A Country Doctor Writes:

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Touching the Mezuzah

Published December 24, 2012 Progress Notes 25 Comments

First published in 2012.

A mezuzah (Hebrew: מְזוּזָה‎ “doorpost”; plural: מְזוּזוֹת mezuzot) is a piece of parchment (often contained in a decorative case) inscribed with specified Hebrew verses from the Torah.

ט וּכְתַבְתָּם עַל-מְזֻזוֹת בֵּיתֶךָ, וּבִשְׁעָרֶיךָ. {ס} 9 And thou shalt write them upon the door-posts of thy house, and upon thy gates. {S}
Deuteronomy 6:9

It’s almost 4:30 and I have three more patients to see before my Christmas mini-vacation can begin. Snow and sleet are beginning to fall outside. Our lab tech, who leaves between 3 and 3:30, just called from home to warn the rest of us that she had seen nine moose on Route 1, probably attracted by the road salt.

“Three encounters in thirty minutes”, I think to myself, “and neither of them completely straightforward”. I used to shudder when healthcare administrators called medical office visits “encounters” , but the more I have thought about it, the truer the word rings to me. Two people meet briefly and try their best to communicate in spite of sometimes very different viewpoints and agendas. I remember the phrase “Marriage Encounter” from my first visit to this country in the early 1970’s – an event where couples learn to see each other with new eyes and communicate more effectively.

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

4:35 – In Room 1 sits Bill Boland, the fellow who always sasses me for my habit of knocking on the exam room door before I enter. He had been in with pneumonia and his x-ray came back suspicious for a tumor. The purpose of today’s follow-up visit is to make sure he is feeling better and to tell Bill he will need more testing. I raise my hand in an automatic door knocking gesture, but catch myself and instead touch the doorframe briefly and take a slow breath before entering the exam room, ready to deliver the disturbing news.

4: 50 – In Room 2 sits Wally Parker, here to talk about his blood sugars. His wife is in the hospital with a lower GI bleed, and her colonoscopy showed an ulcerated tumor that is almost certainly malignant. “Why is he here tonight instead of at Mary’s bedside?” I ask myself as my hand reaches for the doorframe. At the same time I try to clear my mind of my own clutter and my guesses why he has chosen to keep this appointment under these circumstances.

5 o’clock – The child in Room 3 is an 11-month-old with a fever. He belongs to the pediatric group in town, but probably the slick roads and the late hour are the reasons he is here. A new patient, and a sick child at that, requires me to be unhurried and receptive. I must be aware of how well we connect, so neither this child’s young mother nor I miss something important in our encounter. In this case, the child has an ear infection and the mother is a registered nurse with an older child at home who has recurrent ear infections.

At 5:15 I wish Autumn and the new receptionist a Merry Christmas before I leave through the back door.

Route 1 is covered with snow and the large flakes coming right at me make it impossible to see with high beams. I drive slowly with only my low beams, and don’t see a single moose.

Our house is all lit up for Christmas. In one of the sunroom windows shines the metal star-shaped lamp that hung in my bedroom window when I was a child. I remember coming home from school in the dark, looking up at my star on the third floor of our Swedish apartment building, even closer to the Arctic Circle than where I live now.

I can see my wife in the kitchen window, but she can’t see me in the darkness outside. I quickly stomp the snow off my boots on the wooden steps outside the door. My hand touches the doorframe for balance, physical and spiritual, and as a brief gesture of love and blessing:

I am home. It is Christmas.

The Secret Of Life

Published June 23, 2012 Reflections 4 Comments

“The secret of life is enjoying the passage of time”

James Taylor

One of my wife’s mentors has a 104-year-old aunt, who on her 100^th birthday was asked to reveal the secret of her longevity.

“I always have something to look forward to” was her answer.

Wisdom, happiness and longevity aren’t confined to people in cathedrals or ivory towers. They can be found in seemingly ordinary people in the most ordinary places. James Taylor, in his song “Secret O’ Life”, goes on to say, “any fool can do it”. Similarly, the Bible tells us to be more child-like (Matthew 18:4).

That doesn’t mean you have to be childish or think like a fool to enjoy life. It does mean that finding happiness is not complicated, and we sometimes get so wrapped up in our own thinking that we fail to see the simplicity in some of the universal truths about life as well as the beauty of life itself.

Observing which of my patients live well and handle age, illness and adversity the best, I see the power of this every day.

Jungian therapist Robert A. Johnson describes in his book, “Transformation: Understanding the three levels of masculine consciousness”, how the male psyche evolves from simple man (exemplified by Don Quixote), who asks “What’s for dinner?” to complicated man (Hamlet), who asks “What does it all mean?” to enlightened man (Faust), who asks “What’s for dinner?”

Too many of us dwell on the past – what we lost, what we never had, what we should or shouldn’t have done. Too many of us spin our wheels over-analyzing the present. Too many of us fritter away our days and our lives imagining or pining for distant futures at the expense of the present moment.

There is nothing wrong with thinking about the past, but we must each find our own way of making peace with it. There is nothing wrong with trying to understand our present circumstances, but not all of it will make sense to us now. Sometimes it takes years or a lifetime to understand the things we go through in life. There is nothing wrong with having dreams and goals, but we must somehow find joy in the journey towards those goals without feeling that we are wasting our time in our present life, since for some of us, that is all we’ll ever have.

Wisdom, like happiness, can’t be bought or taught. It is only occasionally learned in formal education settings through rigorous study and practice. More often it is earned through hardship and experience. It is gained when we look deep inside ourselves and acknowledge what we see. In the words of C. G. Jung, “One does not become enlightened by imagining figures of light, but by making the darkness conscious”.

In medicine, wisdom is partly gained by being wrong, or at least humbled by facing the limitations of our knowledge. But clinical wisdom must be paired with human wisdom as well as some of that simple joy of life James Taylor sang about, so that we can truly be of help to our patients. Nietzsche, in words that could have been written for practicing physicians, said:

“There is one thing one has to have: either a soul that is cheerful by nature, or a soul made cheerful by work, love, art, and knowledge.”

That is the hope I carry, that my love of medicine, of my wife, my family, and of the arts and the beauty around me will help me be joyful in my daily living. I hope that love will sustain me as the alarm continues to ring at 05:10 on bright summer mornings as well as dark, howling winter ones, this year and for many more years to come.

A Country Doctor Watches Marcus Welby, M.D.

Published June 10, 2012 Progress Notes 5 Comments
Tags: Marcus Welby

The year is 2012. A 58-year-old veteran Family Physician who has just finished a day with more human heartaches than clinical triumphs settles down among the pillows with his wife in front of his MacBook to watch a movie, delivered wirelessly over the Internet:

The year is 1969. A 62-year-old veteran General Practitioner who has just seen his health threaten to fail him, speaks passionately to a group of doctors about how general practice is not dead and general practitioners are not dinosaurs. For the next 98 minutes he proves how much he cares, how well he knows his patients, and how often he is willing to go out on a limb when he feels there is an ethical stand to be taken.

The pilot episode of “Marcus Welby, M.D.” was called “A Matter of Humanities” (how often do you hear that word in medical circles today?). In his passionate speech to the young doctors at the hospital where he had just been treated for his heart attack, he said (and I paraphrase):

We aren’t treating a this or a that, we are treating our patient.

That is pretty much what Family Practitioners say today, and we still aren’t dinosaurs. In fact, the “new” or re-born idea of the Patient Centered Medical Home and other such political reforms may make us more central to the health care machine than we have been since the days when the big HMOs wanted us as “gatekeepers”. Regardless of how our standing with the politicians and insurance companies has come and gone, our patients have kept on coming to see us.

In 2012 more than a few people speak disdainfully about how “the days of Marcus Welby are long gone”. Google has 17,600 search results for that exact phrase, if that is any indication. But many people seem to speak of him without actually having watched or at least remembering much of the show.

I have heard people scoff at his clinical understanding, and I remember once seeing an episode where he used a car battery to deliver a shock to a patient’s heart. But, this was Hollywood fiction – let’s not forget that Marcus Welby himself was a fictional character – and defibrillation and cardioversion were relatively new inventions.

Marcus Welby and his fictional colleagues obviously practiced with the medical knowledge of that time. We may smile at how his attending physicians kept him in the hospital for twelve days or more for a simple heart attack. That may seem archaic by today’s standards, but it may actually have been more humane than what we are doing today with our same-day surgeries and drive-by deliveries.

The purpose of most episodes of Marcus Welby, M.D. was not to illustrate the clinical aspects of a particular disease or its treatment. Most of the stories were about how disease affects people and how a wise and caring physician can help his patients, even in situations when there is no cure to be offered.

An interesting theme in the show is the mentor relationship between Welby and his young associate, Dr Kiley. In spite of his youth, fashionable (for his time) hair and motorcycle, the younger physician represents a more conservative view than Welby. The older physician is more liberal, less distrustful of human nature, and more altruistic than his protégé.

It is obvious that doctors in 1969 had less advanced tests and treatments to offer their patients than we have today, but the ironic thing to me is that Marcus Welby’s patients got a lot more in a way because of his exceptional personal involvement, passion and courage. In that sense, the shows are totally refreshing. Medicine today, with its focus on guidelines and measurable data, has become a rather faceless bureaucracy. I think I know why many people still remember and mention the Marcus Welby character by name. He gave medicine a face, a personal flavor that people still want today. There is a lot of talk and theorizing these days about how medical care is organized and delivered. For example, we read about Accountable Care Organizations; whatever happened to accountable individuals?

Medical knowledge is always subject to change, but the ethics of medicine are a lot more timeless. Marcus Welby, M.D. tells the human stories as they relate to the medical facts of that era, and they are still captivating and thought provoking 43 years later.

My wife and I will be back for more of Marcus Welby, M.D.

Blood – The Doctor Giveth and the Doctor Taketh: Myths, Beliefs and Evidence

Published June 2, 2012 Progress Notes 6 Comments
Tags: blood transfusion, bloodletting, Transfusion risks

This Country Doctor learned something interesting at Grand Rounds the other day. One of the Cityside hematologists gave a talk about blood transfusions that made me think about how slow the medical profession is to change its beliefs and its practice, even when faced with overwhelming evidence that we are doing the wrong thing.

It turns out our profession has been wrong about the benefits of transfusing anemic patients, just like our predecessors were wrong in their belief that bloodletting was helpful.

For thousands of years medical practitioners used bloodletting, drawing off sometimes very large quantities of blood, as a treatment for various illnesses. After this treatment was proven useless and dangerous in 1628 by Harvey, the practice continued for more than 200 years. It is said to have brought on George Washington’s death in 1799 after 9 pints of his blood was withdrawn. Samuel Hahnemann, the physician who founded Homeopathy, looking for kinder, gentler treatments for his patients, wrote in 1809:

“The more refined humoralists, in addition to the impurities in the blood, alleged, besides, the existence of a pretended, almost universal, plethora, as an excuse for their frightful, merciless bloodlettings.”

Analyzing why it took so long to eliminate this type of treatment, Kerridge and Lowe wrote in 1995:

“That bloodletting survived for so long is not an intellectual anomaly—it resulted from the dynamic interaction of social, economic, and intellectual pressures, a process that continues to determine medical practice.”

Legend has it that early adopters of non-bloodletting didn’t dare to withhold this “treatment” for their sickest patients. They, like modern day physicians, were afraid of “doing nothing”.

Today, bloodletting is only used for a handful of conditions where the patient actually has too many red blood cells or too much iron in the blood. But we have gone too far in the opposite direction, thinking that most anemic patients could benefit from a couple of extra units of blood.

In 1999 The New England Journal of Medicine wrote authoritatively about several negative effects from transfusions. Since then the evidence has continued to mount against transfusion in medical patients with anemia. Bleeding surgical patients are in a different category.

But for many years we transfused our sickest patients in hope of helping them do better. When they didn’t, we usually didn’t blame the transfusion, but thought they were just too sick to fully benefit from transfusion. This is exactly what happened in the days of bloodletting.

The new findings about the negative effects of transfusion were ignored, perhaps even swept under the carpet. After all, giving blood seemed like such an obvious thing to do.

Even though we know that anemic patients are more likely to suffer for example heart attacks due to low oxygen delivery to their tissues, it turns out that blood transfusion to correct anemia actually further decreases oxygen delivery to heart muscle tissue. Transfused patients have a greater risk for illness and death than non-transfused patients, all the way down to degrees of anemia that usually raise the hair on every physician’s back. Even our own (autologous) blood donation has this effect due to changes in blood cells and plasma caused by handling and storage. Transfused blood cells have a tendency to be less flexible and slippery than normal blood cells and have been proven to block tiny blood vessels and thereby keeping patients’ own, healthy, blood cells from getting through.

A chilling fact is that even though blood between 30 and 42 days old carries a dramatically greater risk of negative effects than blood less than 30 days old, we still continue to offer it to patients without informing them of the additional risk we subject them to.

The increased risk for illness and death extends well beyond the immediate period after transfusion: We are now seeing an increased cancer risk in people who have received blood transfusions several years ago.

The International Consensus Conference on Transfusion and Outcomes issued this statement in 2009:

“There is little evidence to support a beneficial effect from the greatest number of transfusions currently being given to patients. The vast majority of studies show an association between red blood cell transfusions and higher rates of complications such as heart attack, stroke, lung injury, infection and kidney failure and death.”

At Cityside and many other hospitals, the threshold for transfusion in medical patients has been lowered, and surgical patients sometimes have their operations postponed in order to manage anemia with iron infusions and erythropoietin injections to allow the patient to build up their own blood supply before surgery. And if transfusions are given, they are kept to a minimum.

Such changes in practice are likely to happen in other areas of medicine if we are willing to really practice evidence based medicine and not just do what sounds like a good idea. Too many things have sounded good and turned out bad to make that a defensible strategy.

I can’t help thinking about how uncomfortable many doctors have been over the years when treating Jehovah’s Witnesses, whose religion forbids them to accept blood transfusions. That belief may actually have saved many lives.

Medicine is an ever-changing practice, and it is humbling to realize how doctors sometimes harm their patients by doing what seems to be the right thing to do.

Dr. Martin H. Fischer said it well:

”It is not hard to learn more. What is hard is to unlearn when you discover yourself wrong.”

Rural Medicine – Not Just Runny Noses

Published May 7, 2012 Reflections 4 Comments

A lot of people, many of them medical students, think that rural doctors don’t get to see many interesting cases.

The opposite is true; if you are the only doctor within a wide radius, people will come to you for help, rather than try to pick the appropriate out-of-town specialist to diagnose their problem. In this state with widespread physician shortages most specialists won’t even see self-referred patients.

Sir William Osler wrote:

“The environment of a large city is not essential to the growth of a good clinical physician. Even in small towns, a man can, if he has it in him, become well versed in methods of work, and with the occasional visit to some medical centre he can become an expert diagnostician and reach a position of dignity and worth in the community in which he lives.”

Today, with UpToDate and all the medical journals of the world instantly at our disposal through the Internet, rural physicians cannot blame the size of their patient panel or of their medical community for not keeping up with the essentials in their field. Rural primary care doctors are usually the first ones with an opportunity to evaluate and diagnose our community members’ medical problems, regardless of their complexity or severity.

In situations when I feel stumped with a difficult diagnosis, I sometimes end up explaining to patients that until I understand better what the nature of the problem is, I don’t even know which specialty is the right one to refer them to, since the delineation of specialties follows disease location or mechanism rather than presentation.

For example, a person with weight loss could have an endocrine problem, an intestinal problem, cancer or a psychiatric diagnosis. The family physician is usually in the best position of all specialists to sort out which is the underlying cause.

It is sometimes quite touching when, after I have diagnosed a patient with a rare disease that only a big city or university-based specialist can manage, patients say “ah, Doc, can’t you treat me instead – I’m comfortable with you, and you’re the one who figured out what was wrong with me”.

Rural medicine, in terms of the spectrum of disease we encounter, is the most challenging and most stimulating kind of primary care medical career available to doctors in this country.

The double-booked visit with the Chief Complaint “I think I have a sinus infection” could be a brain tumor. The woman with chest pain could have an esophageal diverticulum, and the man with heart palpitations could have hyperthyroidism, an arrhythmia, a drinking problem or an anxiety disorder – perhaps even a pheochromocytoma.

It is my job to do the right thing, not too little and not too much, for each one of these patients, who trusts me with their care.

It’s all in a day’s work in primary care.

And, oh, one man with a runny nose just didn’t act right. He seemed vague with some word-finding difficulties. I had never seen a brain abscess before, but that is what he had.

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