A Country Doctor Writes:

Talking with my wife on the phone at lunch today, I asked in my usual manner:

“Was there anything interesting in the mail?”

She hesitated for a moment before answering:

“There’s a letter from the Board of Medicine.”

My mind switched into a higher gear.

“A letter? Not a mass mailing?”

“No, it’s a regular, business-sized envelope.”

“Does my name look typed, or is it a mailing label?”

“It looks typed.”

I have had a couple of letters from the Board before. Many years ago two disgruntled patients complained about me. One wasn’t happy that I stopped prescribing pain pills, and another wanted me to provide care via email. Both times all I had to do was give my side of the story, and the complaint was dismissed without merit.

“Was this a letter about a complaint against me?” I thought to myself. I didn’t know if such letters came registered mail or not.

“Do you want me to open the letter?” my wife asked.

“No, save it for me to open when I get home.”

I had arranged to be off this afternoon in preparation for a weekend trip. A surprise April snowstorm thwarted our travel plans, so we had changed our plans to include a nice, early Friday dinner and a classic movie by the fireplace.

“Would the letter from the Board change the mood of our Friday evening and quiet weekend at home?” I wondered to myself. It had already made me feel a little uneasy the moment I heard about it. It could be a simple announcement of some type; it wasn’t necessarily something unpleasant, although I supposed it might be.

As a physician in America, I work very hard. I strive to do what is medically correct and also to take care of each patient’s need to understand and take responsibility for his or her condition. Sometimes when you read the headlines, it feels as if doctors are never safe from criticism and litigation for being humanly fallible.

“Was it my turn now to be called before the Board of Medicine because I had failed in someone’s eyes, or offended someone inadvertently? My mind wandered as I drove through town to do a few errands on my way home. “How bad could it be?” I tried not to worry.

It had already started snowing by the time I got home. The letter waited for me on the dining room table. I opened it quickly.

With a feeling of relief I read the first few words. The letter was addressed to all physicians with licenses coming up for renewal after May 1 this year:

“Written Exam Required at Renewal” it began.

When I renew my license next time, I will have to take an exam about the Board’s guidelines regarding Informed Consent.

One more hoop to jump through to prove myself worthy of continuing to practice medicine, nothing personal…

Edgar Bowler relies on his much younger wife, who sees one of my partners, to help him keep track of his appointments and drive him to the office. Both of them have multiple medical problems and between them they take well over a dozen different medications. She usually handles their prescription refills and pill minders. Some of their medications are quite expensive and not all of them are covered by their insurance, so our office sometimes helps them out with samples.

Recently, Jane Bowler had eye surgery and Edgar had to step in with the help of his son-in-law, Jonathan, and take care of their medications. They came in to pick up a bag of several kinds of medication samples we had saved for them.

A few days ago, Edgar made an urgent appointment for hives. He was literally covered with them. Fortunately, he didn’t have any trouble with his breathing, but I did prescribe both steroids and antihistamines for him. At first, he had no idea what had caused the hives, but as I went down the usual list of considerations, he exclaimed:

“New medications, yes, there was a new one in the bag Jonathan and I picked up a while ago, that might have been it!”

“But I haven’t prescribed anything new for you,” I protested.

“You didn’t?”

“I think we need to take a look at those pills, Edgar. Could you bring them in for us to look at later on?”

Edgar left with his allergy medication prescriptions. Later the same day he returned with all his pills, neatly laid out in his two-week pill-minder.

The ones that seemed to have caused his hives were off-white, oblong, and imprinted with “LILLY 4165”.

The offending drug turned out to be Evista, a selective estrogen receptor modulator, used occasionally for postmenopausal women such as his wife, Jane, and never for men.

How does one explain that on Edgar’s list of allergies in his medical record?

Sally Straub is the only lawyer in town. Her father was the town lawyer before her. He went on to become a judge. Retired from the bench, sharp as ever at 78, he is still “of counsel” with his daughter’s law practice.

Sally is a sympathetic, no-nonsense woman with a big heart in a petite body. She is involved with every imaginable charity and public service organization in our community. Her husband, Jack, is a retired professor from the college up the road.

After knowing her for years, I learned that Sally was battling chronic anxiety and insomnia. To most people, she seemed to be the personification of self-confidence, but she constantly doubted her abilities, even though her social and professional accomplishments were remarkable by anyone’s standards.

“I’ve been in therapy on and off for most of my life, and I’m still not any closer to peace of mind,” she said the other day, adding, “and I don’t want drugs for this!”

I didn’t know quite what to say at first. I only had a few minutes scheduled with her, but she seemed to be at a point where she needed me to help move her forward, somehow.

Guided by a gut feeling, I asked:

“Do you have any regrets in your life?”

She seemed frozen for a few moments. Suddenly, tears welled up and she leaned forward, staring at her hands, which were now folded in her lap. She began:

“You know, Jack and I never had any children.”

I nodded. “I know.”

“Well, you don’t know this, but I was married once before, when I was in college. He was also a pre-law. My parents never liked him. I got pregnant and he didn’t want children. I didn’t feel I could tell my parents, and all the people who knew me told me to just have an abortion. I was scared.”

“So, that’s what you did…” I asked.

“Yes. They offered me counseling and everyone said it was just like having a tooth extraction. I knew right there on the operating table that I had made the wrong decision. I can still hear the sound of the suction device. I hear it every night, echoing in my head when I try to go to sleep. I imagine my daughter – I’m sure it was a girl…”

“And you never told your therapists?”

“They never asked. Or they didn’t seem ready to hear what I felt inside.” She wiped her eyes. “Paul’s and my marriage fell apart and we both moved on. I got busy with law school and my career.”

“Did your parents ever find out?”

“I never told them.”

“Does Jack know?”

“Yes, I told him when we first got together and he’s so sad, because he’s sterile.”

“Do you still blame yourself for making the choice you made back then?”

“Terribly.”

“You and I are about the same age. I know what many people said back then, but that probably wasn’t at all consistent with your values, and people didn’t know then what kind of grief reactions abortions created. Let me get a book I’d like for you to read,” I said. “I’ll be right back, okay?”

She blew her nose and nodded.

I quickly found the thin, blue volume in my office bookshelf and brought it back to Sally.

She took the book from my hand.

“The Four Steps to Healing,” she read out loud.

“It was written by a psychiatrist. It will help you get started. But you’ll need a therapist who understands and respects your values without trying to be politically correct. I know someone who might be able to help you.”

“I feel silly, fifty-eight years old and falling apart over something that happened almost forty years ago.”

I reached both my hands out toward her and she grabbed hold of them and squeezed them briefly.

I wrote the phone number on the back of one of my business cards. “Promise me to call Diane Fehrer soon.”

She nodded. “I will. Thanks.”

Cora Mills had never been treated for asthma before, but when I saw her this winter with a sinus infection and a tight sounding cough, she was wheezing terribly. Her oxygen saturation was fine but her peak flow was in the low normal range. She refused the steroid pills I wanted her to take along with her antibiotic, so I offered her a prescription for an albuterol inhaler.

Cora had never used an inhaler before, so after I wrote her prescriptions, I left her room and got a demonstrator inhaler to show her the proper technique and let her practice a few times.

She had a little trouble coordinating her breathing and activation of the inhaler, so when there was a knock on the exam room door and Autumn, my nurse, announced that the Emergency Room was on the phone, I left Cora to practice on her own a few more times.

The call took longer than I expected, and by the time I got back to Cora’s exam room, she was already wearing her long wool coat, felt hat and scarf, ready to leave.

I quickly wrapped up the visit and told her to come back if her chest symptoms didn’t clear promptly.

Two months went by, and last week Cora came back in for her annual checkup.

“How’d you make out with your asthmatic bronchitis?” I asked.

“I had a terrible time clearing it up,” she quipped. That sample inhaler you gave me didn’t do a darn thing for my breathing!”

No wonder I couldn’t find my demonstrator inhaler the other day, I thought to myself.

“That was a practice device with no medication in it, I explained. I wrote a prescription for the real thing. Do you still have the placebo inhaler we used to practice with?” I asked.

“No, I was so upset with it that I threw it away!” She grinned and shrugged.

“My name is DeWitt. I’m a neurosurgeon in Charleston, South Carolina,” a velvety male voice announced. I cocked the telephone receiver under my chin as I grabbed the chart Autumn handed to me.

“I have just operated on your patient, George Magnusson. He had a large subdural hematoma from a fall that happened a few days ago.” The surgeon spoke in a slow, subtle Southern accent. He continued:

“The reason I am calling is that you’ve had this man on blood thinners for several years now for a pulmonary embolus and deep vein thrombosis he suffered after a motor vehicle accident.”

I glanced at Mr. Magnusson’s problem list.

“Yes, in 2001,” I replied.

“Right,” he continued, “but he has a Greenfield filter, so he is protected from pulmonary embolization.” After a slight pause he continued in a restrained, low voice:

“I don’t believe one usually continues the warfarin under those circumstances. I had to reverse it for the surgery and will be leaving him off it while he’s here, obviously. But I would suggest you discuss the risks and benefits with him when he returns home.”

“What was his prothrombin time?” I asked.

“It was therapeutic. And I expect him to make a full recovery, fortunately for all of us,” he added. “He should be back in your area next week.”

The telephone conversation left me thinking.

George Magnusson had taken his blood thinner faithfully for ten years and had hardly ever been out of the therapeutic range. He was fairly healthy otherwise, and I seldom saw him during the three or four years he had been my patient. When I first met him, I had not questioned his need for chronic anticoagulation.

One school of thought is that patients with a definite trigger for a blood clot, such as a major fracture, can be taken off blood thinners after three to six months. Another viewpoint is that patients with a history of massive clots are better left on their blood thinners indefinitely.

Had I failed George Magnusson by keeping him on warfarin and subjecting him to an unnecessary risk of bleeding as he was getting older? After all, his clots happened after a major car accident with multiple fractures.

In my mind I went over what I remembered about inferior vena cava filters. I had very little experience with them, but never thought of them as a replacement for anticoagulation. At best they only reduce the risk that a blood clot would separate from its location in a leg and travel to the lungs, but a person who is at risk for blood clots in the legs could still develop them.

My most trusted online database stated: “Because patients with IVC filters are at risk for IVC thrombosis, insertion site thrombosis, and recurrence of the initial thromboembolic event, continued use of anticoagulants when there are no contraindications is prudent.”

When George and Ellen Magnusson returned from their winter vacation near Hilton Head, South Carolina, they both looked tired. George’s thick, gray hair had been shaved on one side of his head for the operation.

I went over the pros and cons of staying on blood thinners after trauma-related clots like George’s. Especially Ellen looked reserved.

“Dr. DeWitt was very sure blood thinners weren’t necessary,” she said.

“It’s a judgment call,” I answered. “Why don’t we get a hematology consultation? I’d like to hear what someone like Dr. Hertzog thinks about your situation.”

Ellen and George left the office and we agreed to talk again after the hematology consultation.

This morning I got a call from the Emergency Room. George just came in with a massive clot from his calf all the way up to his groin.

I guess we won’t need that hematology consult, after all.