A Country Doctor Writes:

Archive Page 169

Doctoring in the Here and Now

Published May 7, 2013 Progress Notes 8 Comments

I used to be a stickler for time. One of my first blog posts was about how it felt to go to work without my wristwatch.

I also used to be very particular about knowing the purpose of each visit, partly to help me manage my time, and partly to help me feel prepared and in control of the visit.

I often questioned why my colleagues’ patients would sometimes end up in my schedule for issues that seemed to me safe to wait until the patient’s own provider was available.

Over the last five years I have relaxed about these peeves of mine. I have become more accepting of the fact that patients don’t think in terms of how many minutes they have assigned to them as well as the fact that many patients can’t or choose not to tell the front desk staff why they want to see me on a given day.

Thinking about the way I used to be, I was more efficient than my employer expected me to be, but I don’t believe I quite lived up to my full potential as a healer. There were already then systems in place that made sure the housekeeping aspects of health care weren’t missed for very long if I were to digress in the visit – we had our chronic disease registries and recall systems for pap smears, mammograms and immunizations.

Lately, I have come to think more and more about the physician’s duty to ease suffering. So much of modern medicine is about population and disease management, and there are so many pressures on our time and attention that physicians seem to have little left to offer patients who are suffering, physically or emotionally.

But the systems to manage the measurable aspects of medicine are there, backed up by even more computer power, and we physicians may just need to step back from the numbers long enough in every encounter with each fellow human being to allow us to be open and see our patients as individuals. We need to listen actively to hear their unique agendas. We have teams behind us now to help manage the housekeeping details; we have health coaches and case managers and more nurses than we used to. But since only we have the title “Doctor”, we need to have our senses open to those things only we get to hear.

My wife, reflecting on her years delivering primary health care, always says: “I never had just a Diabetes visit. There was always something else.”

The sad truth is that the health of a nation is more dependent on public health, socioeconomics and the prevailing attitude among the majority of the population. The quality of medical care matters very little. For example, a healthy diet together with an active lifestyle is at least as good a weapon against heart disease as all the cholesterol pills and interventional cardiology that money can buy. It doesn’t take a medical degree to change the attitude of a nation, and trying to do it on a case-by-case basis with each patient at $7 a minute is not effective population management – not that I don’t try every single day.

So, what is the role of the physician in today’s health care system? I believe we are the ones who can best help patients make sense of their symptoms and also understand what the health care system can and cannot do for them.

With common human experiences given names that make them seem like diseases, and with our nation’s increasing confusion about even common ailments and preventive measures in spite of the glut of information out there, physicians can bring wisdom and empathy to a system that provides neither. Since we are closer to the mysteries of birth, disease and death than most people, we need to be there for our patients to turn to when the angst of life afflicts them.

I believe the new systems we have all been required to put in place to meet all the public mandates are actually blessings in disguise. If we are wise, we can meet our quality and productivity metrics through the use of the technology at our disposal and at the same time rediscover and cultivate the ancient art of doctoring. Because the phones at my clinic as well as every other doctor’s office keep ringing, not with patients asking to have diabetes follow-ups, but with patients who have a new concern, a new fear, or the courage – just today, or they will lose their momentum – to finally tell someone their deepest fear.

Pausing, as I do every time before knocking on the exam room door, I clear my mind and I am ready:

“Hi, I am D—. What can I do for you today?”

Absolute Risk

Published May 4, 2013 Progress Notes 2 Comments

Gladys Peppercorn was in to see me the other day, very concerned about a letter she had received from one of the Cityside gastroenterologists.

In very formal words, the letter said the GI office had tried several times to reach her in order to schedule her next upper endoscopy to monitor her Barrett’s esophagus and would she please call them back to schedule the procedure so they could monitor her for her increased cancer risk.

“You know me, I don’t want any unnecessary procedures”, Gladys said as I read the letter she handed me. She had only gone for the test two years ago because she had experienced heartburn for years, and at that time certain foods had been a little difficult to swallow. Her test really came out okay except for the Barrett’s esophagus. Her biggest problem with swallowing was some age-related stiffness of her esophagus.

Gladys’ age was not apparent when I looked up from reading the letter. Ninety years old in just a couple of weeks, she looked radiant, healthy and on top of the world in her purple silk blouse and khaki slacks.

“I do hear you, and I’m going to do some math with you”, I said as I pulled my chair over next to hers and minimized the EMR on my tablet computer and opened UpToDate, the medical database from Boston many doctors use as a reference.

“Okay, here are the numbers”, I began as we both peered at the small screen.

“Having Barrett’s increases your risk of esophageal cancer 30-fold”, I said, pointing at the website. Her eyebrows rose slightly. I continued:

“That would be like me saying that wearing purple increases your risk of getting hit by lightning 30-fold. Would that stop you from wearing this blouse?”

“No, it’s my favorite color”, she smiled.

“And thirty times nothing is nothing!” I concluded. She agreed.

“Look here”, I pointed. “Studies have shown between 1.2 and 4.3 cancer cases per 1000 person years in people with your condition. Let’s exaggerate and call it 5 cases per 1000 patient years. That means that out of a hundred people like you, in the next ten years only five would get cancer and 95 would not.”

She nodded slowly.

“So you have at least a 95% chance that you will not get esophageal cancer in the next ten years, probably more in the order of 96-98%.” I continued: “And then you have to weigh that risk against the risk of anesthesia or the procedure itself causing you harm in some way.”

“I know I don’t want the procedure!” Gladys smiled and rose from her chair. I quickly got up, too. She stretched her hand out toward me and thanked me.

“I always feel better after talking to you”, she said.

I shook her hand and thought that she probably used to wear white lace gloves on warm days like this when she was young.

Controlling Physician Behavior: From Socialized Medicine to Social Marketing

Published April 22, 2013 Reflections 2 Comments

As a Swede, I know all about Socialized Medicine. I grew up with it and I learned my trade in it. I worked under budget constraints, treatment protocols and formularies in the late 70’s and early 80’s while American doctors were essentially practicing the way they wanted here.

I remember one of my surprises when I arrived in this country: I had learned in medical school that trimethoprim-sulfa was the drug of choice for urinary tract infections. Here, I was asked to consider what the bacteria looked like under the microscope and which antibiotics historically worked best for those bacteria. Even though the treatment choice was the same most of the time, I was encouraged to think it through for myself and not just follow convention.

In Sweden, I was often frustrated with “the system” telling me what to do. I felt curtailed in using the knowledge and skills I had acquired, and I admired the ability American doctors had to make independent clinical decisions based on their knowledge and experience, rather than some local government policy. Of course, since then, both the insurance companies and the Federal government have stepped in and regulated many aspects of medical practice, so now I am back in the kind of waters where I once learned to swim. And I still remember how! It isn’t called Socialized medicine here, but it amounts to almost the same thing from the doctor’s vantage point.

I am now trying to understand another “S” phrase – Social Marketing. So far, it looks like that one is much harder for me to get a handle on.

The other day I threw away a chance to make $150 in 10 minutes. I also put an unendorsed $10 check in its enclosed prepaid postage envelope. With a certain amount of satisfaction I placed the envelope in our mailbox at the bottom of our driveway on my way to work. “Make them pay 46 cents to learn about my rejection”, I thought to myself.

Both opportunities for easy money were surveys. The first one wanted me to list colleagues in my own specialty I trusted and might seek advice from regarding pain management for my patients, and the second one asked which specialists I usually asked for advice on certain topics.

I am used to getting surveys and throw away just about all of them. Occasionally I take the opportunity to voice my opinion in one of them if I happen to feel strongly about the topic. But these are a new breed of survey that has appeared very recently. This is part of the new age of Social Media.

Social Media can provide a community of support for doctors, who otherwise risk being alone with the stresses and challenges of their work – that much I understand and respect. But the dark side of Social Media for doctors is when this becomes a channel for influencing doctors’ practice or prescription habits and for discouraging critical thinking.

Our university educations strived to make us independent thinkers, but Social psychology teaches that we are easily swayed in our opinions by people we respect or sometimes just by a majority of those around us.

“Social marketing” to doctors uses existing social networks for commercial purposes. It is the pharmaceutical industry’s evolving strategy in response to doctors turning away “drug reps” from their offices and to the escalating costs of keeping a large sales force on the road. What they do instead is make doctors do the sales pitches for them:

Pharmaceutical companies analyze prescribing patterns, through data they buy legally, of all the physicians in their territory. They then survey doctors to find out who the medical community views as trusted and worth listening to – “thought leaders”. This knowledge is then used to focus the pharmaceutical companies’ marketing efforts.

“Thought leaders”, who aren’t high prescribers of the promoted drugs, are targeted with sales pitches to convince them to use the product more often, while socially well-connected high prescribers are showered with attention and positive feedback, sometimes with an invitation to speak to their peers, for a generous fee, about particular drugs. One primary care doctor not far from where I work made over $50,000 one year from such dinner presentations, according to the website http://projects.propublica.org/docdollars/.

This system is said to create even more loyalty and generate even more business from the high prescribers themselves, something that may actually be more important than the business generated by converting their audience.

What this amounts to is creating peer pressure or inflating the ego of high prescribers instead of spreading information, and this is where my old-fashioned thinking gets me a little confused in today’s Social climate:

Why would I listen to a doctor from the next town over with similar or less experience than I have when I am considering whether to start prescribing a new medication? I have listened to plenty of presentations by prominent experts, and I don’t even trust some of them to be objective and not put the drug companies’ interests before our patients’.

Strangely, old-fashioned Socialized Medicine and the peer pressure of today’s modern Social Media can both have the same effect – making physicians think less critically.

I can’t help wondering: With all the world’s knowledge digitized, with UpToDate, The New England Journal of Medicine and The Lancet on our iPads, with Google Translate unlocking websites from all over the world, aren’t we obligated to use today’s technology and our educated minds to look directly to the primary sources of medical information instead of blindly following government edicts or the latest fad within our peer groups?

Sharing Territory

Published March 31, 2013 Progress Notes Leave a Comment
Tags: #WPLongform

How are we educated by children, by animals!

Martin Buber

In my forties I was the father of three teenagers. I knew enough psychology to perhaps avoid a few common blunders, but nowhere near enough to do a great job raising the three of them. It would be fair to say I learned from them as we went along.

As an only child, I had lived with many expectations to be just the kind of son my mother always wanted to have. I decided early on not to live vicariously through my children. It is a classic, almost archetypal thing for parents to do; wanting for their children all those things they never had themselves. It seems so natural when you love someone to want the best for them and to want to protect them from harm and mistakes in their lives.

One of my first girlfriends’ father was a minister. He introduced me to Martin Buber’s “I and Thou”. I think he was trying to caution me not to be possessive about his daughter. I did learn soon enough on my own that we cannot love and control a person at the same time.

Love requires freedom, even the love of a child. I set out knowing my children were not miniature versions of me, but their own individuals. The fact that all three were adopted made it more obvious that they might not have come into this world with my traits, likes or dislikes, but that should hold just as true for biological children.

A colleague of mine from India once said about her youngest son, “I hope he grows up to be a good person”. It seemed so simple, yet wise: All we as parents can do is give our children the best start we can and hope for the best. An exasperated neighbor once said about her son, “There comes a time when all you can say is I love you, good luck“.

All three of my children have said, in one way or another, that they appreciated my respect for them as individuals. They have also pointed out that they respected me for letting them know when I disagreed with them.

With my children now around 30 years old and my grandchildren still blissfully young, the only experience I have with teenagers these days is as patients in the office. I can certainly draw from my having lived with three teenagers in those situations, but I am drawing more and more from the past few years’ lessons I have learned from P., our white Arabian Princess.

An 800 lb horse who thinks most humans are likely to hurt her or mistreat her is like some of the teenagers that have come into my office. Domination is unlikely to work with a fearful animal of flight with the power to escape or punch your lights out.

Much of what I have done with P., I figured out myself. Emma also pointed me in the direction of horse trainer Carolyn Resnick, whose “Waterhole Rituals” are a foundation for relationship building between horse and human.

P., fresh from the horse rescue, was suspicious of Emma, who had defended her gelding from the kicks and nips P. tried to inflict on him. Perhaps I seemed like the best choice P. had for an ally, knowing nothing about horses, and expecting nothing in particular from her. Perhaps I reminded her of her first owner, the man who named her and raised her from a foal.

Our white Arabian horse gave me a sense of awe. She was so beautiful; I had never seen the facial expressions and body language of a horse up close quite like that before. Her eyes could be glaring when she looked across the pasture at some danger in the nearby woods I couldn’t discern. Whenever she looked at me and I just stood or sat still in the barn or on the other side of the fence from her, her eyes grew soft and kind. If I got up or made a sudden move, they would widen and the whites would show, her neck would stiffen, her tail would rise and every muscle in her body would tighten. Sometimes she would run away from me. If I just sat there quietly, she would come back with a kind, quizzical look, as if to say, “What are you, what are you doing?”

Instinctively, I was doing the first of the Waterhole Rituals, Sharing Territory. By now, four years later, P. and I trust each other, and she will do almost anything for me. She nickers when I approach her and we go for walks around the pasture, side by side, without halter or lead rope. I clean her stall around her and she moves politely when I ask her to.

A horse will naturally move away from an approaching stranger, but is likely to come over and investigate a stranger standing or sitting still inside the horse’s territory. If the stranger walks away, the horse will likely follow.

This is how I have also come to understand working with teenagers. Just like P., they don’t assume your intentions are good and they don’t like it when you tell them what to do, but if you show that you are interested in them and if your interest is genuine, they may want to know you better. But their senses are exquisite – they can smell deceit or trickery miles away and if you come on too strong, they will run like wild mustangs (or white Arabians).

Which brings me back to Martin Buber:

There are two kinds of relationships we can enter into. One is the “I-It” relationship, where we view ourselves as controlling the “other” by taking pleasure from it/him/her or even just by analyzing or classifying it according to our worldview.

The other kind of relationship Buber named “Ich-Du” in German. It has been translated as “I-Thou”, even though “Du” is an informal, intimate word for “you” and not at all as formal as “thou”. This is a relationship where we meet on a level that is free from selfishness, judgment, opinion, even reflection or analysis. It is an intimate encounter between two beings in their most authentic form. This is also the type of encounter man has with God or the Universe when all the trappings of religious ceremony are removed.

An “I-Thou” encounter lacks structure and content. It has no agenda, because any kind of purpose would objectify the “other” and make it an “I-It” encounter. It is simply entering the common space where both of our innermost beings exist.

“Sharing Territory” almost says it better, especially in light of the fact that Martin Buber actually first thought of the I-and-Thou relationship when he as a pre-teen developed a relationship with a horse.

In “Between Man and Man”, he describes a fleeting moment, when he connected with the horse on a level that stirred an awareness in him and briefly brought him into a universal experience where the horse wasn’t just a horse, but a part of a common “Other”, previously unknown to the young Martin Buber:

“When I was eleven years of age, spending the summer on my grandparents’ estate, I used, as often as I could do it unobserved, to steal into the stable and gently stroke the neck of my darling, a broad dapplegray horse. It was not a casual delight but a great, certainly friendly, but also deeply stirring happening. If I am to explain it now, beginning from the still very fresh memory of my hand, I must say that what I experienced in touch with the animal was the Other, the immense otherness of the Other, which, however, did not remain strange like the otherness of the ox and the ram, but rather let me draw near and touch it. When I stroked the mighty mane, sometimes marvelously smooth-combed, at other times just as astonishingly wild, and felt the life beneath my hand, it was as though the element of vitality itself bordered on my skin, something that was not I, was certainly not akin to me, palpably the other, not just another, really the Other itself; and yet it let me approach, confided itself to me, placed itself elementally in the relation of Thou and Thou with me. The horse, even when I had not begun by pouring oats for him into the manger, very gently raised his massive head, ears flicking, then snorted quietly, as a conspirator gives a signal meant to be recognizable only by his fellow-conspirator; and I was approved. But once–I do not know what came over the child, at any rate it was childlike enough–it struck me about the stroking, what fun it gave me, and suddenly I became conscious of my hand. The game went on as before, but something changed, it was no longer the same thing. And the next day, after giving him a rich feed, when I stroked my friend’s head he did not raise his head. A few years later, when I thought back to the incident, I no longer supposed that the animal had noticed my defection. But at the time I considered myself judged.”

“Sharing Territory”, be it with a horse or a human being, is the purest form of encounter there is. I did not specifically set out to “heal” the wounds of my rescue horse any more than I personally believe I have the power to “heal” a troubled patient. But I have often seen that when you enter the space created by stripping away prejudice, projection and preconception, profound healing is possible.

A Country Doctor’s Unlived Life

Published March 23, 2013 Progress Notes 7 Comments

“Just as colleges introduce our young people to knowledge of the world important for the first half of life, there should be colleges for forty-, fifty-, and sixty-year-olds to prepare them for the challenges of the second half…”

Robert A. Johnson & Jerry Ruhl

During my vacation I went to the eye doctor to have a refraction done for a pair of reading glasses. Reading my iPad at night with my progressive lenses forces me, now that I am pushing sixty, to turn my head uncomfortably upward to read through the bottom of my thick eyeglasses. With a pair of dedicated reading glasses, I will finally be able to read up close in dim light with my eyes looking straight ahead.

One of the books I am reading is by Jungian therapists Robert A. Johnson and Jerry Ruhl, “Living Your Unlived Life: Coping with unrealized dreams and fulfilling your purpose in the second half of life”. Of course, that’s stretching it for me – last third is a more accurate description of my current location on life’s roadmap.

Back when I really was closer to the halfway mark, I read Johnson’s “He: Understanding Masculine Psychology” and “Transformation: Understanding the Three Levels of Masculine Consciousness”. The title of my current read, “Living Your Unlived Life”, really spoke to me when I first came across it a couple of years ago: I could have done so many different things, but I made decision after decision that eliminated those options and put me where I am right now. And sometimes, in moments of doubt, I wonder what my life would have been like if I had made a different choice at one of those virtual forks in the road. I knew from age four that I wanted to be a doctor, and ever since I first visited this country, I knew I wanted to be a country doctor here. I got exactly what I wanted, but I didn’t quite consider all the consequences of making a life for myself so far away from my family and everything I grew up with.

I was a Scout, very good with map and compass, and spent many a night by a warm fire under the stars in the vast Swedish forest, Kolmården. Some of us played guitar, all self-taught, and we shared chords and riffs as the evenings grew cold and the others went to sleep in their lean-tos deep inside their mummy sleeping bags. One of my friends, C., was a year older, taller, better looking, and more confident and outgoing, but we became close over the years. He was taking business classes in High School. I already knew I wanted to be a doctor. We lost touch after I started Medical School. The only time I see his face now is on the cover of The Wall Street Journal and when I occasionally watch TV during travel; he is the head of one of the world’s biggest multinational corporations. I sometimes wonder how come I couldn’t also have been a successful businessman, but then, I don’t even like to balance my checkbook, so why would I think I could have made it in the world of finance?

Closer to home, my High School classmate, J., also knew all along he wanted to be a doctor. He stayed on at the University Hospital where he went to Medical School, went into a subspecialty, got his Ph. D., and has been head of his department for many years. He has more influence in a vastly larger organization than I have, and his life seems more straightforward in the sense that he made his career right in his own back yard; he didn’t move halfway across the world and away from his family to find his life’s work. But sometimes when we talk, he speaks of my life as more exciting; considering the path not taken causes a twinge in each of us.

I just got an email again from my army buddy, L., who also started Medical School in Uppsala when I did. A few months into our first semester, his debut novel was published. A year and a half later, he dropped out of Medical School to write full time. He was just awarded one of the most prestigious literary prizes in Sweden. Before I even met L., I harbored secret dreams of writing a great novel. Forty years later, he is still putting them out, and my first one is still more of an idea than an actual draft. In his latest email, he expressed his admiration and approval of my Country Doctor lifestyle and confessed he was jealous about my having goats.

As I sit here near the end of my week off, I think of where I am in life right now. The minutes go so fast at work, and the evenings and weekends at home are so short; I don’t often have time to think as much as I have this week. While we were cooking this afternoon, Emma said, “This is the first time you’ve really just been home for a whole week in years.”

I know the psychological task for people my age is to make peace with who we are, and to gather up those dreams and desires we never seemed to have parted with willingly, as well as the wounds we never took time to heal; we must now give them their rightful, if only symbolic, attention in our lives in order to be whole persons.

The central idea in “Living Your Unlived Life” is that the “unlived” parts of our lives can be lived out in totally symbolic form – “Doing something by not doing it”. Symbols, unlike signs, have many interpretations and can even encompass seemingly opposite notions.

So, my only multinational business is being both a Swede and an American, practicing modern, yet old-fashioned primary care medicine in rural America among French-Canadian patients.

My only sphere of professional influence is my exam rooms and the community I serve. My life is here, and it is rich with nuances, contradictions and memories. I have few regrets, and even they make up part of the unique substance of my life.

My only literary calling, at least for now, is to keep adding to this five-year-old weblog about how it feels to do the work I do.

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