A Country Doctor Writes:

My eyes played a trick on me the other night, or perhaps it was my subconscious. Emma and I were reading by the fire – my nose was in one of my medical journals and she had a stack of animal behavior books next to her while looking intently at the screen of her laptop computer.

As I was reading along I registered the sound of the dogs snoring rhythmically nearby. My eyes glanced over my magazine’s headlines with words like guidelines, accountable care, pay-for-performance, evidence-based and quality.

I had just made the quiet observation that there are innumerable forces that create and use buzzwords like that when trying to tell front-line doctors like me how we should do our jobs without really thinking for ourselves when Emma broke the silence in our living room.

“This is really interesting”, she said. “The way clicker training works may be by stimulating the amygdala of animals, so they feel instant joy before they consciously become aware that the trainer approves of what they just did.”

I knew a fair amount about clicker training; Emma has been using it on our canine family members and I have seen it work wonders with our adolescent female German Shepherd.

“Isn’t it just a conditioned response like Pavlov’s bell?” I asked as I looked up from my journal.

“Well, some people seem to think the actual sound of the clicker may be a more direct way to stimulate the amygdala than other sounds or words people use in training.”

My eyes moved from my wife’s face, framed by her beautiful long brown hair, to her eyeglasses reflecting the light from her computer screen, to the stack of books next to her. Suddenly my mind jolted at the title of the book on top. For a split second I thought it said:

How to Clicker Train Your Doc 

Emma was back to reading her webpage. The dogs snored peacefully. My mind was spinning.

Physicians are not quite subjected to clicker training, but we are certainly recipients of signals that are aimed at our preconscious minds, if not our amygdalas. All those people and institutions that try to influence physicians’ behavior are trying to get into our minds below the radar of our critical thinking, just like advertisers work on all of us. They use feel-good messages that try to do what clicker training does to our pets – create new behaviors we would otherwise not pick up on our own.

But doesn’t it go deeper than that for most doctors? It seems to me we often make ourselves do things that run counter to our nature. We do what others say we are good at, even when there’s no one around to cheer us on – even when doing it is to our own ultimate detriment. We end up using our burnout skills because we have created our own conditioned responses.

I opened my own laptop and started reading about clicker training and the amygdala. Wikipedia gave me the following quote:

“Clicker–trained animals become great problem–solvers, develop confidence, and perform their work enthusiastically.”

Just like doctors…

Morbus Iatrogenicus

From Latin morbus (disease), Ancient Greek iatros (doctor, healer), -genēs  (born) – similar to Latin genus (kin): Disease caused by the physician.

*

“There are some patients that we cannot help; there are none whom we cannot harm.”

Attributed to Arthur L Bloomfield

John Fernald in room 4 was clearly not right. He seemed drowsy, weak and disoriented and he had a low-grade temperature. His wife and I had to help him up on the exam table. His chief complaint was chills.

John was a tall man, generally very healthy. He had an enlarged prostate and took pills for his urinary frequency. Over the past eighteen months he had gone for a couple of PSA tests and they were steadily rising, but just barely over the upper limit for a man his age with a good size prostate gland.

Three days before, he had undergone a prostate biopsy by his very competent urologist at Cityside Hospital. John had received the usual antibiotics after the procedure, but he sure looked septic to me.

John said very little, but his wife, Zena, was in complete agreement with sending him over to the hospital for admission.

Across the hall in room 1, John’s contemporary and neighbor, Bill Boland, sat awkwardly in the exam room chair with an expression somewhere between pain and motion sickness.

He had a habit of always sassing me for knocking on the exam room door before entering. “Don’t knock, for Pete’s sake, it’s your room!” he usually yelled as I entered the room. Then, he would always stand up from his chair to greet me with a firm handshake.

“Pardon me if I don’t get up”, he moaned.

He was in my schedule for back pain.

“What happened to your back?” I asked.

“I have no idea. It’s been aching for a week now, and it’s just getting worse.”

“Any injury? Did you fall or lift anything heavy?”

“No, nothing.”

“Any pain or tingling down your legs?”

“Negative.”

“Do you feel better when you lie down?”

He shook his head. “No it aches the same…”

By that time I was worried. When a man in his age bracket has back pain, it is more likely to be something ominous than it is in a young or middle-aged person. The fact that his pain didn’t get better at rest was particularly disturbing.

I flipped through his chart. When was his last blood count, chemistry panel? Any risk factors for cancer? Had he had his screening tests for colon and prostate cancer? Nothing seemed unusual or less than up-to-date. In fact, he had just had a colonoscopy a month earlier by our top gastroenterologist to follow up on precancerous polyps removed three years before, and this time his scope had yielded two more polyps but no cancer.

On his physical exam I noted there was no pain when I tapped over his kidneys. Tapping on the lower spine caused him severe discomfort, but there was no muscle spasm or tenderness. He had drops of sweat on his forehead, but no fever.

I ordered bloodwork and an MRI. Autumn was able to get his MRI for the following afternoon. Bill and I agreed to touch base the next morning about his results.

John Fernald with his fever got settled into the hospital and Bill Boland with his back pain went to the pharmacy for some pain medication. I kept thinking about the two neighbors as my day continued.

Two days later, John was still in the hospital and on intravenous antibiotics. His blood cultures were positive and in all likelihood his blood poisoning was a direct complication to his prostate biopsy, which turned out to be negative for cancer.

Bill, my back pain patient, sounded uncomfortable when he answered the telephone. His bloodwork showed signs of inflammation and his MRI showed osteomyelitis of his lumbar spine. We arranged for admission to the hospital for blood cultures and intravenous antibiotics for him, too. I had never seen a bone infection develop as a complication from a colonoscopy before, but I had read about the possibility. Could this be what was going on with Bill?

That was almost three years ago. John Fernald’s PSA is a little higher than it was, but neither his urologist nor John are eager to go ahead with another biopsy. Bill Boland still has back pain, but it is mild and seems to get worse when he stands at the workbench in his shop too long. He has noticed some blood in his stool a few times lately and, technically, he is due for another colonoscopy.

“I’m not having one of those again, Doc, I’ll tell you that. You can’t tell me I got that spinal infection from anything else but that scope test!

John is now of the age when he is less likely to die from a newly diagnosed prostate cancer than something else like a heart attack or stroke. Bill faces a 2% ten-year-risk that any new precancerous colon polyp will turn into a cancer. And in ten years he’ll be 80 years old.

First, do no harm.

“If you carelessly squander your jing then you create a situation of potential harm to your health and longevity. Eastern medical schools all say this.”

                      William Bodri

”So, you need a referral to a pulmonologist?”

“Yes, I’ve been to the University Health Center almost every month since August and they’re getting tired of seeing me there.”

“Did you have much trouble with your asthma when you were younger?”

Kaitlynn and her mother exchanged a quick glance and a mutual head shake. The young woman continued:

“No, they called it exercise-induced asthma then, and I just used an inhaler before sports.”

“And now you’re on Pro-Air, Claritin, Advair and Singulair?” She nodded yes to my rhetorical question as I finished my thought: “And you’re still miserable.”

I knew all she seemed to want from me was a pulmonology referral for when she got back to the University after break, but I was intrigued and I wanted to do a good job facilitating the consult.

“What’s your best and worst peak flow?”

“400 on a good day, 200 when I’m sick.”

“Did you ever have a chest x-ray?”

“Yes, the clinic sent me for one.”

“Do you know what it showed?”

“My lungs were too inflated, I think.”

“Are you exposed to cigarette smoke?”

“The guy I live with smokes, but not inside.”

“You have an apartment?”

“Yes.”

“Any pets?”

“Two cats.”

“Did you grow up with cats?”

“No.”

“Do you have wall to wall carpeting?”

“Yes.”

“Any mold problems?”

“I don’t think so.”

“Is there anything you think might be bothering your asthma?”

“Well, my best friend has a dog and I think I’m worse around the dog.”

I started my physical exam while continuing to ask Kaitlynn questions. I noticed the ‘allergic shiners’ under her eyes. Her nose was congested and she had coarse, sonorous rhonchi and higher-pitched wheezes in both lungs.

“Do you ever have heartburn?”

“Actually yes. I was diagnosed with a hiatal hernia when I was very little and there was some problem with my swallowing.”

I finished my exam and sat down across from Kaitlynn and her mother.

“I think definitely you need some testing”, I began. “You could have some other, rare, lung disease, but this is probably asthma. The question is what caused it to get worse. You could be allergic to your cats, because no amount of medication can stop you from reacting to your own cats who live in your apartment if you have a severe allergy to them.”

She looked down. I continued:

“You may have stomach acid going into your lungs while you sleep, or you could be aspirating small amounts of food or fluids and your lungs could be reacting to that. Or, maybe your childhood asthma just got worse – it sometimes does that in your age group.”

Mother and daughter were both nodding. I felt I had achieved a fair amount in just a few minutes. As my eyes met Kaitlynn’s, she looked amused. She turned toward her mother, who was almost grinning. I thought I must have really somehow impressed them with my quick analysis. I cleared my throat.

“Here’s my suggestion: Let’s get a blood test today to screen you for some common allergies like cat and dog, and let’s pick a pulmonologist near the University…”

Kaitlynn and her mother exchanged looks again.

“I already had a blood test. Doctor Freese did that the first time I saw him, but I haven’t heard the results yet.”

“Who is Doctor Freese? The Student Health doctor?”

“No, the lung specialist.”

I raised one eyebrow and squinted with the other eye.

“Have you already seen a lung specialist?”

“Yes, and he said the same thing you did”, Kaitlynn giggled.

I sighed.

“So you didn’t need me to refer you to a lung doctor – you needed an insurance referral, so his fee will be covered by your insurance…”

“That’s right. We thought you knew that.”

“I didn’t, but we’ll take care of it.”

The two of them got up from their chairs simultaneously, gave each other another bemused look and said good-bye as they left the room.

There I stood, watching them leave and thinking I had just spent some jing I could have used better somewhere else.

My wife, who worked side by side with me as a nurse practitioner for over ten years, is my proofreader. She actually worked as a proofreader for a small New England weekly newspaper many years before I met her. She is also my best friend and my sounding board.

My first version of the previous post on this blog didn’t meet with her approval. She pointed out that my narrative sounded jaded and encouraged me to come back to it on a day when I was less tired. I gave the post a few days rest before revising it and felt better about the second version.

The other night, as I was describing a difficult day in the office with a schedule that didn’t make my job easy to do, she reflected:

“You treat your patients better than you treat your staff, or your family sometimes, for that matter”.

I looked up from my dinner plate. She wasn’t joking.

“You can be such a healing presence for your patients”, she said, “but you have a tendency to turn that off in dealing with the rest of us. You could be more healing in all your relationships”.

I thought of what she said. She was right, of course. I can be hard on myself and on those around me. I tend to think of us as working only for the patients or some abstract ideal of perfection rather than also with each other.

How many times have I simply told my wife or my children that their symptoms – sprains, migraines or bellyaches – will go away without offering a fraction of the support my regular patients get in the same situations? And how many times have I been less attentive to their worries and heartaches than I should have been?

I realize my loved ones get less care than they deserve, because “I already gave at the office”.

Do I really think I have a right to switch off my healing presence? I don’t mean that I or any other physician should try to work longer hours or take on more patients than we are able to take care of. What my wife made me think about is my whole way of being:

I always wanted to be a doctor. Now that I am one, I am a doctor every moment of my life. I am not a husband or a father or a pet owner just certain days or hours of my life. Neither one of those roles is “just a job”. Neither is being a doctor, particularly in specialties that profess to treat the whole person.

Obviously, I am still working at it. I’s my New Year’s resolution.

Trevor Dubay was in to see me during a very busy afternoon session on December 22^nd. I hadn’t seen him for almost a year. Last time I saw him he had come in with indigestion and acid reflux and the medication I had prescribed for him must have worked. He had called in for refills 3 and 9 months after his office visit.

This time he was in my schedule with a concern about heel pain. “Plantar fasciitis”, I figured before I knocked on the exam room door.

“Hi there. I haven’t seen you in a while. How’s the heartburn?” I asked.

“Doing good, as long as I take my pills, but I can’t go without them very long.”

“Any trouble swallowing, cough, hoarseness or belly pain?”

“No, not at all.”

“Then, in your age bracket, as long as the pills work, we’d just tell you to keep taking them. Then, maybe at 50, we’d send you for a scope test. Now, today you’re here for some heel pain?”

Sure enough, he had the typical heel pain when he first started walking in the morning and he was worse those days at work when he had to do a lot of walking on concrete floors. His physical exam was consistent with the diagnosis, so I started explaining the mechanism behind his condition and the various things we can do for it – anti-inflammatory medication, ice, stretches, heel cups inside his work boots, ultrasound treatments and, the last resort, steroid injections.

I went to pick up my handout for plantar fasciitis and heel spurs and he agreed to a physical therapy referral. I entered the request into the electronic medical record.

“Why do my hands go numb at night?” he asked when I had finished typing.

“Both hands, all fingers?” I asked.

“Uh-um”, he nodded.

“Ever happen during the day?”

“Once in a while.”

“Any neck pain?”

“No.”

“Show me how far you can turn your neck each way.”

His range of motion was normal, as was the strength in his arms and hands. He had normal feeling in all fingers. Tinel’s and Phalen’s signs were negative – no sign of carpal tunnel syndrome – and Adson’s maneuver was negative – no sign of cervical ribs or any other impingement of the circulation to his arms. He did wince slightly as I pulled his right arm back, though.

“My shoulder’s been sore for years”, he explained.

“That wouldn’t explain both hands tingling, though”, I said. “I don’t think you have carpal tunnel syndrome, and it doesn’t look like a clear cut neck problem, although sometimes too thick a pillow can trigger this sort of thing. I think you have what we call acroparesthesias…”

“What do you think of this rash?” he interrupted, and exposed his neck and upper torso.

“That’s called Tinea Versicolor. It’s an infection that changes how the pigment in your skin behaves, We treat it with athlete’s foot creams, but then you have to tan a little to even out the color sometimes.”

“Oh, I can buy one of those creams over the counter, right?”

“Sure, any one of them. Leave it on for a good ten minutes, then wash it off. Do that once a day for a week.”

“Great.”

“So, for your heels, you’ve got the exercises, you can get the heel inserts, buy some naproxen. They’ll call you from physical therapy for an appointment. And – if all else fails – we can give you a shot.”

He winced.

“So, you and Beth have a good Christmas”, I said as I got up from my stool and reached my hand out towards him.

“You too, but what about my shoulder?”

I paused and glanced at the time; 22 minutes into his scheduled 15 minute visit.

“Well, that’s a whole other project. We’ve covered a lot of ground today already, and my next patient is waiting. We could order an x-ray and have you come back for a full evaluation of your shoulder if you’d like.”

“Never mind”, he said.