A Country Doctor Writes:

The cognitive part of the practice of medicine spans between two extremes, from registering and recognizing the most minute nuances of human and biological expression to seeing the overarching big picture of complex constellations of details.

Like the arts of painting and photography, it requires us to see both the unique and the universal in the most ordinary manifestations of everyday human life. But instead of capturing with imaging tools what we see and perceive, we turn those impressions and observations into the understanding and interventions we call diagnosis and treatment.

The art of medicine involves both technical mastery of treatment and the carefully honed ability to register, analyze and evaluate a vast array of what we might call data. While there is still respect for masterful treatment, perhaps especially when it is of a technical or procedural nature, there is growing disdain and disrespect for what we used to call clinical judgement. In picking stocks, web design, marketing and many other human endeavors, experience seems to have retained or even expanded its value, but in medicine it is often downplayed or even ridiculed.

Non-physician healthcare thinkers have evangelically big hopes for “data”, entered into medical office computers by fallible, disillusioned (think “Meaningful Use”) and distracted humans and new generations of “connected” medical instruments, and analyzed by centralized computers at Medicare, research institutions or big insurance companies. The vision is that more data will unlock the hidden potential for economies of scale and unseen patterns of disease, and generate vastly improved accuracy and efficiency of diagnosis and treatment.

But more data doesn’t always lead to better insights. Borrowing from other arts, a well-written poem can sometimes convey to the reader as much as a novel. And the weight of each piece of “data” isn’t the same to an experienced physician as it is to a computer. Humans in the healing arts can do the work of a recording device, a lie detector, a microprocessor, a translator, a judge, a pastor and a teacher.

In real therapeutic encounters, the agenda is not always the stated one, the given history isn’t always accurate and the clinical exam isn’t always typical or even relevant; sometimes the physician gives more weight to the unspoken clues in a case, something a computer isn’t likely to do.

Even our definition of disease lends itself poorly to interpretation and intervention guided by a computer. Examples are obesity, diabetes and chronic back pain. The measurable parameters of these conditions, biometrics, average laboratory values or pain rating scales, tell little about what role the disease plays in the patient’s life. And, unlike routine cases of pneumonia or step throat, sometimes the disease defines the person across a whole lifetime, and takes on archetypal meaning. Just talking numbers isn’t likely to change the manifestations of such conditions. Only going to the depths of the subconscious can alter the trajectory in most such cases. It would be naive to think that computers can do anything for such patients. Only a human with considerable skill and wisdom can penetrate the layers surrounding the core of these conditions.

The art of medicine is making the connections on a personal, case-by-case level with the archetypes that most of us relate to on some level, but which almost never exist in the physical realm. But they exist in the inner lives of all of us, as heroes and villains, as our inner children, older selves, and better or worse incarnations of our own spirits.

Classic disease presentations are like archetypes; we look for them all the time, and we think we see glimpses of them, but we seldom see the true personification of them.

And, the most important archetypes of all in the realm of medicine, the Patient and the Healer, hover in the air above us in every clinic room, hospital ward and nursing home. Patients enter the therapeutic encounter with ancient perceptions of what healers can or should do for them, and providers have visions of how patients should behave; we fill these roles for each other in the slowly evolving ritual we call healthcare.

It is probably terribly inefficient, but modern life generally is; we are not machines, but an ancient species with stone age reflexes in a postmodern society.

When a wife suddenly comes in for her husband’s appointment, I usually worry a little; when a husband shows up for his wife’s visit, I sometimes worry a lot.

I have come to expect that when I enter an exam room and a male patient has his wife with him in the room, she is there to make sure I hear some part of his symptom history that he has never told me before.

It may be vague chest pains after splitting wood, snoring and interrupted nighttime breathing, excruciating headaches or profound and worrisome memory lapses. Men can be minimizers when it comes to bodily symptoms, and women end up being the designated worriers in many families.

Sometimes, the wives talk about their husbands during their own appointments, and I can listen, but I can’t usually say much. Even if spouses have given me permission to share their medical information, the foundation of medical diagnosis and treatment is the exchange and relationship between doctor and patient.

Not infrequently, wives ask me to speak to their husbands about something without letting them know who put me up to it. That can be a difficult request to honor, but sometimes I know I am in a unique position to turn a bad situation around.

Concerns about things like problem drinking are easy to handle, as we are expected to screen for those sorts of things anyway. Less straightforward is the angry and irritable husband who himself denies any psychological symptoms when I screen him for depression in the office. Not long ago, such a husband admitted to insomnia and feeling some stress but denied that it affected his mood or behavior. I treated his insomnia with an antidepressant that is commonly used for insomnia, rather than a straight sleeping pill. He was pleased with how the medicine worked, and his wife was very grateful when she told me he wasn’t just sleeping better, but he also wasn’t tense or edgy anymore.

One request I get periodically is from wives of recently retired husbands to help get the men to stop following them around, questioning and offering helpful advice about everything the wife used to do without the husband’s interference all the years he was working. “Please tell him to get a hobby or something“, is a plea I have heard more than once. In that kind of situation I offer what sounds like generic advice I might give to anybody in that particular stage of life.

Two things about wives’ visits worry me.

The first thing is the wives who come in numerous times with multitudes of concerns. Usually the underlying problem is somatization and anxiety, which can often be very difficult conditions to make better, but sometimes the source of the psychosomatic symptoms or anxiety is a bad or abusive marriage that the patient may or may not be admitting, even to herself.

Sometimes the frequent return visits of wives, or in some cases mothers with children, are acts of self-protection in situations of domestic abuse. By going to the doctor’s office often, abused wives sometimes create a measure of relative safety by indirectly letting her husband know that there is someone who will notice if she is distraught from emotional abuse or if she has a bruise or any other visible sign of physical abuse.

The second worrisome type of wife visit is when the husband starts coming in. Unlike the wives who add to their husbands’ medical history, a lot of men who come in for their wives visits sit quietly and just listen. That raises the possibility that instead of being there out of concern for her health, he could be there to discourage her from revealing anything about a bad or abusive relationship.

Nobody wants to be paranoid, but as members of a healing profession, our mission is not only to prevent and treat disease, but also to prevent and relieve suffering when we have the opportunity to do so.

One in four women in this country will experience domestic abuse in her lifetime, which makes this a true epidemic, almost as prevalent as obesity. Are we physicians considering it in our differential diagnosis often enough?

Twenty years ago, I changed the name and focus of the “annual physical” I offered my patients. I designed a new form on my laptop with Geoworks, my favorite DOS-based (pre-Windows) desktop publishing program, and rolled out my “Annual Health Review”.

I explained to patients that many of the things we used to do in routine physicals every year had proven to be of little value, but there were more and more screening and preventive services we simply needed to talk about. It was also a time to do a thorough review of systems, and to update the family history.

When patients started talking about sore knees, allergies or frequent urination, I would try to gently steer the conversation by saying something like “those are things we can look into some time, but today I’d like to focus on the big health issues that could kill you”.

This approach was generally well accepted, and my homemade form made documentation quick and efficient. As the years went by, and as guidelines changed, some things disappeared from my routine. For example, screening or baseline EKGs were proven to be of little value, and I also stopped doing visual screenings on adults, because I wanted them to go to an eye doctor to get their intraocular pressure checked. My own Schiotz tonometer had become a veritable museum piece as it is so much more awkward for patients than modern tonometers.

I never did have a set of routine blood tests for a routine physical. Even when PSA testing for prostate cancer screening was de rigueur, I reasoned “this is America, and nobody has to do anything; who am I to boss people around by requiring that they have certain tests?” Ordering blood test was something I always did with the patient’s informed consent. Even with cholesterol, I always had plenty of patients who felt they had a healthy lifestyle and simply didn’t want to know what their cholesterol was.

I talked with patients about diet, alcohol, seat belts and all kinds of lifestyle issues. But I didn’t screen for things we essentially cannot treat, like early dementia. In our annual conversations, I usually got a good sense of who was high-tech in terms of wanting “everything done” in case of a cardiorespiratory arrest, but I admit I wasn’t quite systematic in collecting Advance Directives.

Of course, my Annual Health Review was not covered by Medicare, since it was perhaps technically a physical. But Medicare did pay for long visits where three or four chronic health conditions, even stable ones, were reviewed, so sometimes it was possible to add the Annual at no charge to a chronic care visit.

The other doctors in my practice used the same form, but I know each one carried a slightly different conversation with their patients. This visit was in the hands of my colleagues a reflection of each one’s style and of their patients’ preference. Dr. A ordered a few more blood tests, Dr. B recommended vitamins and supplements, and Dr. C promoted exercise with more passion than I did, and so on. These differences caused patients to gravitate to the one doctor among us that resonated most with their own ideas. This was personalized health care before patient-centeredness became formalized and formulaic.

All of us were pretty comfortable with our combined physical and health review visits.

Fast forward twenty years.

Today, under the new world order, doctors are mandated to perform Annual Wellness Visits on their Medicare patients, but not according to their own best efforts or their patients stated preference – one item missed or omitted out of deference to conflicting guidelines or common sense, like the kindergarten-style visual exam for new Medicare beneficiaries in their first six months of coverage, and no payment is collected. And similarly, check a few basic things like lung or heart sounds, the presence of leg edema or skin cancer, and the free insurance benefit is forfeited.

What was a naturally evolved focused physical combined with an individualized health risk assessment has been replaced by a tightly scripted no-touch session that leaves many doctors and most patients confused and bemused.

This new “Annual” feels like an administratively reinvented wheel, downright square and not rolling very well at all, at least on the roads where I travel.