A Country Doctor Writes:

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.

Sir William Osler spoke of the influence of these three forces on the life and conduct of a physician. He eloquently used temperature analogies to characterize the necessary qualities of a physician – burning hot or keeping cool, but never being lukewarm:

”….of Art, the highest development of which can only come with that sustaining love for ideals which burns bright…”;

 “Science, the cold logic that keeps the mind independent and free from the toils of self-deception and half-knowledge”;

“of Charity, in which we of the medical profession, to walk worthily, must live and move and have our being.”

                                      (Aequanimitas, 1904)

Today’s medicine tends to be more tepid, at least in my field, Primary Care. Others clamor to set our priorities, to the point that doctor and patient sometimes both feel marginalized. The personal doctor-patient relationship is sometimes replaced by a more generic consumer-provider exchange, where a patient may see the physician as just a necessary intermediary between their need and the solution they already know they want – as in the case of asking for a drug advertised on television.

We must start with what Osler calls “the cold logic of Science”. It is our role and our duty as physicians to view new claims of clinical benefit from tests, procedures or pharmaceuticals with a critical mind, applying our training and experience. Simply following guidelines is an abdication from our professional responsibility. You don’t need to go to medical school to follow guidelines – in fact, it may make it harder sometimes.

The burning flame behind our passion for the Art and compassion for our fellow human beings, what Osler calls Charity, must never be lukewarm.

We all have to work at the Art of medicine. It is easy to slip into routines of complacency; another case of this or that, giving it our usual “Spiel”. Seeing each patient and each clinical presentation as unique is necessary in order to connect with the other person in the exam room. Finding the right way to approach each one of many seemingly similar case histories is what makes a personal physician just that – each patient needs something slightly different from us. The better we understand those needs, the more effective we can be.

The Art of the medical practitioner lies in the balance between cold science and hot passion. This is where the chemistry between physician, patient and disease takes place.

Call it chemistry, even alchemy: As physicians, we are catalysts in each patient’s transformation. And just as any other catalyst, we cause a chemical reaction to take place without being consumed ourselves in the process.

Our true challenge as physicians in today’s health care climate is keeping the flame Osler spoke of. Without that flame we are at risk for straying from the ideals behind our profession.

Osler warned us never to feel lukewarm about being doctors:

“By far the most dangerous foe we have to fight is apathy – indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction.”