A Country Doctor Writes:

David Mendel’s book “Proper Doctoring”, published in 1984, the year I finished my residency training, just came out in a new edition, seven years after his death. Born in London in 1922, his words very much sound like those of the generation before me, but they are somehow also timeless and as relevant today as they were thirty years ago.

On the topic of bedside manner, he writes:

“One absolutely essential ingredient of proper doctoring us the much-maligned bedside manner. The best doctors acquire one over the years, but many never do. I think that this is due to the usual overswing of the pendulum. Around the turn of the century, medical remedies were not very effective; in the circumstances the bedside manner was all there was. Now that we can cure many diseases, both doctors and the public have replaced the wise avuncular physician of the past with the ’intensive care whizz-kid’ image. We don’t need all that mumbo-jumbo when we have proper scientific methods, they say.”

Indeed, a physician from the generation before Mendel, Swedish-born Axel Munthe, writes about his days as a popular young doctor in Paris in his 1929 memoir, “The Story of San Michele”. At the time there were some very successful doctors in Paris, who had the reputation of being quacks, with fake diplomas but with charming bedside manners. They were all called to the police precinct to have their credentials examined. The most successful one showed up at the last minute and requested a private meeting with the Commisaire. He implored the official to keep his diploma from a prestigious German university secret, as he felt he owed his financial success to his reputation of being a quack.

Today, eighty-five years after Munthe’s best seller and thirty years after Mendel’s book, the pendulum has yet to turn back. The caring 1970’s family doctor, Marcus Welby, has given up his spot to “House”, whose brilliance excuses his personality deficiencies.

Mendel describes science as one of four legs on “the medical couch”. The other three are wisdom, experience and caring.

William Osler, by many viewed as the father of modern medicine in North America, in an anecdote retold by author and physician Larry Dossey, exemplified good bedside manner:

“After revolutionizing how medicine was taught and practiced in the United States and Canada, in 1905, at the peak of his fame, he was lured to England where he became the Regius Professor of Medicine at Oxford. One day he went to a graduation ceremony at Oxford, wearing the impressive academic robes that are a feature of the occasion. On the way he stopped by the home of his friend and colleague, Ernest Mallam.

One of Mallam’s young sons was desperately sick with whooping cough. The child would not respond to the ministrations of his parents or nurses and appeared to be dying. Osler loved children greatly and had a special way with them. He would often play with them, and children would invariably admit him into their world. So when Osler appeared in his dramatic ceremonial robes, the little boy was captivated. Never had he seen a human like this! After a brief examination Osler sat by the bed, peeled a peach, cut and sugared it, and fed it bit by bit to the enthralled, speechless boy. It was his first nourishment in days. Although recovery was unlikely, Osler returned for the next 40 days, each time dressed in his magnificent robes, and personally fed the child. Within a few days the tide had turned and the little boy’s recovery was assured.”

Larry Dossey goes on to say:

“Compassion is not antiquated. It remains a crucial factor in healing and will never go out of style. It is always available for any healthcare professional who is wise enough to claim it.”

Bedside manner is sometimes now included in medical school curricula, but ultimately it is probably better inspired than taught. If we as physicians give more thought to the roots of our profession, or “proper doctoring”, we will be less distracted by the technical aspects of our work, and more likely to see our patients and their suffering as the real and only reason we entered our profession.

And may the pendulum soon return.

Doctors today are often accused of being uncaring: Their eyes are glued to their computer screens and their attention is focused on test results and technology instead of patients.

But some doctors care too much: A seasoned cardiologist blogs about letting his emotions lead him astray in keeping an elderly patient on life support too long. Was it his emotional attachment to the charming, elderly woman, or was it professional hubris, Dr. Sandeep Jauhar asks himself.

Sir William Osler wrote a hundred years ago about the mindset behind the conduct of skilled, seasoned physicians. He used the ancient word Aequanimitas, derived from the Latin words “aequus” (even) and “animus” (mind/soul). Every religion values the concept, and many of them use the actual word, equanimity, as do teachers of Buddhism and yoga.

Osler wrote about the levelheadedness required of doctors:

“Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.”

Some people have taken this to mean that Osler somehow didn’t care deeply for his patients, but he emphasized that this was not a call to be uncaring:

“Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening “the human heart by which we live.”

In Osler’s time, many more diseases were incurable than now, and he spoke to medical students about the limitations and uncertainties of medical practice:

“A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the uncertainty which pertains not alone to our science and arts but to the very hopes and fears which make us men. In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions.”

This acceptance of not knowing and not being able to control the ultimate outcome of our efforts has become unpalatable for some in healthcare today. We are now workers in a medical “industry”, based on a manufacturing paradigm. And the goals of this industry are not necessarily those of its “customers” – our patients. Corporate quality metrics can clash with patients’ desires.

Just like Osler spoke about equanimity in the face of suffering and the ravages of disease in the early 1900’s, we may want to apply it to the modern frustrations of doctors today; if we cannot control the system of healthcare where our patients’ and our own lives intersect, we risk descending into a spiral of frustration. Borrowing from Buddhist writings, there is an alternative to despair today, too, in equanimity:

“Without this….it’s easy to fall into compassion fatigue, helper-burnout, and even despair. Equanimity allows you to open your heart and offer love, kindness, compassion, and rejoicing, while letting go of your expectations and attachment to results. Equanimity endows the other three brahmaviharas (sublime attitudes, Buddhist virtues), with kshanti: patience, persistence, and forbearance.”

Frank Jude Boccio, teacher of yoga and Zen Buddhism

True equanimity is being stirred in our hearts by the needs of each one of our patients. But we must not be shaken into despair or resignation by their suffering, by the limitations of medical science, or by the shortcomings of a healthcare system we cannot control.

The horse that came into my life has made me think about many things from a different perspective. I have learned about the horse’s subtle ways of communicating, her extrasensory (compared to our own) perception, and her instincts of flight. I have also become more aware of the energy I bring to my relationship with her. With no learned tricks or horse management skills, I have established a way of communicating with her built solely on mutual respect and affection.

She always tries to see what I am looking at, my books and the picture of me and her on my iPhone. I know that horses have an almost 360 degree field of vision, but a very small area of binocular vision. They also have a blind spot right in front of their nose.

Monocular vision gives horses the ability to detect danger from almost every angle, but with fewer details than our human vision. A wind blown piece of paper can seem as threatening as an approaching predator.

Even when grazing lazily on warm summer afternoons, my horse has one ear turned in each direction and she maintains her 360 degree visual vigil. She is always multitasking.

This is where I have started to see parallels with my own workday. I seldom have the luxury of doing one thing at a time, namely take care of the patient in front of me. Today’s physicians, like horses on the savanna, seem to be having to keep a 360 degree field of awareness, even when we are alone with our patients in the exam room.

It is not enough to be doing the work of diagnosis, of weighing all the components of crafting a treatment plan: If I choose to prescribe a quinolone antibiotic, what is my patient’s kidney function, is he on blood thinners, did I double check the allergy list? I must also remember to print the patient information, even though I verbally warned my patient about the risk for tendon rupture. I must be aware if his insurance covers my choice of drug and, because he is on replacement steroids for his Addison’s disease, I need to submit a prior authorization request to Medicaid, which wants me to go on record that I am aware of the theoretically increased risk of tendon injury, even though my patient is only on replacement steroid therapy.

I must also be cognizant of the time, my schedule, the health maintenance reminders and the chronic disease monitoring my patient is due for.

All these considerations, which happen almost subconsciously, need to be documented in the medical record, both for medicolegal and for billing purposes. Watching out for all the pitfalls in patient care is probably a lot like grazing on the savanna for my Arabian and her ancestors.

Any wonder, then, that sometimes, at the end of a busy day, I feel as if I have done a lot more than the doctoring I bargained for.

Stepping into the ten foot stall of my 800 lb friend, I cannot afford to be edgy or distracted. This is when we spend time together inside, focusing on our shared field of binocular vision, where we share the depths of each other’s gaze, and where we share our territory with mutual respect.

This is the focus I must strive at maintaining every day, at work as well as in my dealings with those I love. I need my 360 awareness, but as a human being, and not an animal of prey, I need to keep my main focus straight ahead, or I will lose my depth and my courage.

My ninety-three year old patient and friend Arsène Voisine died last week. I have written about him before in a post titled “Attitude!”, and in the four years since then, his spirit never faltered. Funny and inquisitive as ever, he lost only a small fraction of his razor-sharp wit and analytical power as time passed. He did stop driving to the big city dance hall on Saturday nights, but we still talked ballroom dance favorites every time I saw him.

His heart condition worsened and he had a small stroke a year ago. In spite of my efforts to reduce his risk, he had another stroke last week and died a few days later surrounded by his family.

Friday afternoon, our office fax machine printed up his discharge summary. It made me think about how awkward this term is. My hospitalist friend, Dr. Harris, didn’t discharge Arsène Voisine. He was just witness to the end of a ninety-three year old life, a life lived well, filled with joie de vivre until in one instant his brain could no longer make jokes, remember cha-cha steps or question the doctors’ treatment strategy.

Arsène left us with only our vivid memories of his joy and vitality. He left into the arms of the God he sometimes spoke about, but Dr. Harris didn’t discharge him. The summary of what happened during his two and a half day hospitalization is better described by the word we used for discharge summaries in Sweden – “epikris”. This word is derived from the Ancient Greek word for “determination” or “judgement”. The 1881 edition of Sweden’s largest encyclopedia defines the word as “a scientific account of an illness, pertaining to its cause, course and outcome”.

The corresponding English word for “epikris”, “epicrisis”, is almost never used for discharge summaries in the U.S. and I don’t believe it was ever commonly used. But perhaps we should use it when we don’t discharge patients ourselves, but they leave in spite of our efforts, on their own or God’s accord.

Almost daily, I get messages like this one: “What can I take for a cold?”

My answer is usually in the negative. The more time I have or the needier the request seems, the more I might elaborate, but the bottom line is that I don’t recommend anything for “fighting a cold”. In fact, I recommend surrendering to it.

Why take an antipyretic like acetaminophen/paracetamol, when such drugs have been proven to prolong viral illnesses? Why take antihistamines or decongestants when they thicken mucus and increase the risk of developing a sinus infection? Why take a cough suppressant if there is sputum to be eliminated? Why hide the symptoms of a contagious illness only so you can go to work and infect others?

My weekend of preliminary symptoms came into full bloom when the alarm went off at ten past five this morning. Coffee with sugar and half-and-half never felt so good going down my throat, even though I could barely taste anything. I coughed so hard that the cat, who usually sharpens her claws on my chest in the morning, decided to keep her distance.

A text message to my office manager and out to the barn with warm water and grain for the horse and the goats, then I was back in bed.

I read The New York Times on my iPad and paused after reading the article about the blood pressure medication Benicar (olmesartan) causing a celiac-like diarrhea. Isn’t that what Mr. Waddell is on, the man who stopped his stomach pill, omeprazole, to no avail? And I had been trying to tell him to give up beer, since that was the only thing I could blame his symptoms on. I resisted the temptation to log into our electronic medical record system to check his medication list; I can do that when I get back to the office in a day or two.

I dozed for an hour or so, then I made amends with the cat. I managed to sign the grandchildren’s Valentine’s Day cards before it was time to let the barn animals out in the pale February sunshine.

I reflected on the last time I was sick. That time I had a mysterious and rather unnerving illness that made me a little concerned I might have something serious. Only my profound fatigue and suppressed brain activity kept me from actually worrying about it. This time, everything is utterly familiar, and I have simply settled in for a few days of submission; my life has to slow down, and there is really nothing I can do about it.

The day inches on. I sleep, read and cough. I hear my wife fixing supper downstairs. She is playing Mozart. But why “Requiem”?