated, but his diarrhea had come and gone for a week and a half when I saw him a few weeks ago.

I saw a young woman the other day with severe and longstanding hidradenitis suppurativa. She knew very little about her disease. I logged in to UpToDate and printed out “The Basics”, a two page summary for patients, and the 18 page article for medical professionals. I showed her the pictures of what Hurley Stage II and III look like and we agreed she is probably a stage III. She had had one lesion lanced a few years ago and she had tried one topical agent. I suggested chlorhexidine, prescribed doxycycline and ordered a dermatology consultation to see if she is a candidate for more advanced medications and to help her learn more about her disease. I encouraged her to read the article and to ask the dermatologist lots of questions.

She seemed encouraged as we wrapped up our visit.

Back in my office, I clicked on the “Patient Education” icon and printed out the information that comes with every certified EMR. It was two thirds of a page long, in a large font with one and a half line spacing, and it said very little about her disease. I did what I often do – dropped it in the recycling box next to the printer.

Why print it if I was going to throw it away? Because we get Meaningful Use credit ONLY for patient education that is printed from the EMR. But since the handouts are so embarrassingly rudimentary, I click for credit and give my patients the real stuff from my personal UpToDate account.

This is how a lot of things work in today’s healthcare: Meeting some arbitrary requirement and then making sure the patients get what they really need.