A Country Doctor Writes:

I, like most primary care physicians, have many patients on chronic “blood thinners”. Warfarin, essentially the same chemical as rat poison, is the most common drug we use, and it can be difficult to manage. Because its effects are counteracted by vitamin K, simple dietary changes like eating fewer or more greens can change the effects of warfarin. There are also many drug interactions to keep in mind.

Because of these interactions we never assume that patients can stay on the same dose of warfarin indefinitely. Some people’s numbers vary enough to warrant testing a few times per week. Our clinic’s minimum standard is that even stable patients get a blood test once a month to monitor the medication’s effect.

We measure the “prothrombin time”, or how many seconds the blood takes to clot, and “INR”, International Normalized Ratio, which is, roughly speaking, how long a patient’s blood takes to clot compared to an untreated person’s blood. We typically strive for an INR of 2 to 3, which is 2 or 3 times the normal, untreated, clotting time.

Antibiotics are among the most common drugs that interact with warfarin. Only a handful of antibiotics are safe in this regard. Penicillins, cephalosporins and nitofurantoin are choices we don’t worry about. Azithromycin sometimes interferes, and common urinary antibiotics like sulfa and ciprofloxacin almost always interfere to some degree.

Florence Fitch, an elderly patient of mine with atrial fibrillation, had a urinary tract infection and had seven days of ciprofloxacin prescribed by another doctor. She ended up in the hospital with an intestinal hemorrhage and needed two units of blood.

Today I saw Gwen Hubert. She has high cholesterol and atrial fibrillation. She must have been on warfarin and simvastatin for ten years. Her numbers were always quite stable. When I saw Gwen the last time, she had complained of fairly significant muscle aches. Her cholesterol was perfect and her creatine phosphokinase (CPK) test didn’t show any sign of muscle damage. Still, even when there is no damage, people on simvastatin as well as all the other statins can have bothersome muscle aches.

At our last visit, Gwen and I agreed that she would not take the simvastatin for three to four weeks. If there was no difference, she was to start her cholesterol pill again and see me a month or so later.

She had had an INR drawn the other day and her level was high enough that we had called her to tell her to skip a day of warfarin and start taking a lower dose after that.

Gwen was concerned when I saw her.

“I’ve never had a high INR before. Do you think starting the simvastatin again caused a problem with my warfarin?”

I looked at her flowsheet. About the time we stopped her simvastatin her INR had dropped. I hadn’t thought much of it and just increased her warfarin dose a little. The following week her number was higher, but still not in range, so we had her increase her dose some more. That took care of it. Then, when she started the simvastatin again, her INR went up to 4.

“I haven’t seen simvastatin do that before, but I’ll look it up.”

Our usual drug interaction website didn’t respond. The first result on my Google search was an abstract of an article from Oslo, Norway, published in 2007:

An 82-year-old white female was admitted to the hospital because of an international normalized ratio (INR) value greater than 8, which was detected at a routine follow-up visit to monitor warfarin therapy. Four weeks earlier her lipid-lowering therapy had been switched from atorvastatin 10 mg daily to simvastatin 10 mg daily. She had been treated with 2.5 mg of warfarin daily for almost 30 years due to episodes of deep venous thrombosis and lung embolism. Her INR had been stable within the treatment range (2.0-3.5) for more than 2 years before the INR increase. Upon hospitalization, she was given 5 mg of vitamin K orally. A few hours later she lost the feeling and movement of her right arm and a computed tomography scan showed major bleeding in the left cerebral hemisphere. She died the following day.

DISCUSSION: One study has shown a lack of interaction between warfarin and atorvastatin. In comparison, 3 studies have shown significant increases (10-30%) in warfarin effect and/or reductions in dose requirement after starting concomitant simvastatin treatment. The interaction mechanism between simvastatin and warfarin is not known but is possibly associated with reduced elimination of warfarin. Use of the Naranjo probability scale showed that the likelihood of warfarin-induced INR increase following the switch to simvastatin was probable.

CONCLUSIONS: Atorvastatin and simvastatin appear to differ in their potential to interact with warfarin. Clinicians should be aware of the interaction risk when starting simvastatin treatment in patients on warfarin therapy. 

In Gwen’s case, restarting a drug she had been on for over a decade could have had the same deadly effect.

One of the movies we watched this holiday season turned out to be a wonderfully relevant commentary on medicine in 1947, and also today. In “Welcome Stranger”, Bing Crosby plays Dr. Jim Pearson, an easy-going, rootless Californian, who takes a locum tenens position covering for Dr. Joseph McRory, a crotchety old country doctor in Fallbridge, Maine, played by Barry Fitzgerald. The country doctor is planning his first real vacation in 30 years, but when he lays eyes on his young replacement, he starts to wonder if he can leave his practice and his little town in the hands of such a stranger to life in small town Maine. The town’s young pharmacist notices that his fiancée, schoolteacher Trudy Mason, played by Joan Caulfield, is attracted to the California doctor, and recruits another young physician to come and apply for the temporary position. As the elder physician begins to change his mind about taking a vacation, he becomes ill with appendicitis. Dr. Pearson (Bing Crosby) does the operation with the pharmacist’s fiancée as first assistant. This convinces the country doctor that Pearson is a capable physician, and the two develop a real friendship during the postoperative recovery period. The relationship between these two very different physicians, who find themselves more and more similar as their friendship evolves, serves as the film’s core motif. The romantic subplot is between Dr. Pearson and Miss Mason. They seem to be getting along better and better and the pharmacist provokes a breakup of his engagement to Miss Mason. The pharmacist’s candidate to cover for old Dr. McRory, Dr. Ronald Jenks, gets turned down for the temporary position now that Dr. Pearson has proven himself, but Jenks doesn’t retreat. He simply hangs out his shingle in competition with the old country doctor. He even plots to replace the veteran physician as Medical Director at the town’s brand new hospital, based on his ability as a younger, more recently trained doctor to bring new ideas and new methods to the small hospital. The hospital board is suddenly leaning in the new physician’s favor. Bing Crosby’s character, Dr. Pearson, comes to the older doctor’s defense with the words: “Nobody has discovered a substitute for skill or wisdom or practical experience… or for goodness of heart.” The only opportunity offered for the older doctor to prove himself current enough to keep his position is to take a test of basic medical knowledge. He reluctantly agrees and Dr. Pearson helps him prepare. Suddenly a medical emergency brings all three physicians to the school, where several boys seem to be in the early stages of a critical illness. The arrogant Dr. Jenks diagnoses them with Eastern Equine Encephalitis and insists that everyone in town gets urgently vaccinated. The seasoned older physician walks around the school and finds remnants of cigars in the sink in the boys’ bathroom. He confronts the boys, who admit they got sick from smoking cigars. His down-to-earth diagnosis puts the book-learned challenger to shame. The hospital board asks him to lead the new hospital into the future. He declines, unless Dr. Pearson decides to stay on and work with him. Pearson at that very moment proposes to Miss Mason, and when she tells him “yes”, he agrees to become Dr. McRory’s new full-time associate. The tension between practical wisdom and academic theory in medicine exists today as much as it did in 1947. The arrogant challenger without compassion and common sense reminds me of some of the doctors striving for power in medicine today, too. That’s what makes this movie a classic; it portrays a bygone era, and at the same time it makes us think about where we are today.

Author’s note: Long after writing this post, I came across the appendicitis story line in A. J. Cronin’s writings about Dr. Finlay, immortalized in books and two TV series.

Mrs. Blouin was new to our practice. Her previous doctor, in the next town up the road, had left the area just over a year ago. Her presenting complaint was “Wants Reclast infusion”.

Reclast is a once-yearly $1,200 intravenous infusion for osteoporosis, primarily for patients who cannot tolerate the older treatment alternatives.

I have many misgivings about osteoporosis treatment, and have not yet prescribed Reclast. It has a long list of drug interactions and side effects, and it is still very new.

It didn’t take me long to realize that there were other issues afflicting Mrs. Blouin. She was fatigued, her blood pressure was very high, she had no idea what her cholesterol was, and she had a foreboding family history of cancer and heart disease.

Dr. Greyson’s notes mentioned her blood pressure being up a bit, ongoing fatigue, breathing problems and several other symptoms. Reading through them, I wasn’t sure how osteoporosis came to be the predominant concern.

“How did you and Dr. Greyson come to focus on your bones?” I asked.

“I don’t know”, she answered. “I guess he thought they were really that bad.”

“It sounds like we need to look at the whole picture right now. You couldn’t get your infusion now anyway without some fresh bloodwork. We might as well see if we can find out why you’re tired, check you for anemia and thyroid problems. We could also check your cholesterol if you’d like. And I’d like to check your blood pressure one more time, since it’s higher today than it was last year at Dr. Geyson’s.”

I had moved the focus of our visit away from what Mrs. Blouin had come to see me for. So had Dr. Greyson, but in the opposite direction.

Physicians change the subject of patient visits all the time. Sometimes we do it because we feel there is a more pressing issue than the one a patient came to see us for, like correcting a high blood pressure or screening chronically ill patients for depression, which may be a barrier to achieving better health. Other times we may be guilty of shifting the attention away from a symptom we are unfamiliar or uncomfortable with in favor of something we find easier or more satisfying to deal with. Sometimes we may avoid or postpone issues that aren’t easily solved in a fifteen-minute-visit.

I sometimes hear patients say about other doctors: “He didn’t seem concerned about my symptoms”. Some people may say that about me too; I know I don’t pay as much attention to arthritis pain and old sports injuries as some patients might expect when they come in for physicals and have unmet screening needs for cancer and cardiovascular risk that I feel a need to cover in my half-hour with them.

But where do we draw the line? When is it fair to change the agenda for a patient visit and when is it not? When are we doing the right thing by steering our patients toward issues they may not have thought of as priorities, and when are we doing the wrong thing by not making them equal partners in their own health care?

I never did get my haircut for Christmas. The past few weeks, things seemed to be going at warp speed. Yesterday, my half-day at the office dragged on past two o’clock, and then there were two admissions, two 60-day reviews and several sick visits at the nursing home to take care of.

The week was interspersed with e-mails from my cousin in Sweden about his father. December 3^rd, at my own father’s funeral, R., his youngest brother, sat in his wheelchair in the center isle of the chapel. Afterwards, in the parish hall, he said “next time it will be my turn”. He felt a strange chill, but refused the black knitted throw his wife had brought with her.

Two weeks later, his doctor predicted he would be gone within hours. My cousin’s e-mails brought back memories of my own father’s passing. My father used to call me R., then correct himself when he realized I was his son, not his younger brother. I took it as a compliment, a sign that he sometimes saw me as a member of his own generation.

My uncle lingered on, and my cousin’s e-mails grew more philosophical. My replies contradicted their young doctor’s attempts at predicting the course of life’s biggest mystery.

Day by day, sometimes hour by hour, the messages told the story of my uncle’s changing neurologic condition and his family’s winding journey between extremes of hope and despair but inevitably away from the way things used to be.

As Christmas drew nearer, new snow fell outside while the family’s vigil continued. The e-mails arrived at a steady pace. My uncle’s breathing took on the familiar pattern I had listened to as I sat through long days and nights at my father’s bedside.

When the snowfall stopped and my uncle’s coma deepened, my cousin wrote metaphorically: “Fine flying weather, but no traveler yet.”

My day at work continued; there were so many things to take care of before we closed for the Holiday. Finally I arrived at home some time after seven o’clock with a couple of last-minute grocery items and a stack of Christmas cards from the office.

After a Swiss fondue and some Chianti we tried to watch a Bing Crosby movie, but we both kept nodding off, so we decided to postpone the movie until the next day.

Even though today was a Holiday, we woke up at five. Over coffee in bed I checked my e-mail. My cousin had written:

“The night flight departed at 0330 hours. The traveler disappeared with a broad smile on his face.”

I finished my coffee, got dressed and headed outside toward the barn with warm mash for the horse.

Walking across the yard, dimly lit by the almost full December moon, I paused to listen to the perfect silence of the Christmas Eve morning. I noticed the blinking lights of a small airplane moving across the sky. My eyes suddenly grew moist and I lost sight of the plane.

I thought of my cousin’s metaphor about his father’s passing, remembered my own father’s last breaths, and wondered if the two brothers had hoped to meet again. My father never spoke about what he really believed. 

The chill of the early morning crept inside my leather jacket and I hurried to get inside the barn door.

B. C. and his wife came in for his diabetes follow-up the other day. His blood pressure and blood sugar have been out of control for over six months now, but he has refused to try new blood pressure medications and he won’t consider insulin. He even hates pricking his fingers, so he had ordered a glucometer that uses blood samples from the forearm.

“I feel good”, he always says.

Even though we have seemed to be at a medical standstill, I have enjoyed our visits together. He has told me many things about the wildlife around here and he has helped me understand our male dog’s reactions to the wolves and coyotes that surround us.

“Here, this is for you”, he said as he handed me an oblong envelope. Inside was a Christmas card with a picture of the two of them – she in a long dress, he in a colorful costume with a bearskin draping his back and the bear’s head on top of his.

“That’s me in full regalia”, he said proudly.

His face in the picture was quite pale.

“How’d your face get that that white?” I asked, wondering if he was starting to feel poorly some of the time.

“Grease paint.”

I thanked them for the Christmas card and got down to business.

“Have you checked any blood sugars after meals?” I asked.

“No, my new machine hasn’t come yet, so I’ve only checked a few times, but my sugars are down”, he smiled.

The three readings he remembered were actually in a good range.

“Are you eating differently?”

He shook his head. “I eat about the same.”

“No, we got rid of all the junk food”, his wife corrected him. I noticed he had lost a few pounds.

“I went to he herb woman”, he said, “and she gave me a mixture of thirty-two herbs that I’m supposed to take with each meal. It tastes like salt, but there’s no salt in it. I’ve also been taking my cinnamon.

“And I’ve been reminding you about your pills”, his wife interjected.

He ignored her comment.

“Between that and the fenugreek my blood sugars have really come down and I feel great; I have so much more energy.”

“Well, I’ve got to hand it to you. I don’t know exactly how the stuff lowered your blood sugar, but it sounds like you should keep taking it.”

He grinned proudly and gave his wife a triumphant glance.

“But, just to be safe, I hope you’ll keep taking your regular pills, too. And watch the junk food, okay?”

“I will”, he said, rising from his chair.

“Merry Christmas my friend”, he said, offering his big hand in a firm shake.

“You too”, I said, “both of you.”

His wife, now standing behind him, looked into my eyes and silently formed the words with her mouth:

“Thank you.”