A Country Doctor Writes:

One of the first challenges I faced as a foreign doctor from an urban background practicing in a small town in this country was finding the right way to explain medical issues to my male patients. They were farmers and fishermen without much experience with illness, medications or medical procedures. Most of them came to see me reluctantly at their wives’ insistence.

Gradually, I found my voice and a style that has served me well over the years. As a Boy Scout and grandson of a farmer with more than an average interest in automobiles, I have found enough analogies from my own experience to be able to cross the cultural barriers I have encountered in my new homeland.

I may explain risk aversion by talking about why some men wear both a belt and suspenders. Heart attacks and angina are, obviously, related to plugged fuel lines. Beta blocker therapy is similar to shifting your manual transmission into fifth gear. Sudden discontinuation of beta blocker therapy is like releasing an inadvertently engaged emergency brake while driving with your gas pedal fully depressed. Untreated hypertension is like driving down the highway in third gear, and orthostatic hypotension is a lot like getting poor water pressure in an attic apartment.

Other, perhaps less obvious, analogies I have perfected over the years include the following:

Finasteride to slow progression of benign prostatic hypertrophy:

You buy a new car and the dealer sells you a rust proofing job. Five years later, your car is rust free. Is it because you paid extra for the rust proofing, or would the car have been OK anyway?

Why carotid artery stenosis up to 80% can be asymptomatic:

If you water your plants with a garden hose and compress the hose by 80%, the water will actually squirt faster and further than if you just stand there with a soft grip on the hose.

What to do when a test result and your judgment conflict:

When the terrain and the map disagree, follow the terrain.

Why some people with high cholesterol escape heart disease while others get more atherosclerosis than expected because of inflammation, as measured by C-reactive protein (CRP):

Some people’s arteries are like Teflon, nothing sticks, and other people’s arteries are like a scratched-up aluminum pan, everything sticks to the bottom.

Why skipping just one dose of your antihistamine can cause a major allergy flare-up:

If your townspeople are trying to discourage out-of-towners from stopping in and causing trouble at your local hangout and your strategy is to make the place look filled to capacity, be sure you get there as soon as they open, and don’t you all take a break at the same time, or the place will look empty and they’ll be sure to stop in.

Why some people can take an antibiotic several times before they get a rash from it:

Just because your neighbor’s pit bull doesn’t bite you the first time you see it, do you really know it won’t bite you the second time?

Our job as doctors is to meet our patients “where they’re at”, as people say around here. That’s not the English I learned in school, just like the explanations and analogies I use with my patients aren’t exactly the ones I learned at Europe’s second oldest university. But all the book knowledge in the world won’t help you be a better doctor if people don’t like or understand the way you speak.

Today, a nurse I work with at the nursing home gave me the nicest compliment. Her husband had, reluctantly, been in to see me a few weeks ago. She told me that her husband thought that now, for the first time ever, he had a doctor he could talk to – one that talked the way he did and laid things out plain and simple without putting on airs or making things complicated.

Comments like that always make my day, just like hearing that people forget I am a foreigner and “from away”.

We have a joke at the clinic that the only type of paper that doesn’t need a doctor’s signature is the toilet paper. We are constantly scribbling our abbreviated signatures on incoming x-ray reports, specialist’s consultation reports, ER reports and lab results. Once signed, these papers get filed in the patients’ charts, and may never be looked at again.

Unsigned reports, paper clipped to the front of patient charts, clutter countertops, shelves and desks throughout the office. There is great pressure to just sign off on them, so they can be put away.

But out of sight is out of mind.

At the nursing home, rounding doctors open their folders and find stacks of lab results, some x-ray reports and the occasional consultation note. Each piece of paper gets a few seconds’ attention before it gets signed off. The charts are not pulled, and the system more or less assumes that each doctor knows the “story” behind each lab report he quickly scribbles his signature on.

But sometimes we get the results of a test ordered by one of our colleagues. What if we don’t notice and sign off anyway?

On a sweltering August afternoon at the boarding home across town I had seen Roger Greary, a sixty pack-year smoker with high blood pressure and borderline kidney function. He was short of breath just walking to the dining room and he had a hint of ankle swelling. I ordered some bloodwork, which included a screening test for heart failure. My handwritten chart note outlined my plan on how to proceed, depending on his test results.

Last week, rounding on a couple of the other residents, my folder contained a request from an oral surgeon to clear Roger Greary for several extractions under anesthesia. I asked to see Roger’s chart and saw my note about his increased shortness of breath.

Flipping to the laboratory section of his chart, my heart sank as I saw the markedly elevated BNP level, a sign of heart failure, signed off by another doctor while I was out on vacation.

I ordered an echocardiogram, started him on furosemide, increased the low dose lisinopril Roger was on for high blood pressure anyway, and jotted down a quick reply to the oral surgeon that we needed to take care of Roger’s heart failure before giving him the go-ahead.

At the office this afternoon I signed off on a stack of prescription refills, more than twice the usual amount, since two of my colleagues are away at a medical conference in Boston. One of my oldest patients needed a routine refill. As I flipped through his chart, my eyes landed on a complete blood count done the day after I saw him last.

His white blood cell count was 30, three times the upper normal limit. The differential showed a “right shift” without atypical cells, so it looks like chronic lymphocytic leukemia, which we wouldn’t treat unless he developed symptoms. But I don’t remember thinking about CLL when I signed off on that report, and it is definitely my signature. Did I scan the report too quickly and mistake his new white count of 30 for his old hematocrit of 30, just a sign of his chronic, stable anemia? Did I sign off on it while listening to a nurse tell me some urgent news about another patient?

Fortunately, my elderly patient is coming in again very soon, and I will be sure to check this out thoroughly, but I have become sensitized again to the dangers of signing off on too many lab reports in too little time.

Signing lab reports is important work, and sometimes we only get one chance to do it right.

Autumn, my nurse, called about 7:30 last night. Her five-year-old son, Curtis, had just come running into her kitchen from his bedroom, crying “Mommy, Mommy, I’m going to die!”

“Why, Curtis?” she had asked.

“I swallowed a screw”, he sobbed.

Autumn tried to get him to describe the size of it, but he couldn’t tell her.

Curtis sees a pediatrician in the city for his health care, but Autumn often runs things by me. I am fine with that arrangement, as it can sometimes be hard to be both coworker and care provider.

My advise to Autumn was to take Curtis to the emergency room in case the screw was very large, although that seemed unlikely. An x-ray would settle the issue.

As I was about to fall asleep last night, I got a text message, saying “Doing X-rays now”.

This morning I got the rest of the story from my slightly tired-looking nurse:

Curtis felt well, was his usual social butterfly, and really enjoyed his visit at the hospital. His physical exam was normal, and the angst he had first experienced was long gone. He asked the nurses and the young doctor all kinds of intelligent questions.

While waiting for the x-ray, Curtis asked his mother: “Will an x-ray show everything in your stomach?”

“It certainly will. Why did you ask?”

“Will it show pennies?”

“Yes, Curtis, don’t tell me you swallowed a penny, too?”

“I might have.”

“Might have? When did you do that, and how many pennies did you swallow?”

“Only one penny, maybe two or three days ago…”

The doctor came in with the x-ray. It showed a one-inch screw in Curtis’ duodenum. After the doctor had made sure that Curtis was still feeling OK, he went to call Curtis’ pediatrician.

“See, I told you it was a long time ago I swallowed the penny”, Curtis said.

The doctor came back, frowning.

“Well, doctor Patterson’s partner wasn’t very nice. He said ‘Why’d you call me about it, you’re the emergency room doctor!’ Anyway, my feeling is that this thing will probably pass just fine, now that it’s already out of the stomach. Bring him back if he has any symptoms, otherwise just check his stools.”

Turning to Curtis, the doctor said:

“You seem like a really bright young man, Curtis. What do you want to be when you grow up?”

Curtis answered without a moment’s hesitation:

“I want to be a doctor, so I can go to the hospital every day!”

Skip Rollins drove 35 miles to see me today for his blood pressure follow-up. A few months ago I had prescribed a mild diuretic, hydrochlorothiazide. I had ordered a blood test to be done a while after he started taking it in order to check on his potassium level and kidney function. Then I saw him in follow-up, and his blood pressure was normal. We had agreed on a follow-up in November.

Looking at his chart before knocking on his exam room door, I saw numbers I didn’t like – 154/110. His blood pressure was right back where it started.

It didn’t take long to figure out what happened.

“Oh, those pills, I ran out of them a month ago. You didn’t give me a refill”, Skip rumbled in his big-barreled baritone voice.

I paused.

“No wonder your blood pressure is up again, then, Skip. I’m sorry I didn’t check if you had a refill, but, you know, you can just call us or have the drug store contact us if you run low on your medication.”

“Oh, I figured you didn’t want me to take any more of them.”

“No, I just didn’t want to write for more than one refill when we started with that medicine in case it wasn’t going to work out for you.”

I wasn’t sure he needed to hear that I also don’t write for several refills in case patients don’t get their labwork or no-show for their follow-ups.

“Well, I see the stuff worked, and I still seem to need it”, Skip mused.

“Definitely. Once someone’s blood pressure is up, it usually stays up unless they lose weight or cut out the salt. Your blood pressure was real stubborn at first, remember? Here’s a script with refills for a year, but I’d like to see you in March again, okay?”

As medical providers, we often assume our patients will understand our routines and our way of thinking, but, at least around here, so many of our patients have little or no experience with disease and with the health care system. Skip never imagined that high blood pressure was a chronic condition with possibly lifelong treatment. I thought everybody knew that, and I failed him.