A Country Doctor Writes:

One of the teaching activities I am involved with is a Rural Preceptorship for medical students from one of the major medical schools.

Looking through some of the materials I received a while back, I saw a list of objectives that caught my attention. Students are expected, through their different experiences, to specifically advance in the areas of “talking like a doctor” (giving oral case presentations), “writing like a doctor” (recording chart notes), “thinking like a doctor” (applying clinical knowledge) and “acting like a doctor” (showing professionalism).

I was reminded of my experience when a Hollywood movie crew came to our area many years ago to film a horror movie with a doctor in one of the main roles. I did an insurance physical on the child star, helped the prop man get the medical items he needed and I took care of the film crew’s accidents and illnesses. I also met with the actor who played the young doctor.

Although I had never heard of him, he carried himself like someone who was used to fame and attention. He was casually dressed and looked like he could have been from downstate or even around here if it weren’t for his alligator boots.

The one question I remember him asking me was how disturbed he should be as a young physician when suddenly faced with an accident victim who has had his head partially crushed.

I thought for a while.

The closest I had come to that was early in my first residency, back in Sweden. The first night of the county fair a pretty, seventeen-year-old girl was brought in by ambulance in cardiorespiratory arrest. She was reported to have fallen off a merry-go-round. Ambulance protocols weren’t as advanced then as they are now. She arrived on a stretcher without a back board or rigid neck collar. The chief surgical resident was the doctor in charge of all things surgical in the emergency room at our community hospital. I assisted him as we relieved the ambulance crew giving chest compressions and ventilating her with a bag and mask.

Her pupils were unresponsive and her chest didn’t move with our efforts to ventilate her. As I leaned close and smelled the strange blend of blood and alcohol I have since come to associate with violent deaths, I noticed the swelling around her neck. I knew her windpipe was torn and we were pumping air into the soft tissues of her neck. The surgeon saw it, too, and ordered the resuscitation halted. Carefully, he moved her head, and we both cringed as her neck just continued to move to the side. She must have broken her neck falling off the merry-go-round.

All of it seemed surreal – the beautiful young face with unresponsive blue eyes, the swollen, limp neck and the smell of death and alcohol.

The surgeon called off the code and we covered up her face. Neither one of us said anything, but I could tell he felt as sick about it as I did.

“How disturbed do you think I should be?”

The Hollywood actor repeated his question. His earnest expression came back into focus as I cleared my mind of the images I had carried with me all these years.

“Ummm…….”, I answered, “quite disturbed”.

Psychotherapy appointments have traditionally lasted 50 minutes with 10 minutes for paperwork. This has lead to the expression “The 50 minute hour”. More recently there has been talk of incorporating psychotherapy techniques in brief visits in Primary Care. The provoking title “The Fifteen Minute Hour” is from a book about addressing the emotional aspects of disease in Primary Care during brief appointments. The title and the concept seem relevant to much of what we do in my specialty.

In Primary Care we seldom spend more than 15 minutes at a time with an established patient. Yet we are required to cover infinitely more details and consider more outside authorities in every visit today than when I first started practicing medicine. Between health insurance and office administration, there are now many more mouths to feed from the office charges than there were then. Sometimes it feels like we are not alone in the exam room even for the short time we do have.

Except for doctors in concierge medicine or micropactices, most of us cannot change the amount of time we have with each patient. Even if we hope to change the system, the patients we see today deserve the best we can give them in today’s 15-minute visits.

This is what I do in my busy, rural practice:

I work hard to focus on a purpose for each visit. If neither the doctor nor the patient knows what they are supposed to accomplish in 15 minutes, chances are not much will get done. In my schedule, nobody has just a “follow-up” or an “office visit”.

Established patients come to see me for one of two reasons. They may have identified a problem, such as back pain, a cough or a rash, and made an appointment for this. They might also have a follow-up because I requested them to come back in 1 or 3 months for their blood pressure, diabetes or some other chronic problem.

I look at my daily schedule to see how they day will flow based on the stated reason for each appointment and my knowledge of each patient. This helps us see where we might be able to squeeze in (double book) someone. For example, an appointment for fatigue and weight loss is likely to use up more time than an appointment for an earache. Some individual patients typically tend to need more time than others. Knowing the purpose of each appointment also helps focus the staff and me. Schedule notations like “Follow-up Blood Pressure, bring cuff” (to compare the patient’s own equipment with ours) or “Follow-up Diabetes, do comprehensive foot exam” eliminate guesswork.

I also keep in mind that I sometimes have more than one opportunity to get the results I strive for. Short visits in Primary Care often occur in the context of a doctor-patient relationship that stretches over an extended period of time and possibly even spans generations. A teacher would not try to cover a semester’s worth of material in the first week or month, and then just spend the rest of the semester repeating and reinforcing that information. It is the same with many chronic conditions we treat. Together, the patient and I decide on a general plan of action. We then patiently make small adjustments over time until we see the results we aimed for.

I try to see patients with chronic conditions like Type 2 Diabetes every three months with fresh blood tests done a few days before the appointment. We go over the results together and work out the next steps in the patient’s care. Every visit includes an overview of the major components of the disease. In diabetes, this list includes blood sugar control, blood pressure, kidney function, cholesterol/lipid status, foot problems, eye problems, heart issues and depression. After the overview, we usually focus on the most pertinent issue, such as improving blood pressure control. Even if every area could use some improvement, it isn’t generally feasible to attack several issues at the same time. Doing one thing at a time tends to bring better results in the long run.

I sometimes schedule brief, very focused visits for one aspect of complicated conditions like diabetes. If I prescribe a new blood pressure medication for one of my diabetic patients, the standard of care may require a blood test shortly afterward. I naturally also need to see what difference the medication made on the patient’s blood pressure and how the medication was tolerated. The visit to check blood pressure and laboratory results is a quick, separate visit between the scheduled quarterly diabetes visits. Chances are in these types of highly focused visits with a limited agenda, there will be time for “extras” that might never get addressed if every visit is a very comprehensive one, crammed into 15 minutes.

I try to be flexible. Every week I see patients whose priorities have changed since the appointment was made. It is important, early in the visit, to determine the best use of our time. I might say, for example, “I had asked you to come back to follow up on your headaches. Is that still OK with you, or do you have anything else you’d rather spend our time on today?”

It is not unusual to see patients who are uncomfortable or upset due to something unrelated to the scheduled purpose for the visit. There is probably no better way to alienate a patient than forcing your own agenda when he or she is in distress and needs you to pay attention to that. Showing that you are ready to listen, by closing the paper chart or pushing away the keyboard, and making eye level contact aren’t “techniques”, but ways of giving the patient permission to take the lead.

The 15-minute appointment is the canvas we have to work with today in the art form we call medicine. I wouldn’t work the same way if I had a bigger canvas to paint on, but each piece of art has to fit its medium.

I used to get frustrated when patients, typically at the very end of a long visit for some other serious problem, would utter one-liners like “What can I take for headaches?” “How do I know if I have cancer?” or “Why can’t I lose weight?”

Now I have a one-liner, of sorts, myself in response to those types of questions. I usually lean back slightly, widen my eyes, nod and say:

“Now, that’s a big question that can’t be answered well in just a few words. There are even specialists in Boston who deal with nothing but that their entire careers. I could sit down with you some time and start working on it if you want.”

It is very important not to give off-the-cuff answers to questions that may seem casual. The patient may pop the question that way because of fear, or may not realize how complicated the question really is. The patient who asks for something for headaches may be the one with a brain tumor or an aneurysm, and the one who asks casually about weight may be on the verge of revealing a serious eating disorder.

A careless, quick or off-the-cuff answer, even to a seemingly off-the-cuff question, is neither therapeutic nor safe. It also devalues our profession. Not every answer we give needs to be lengthy, but every answer or intervention needs to be proportionate to the problem. A question about dandruff may be appropriately answered in a sentence or two, but certainly not a question about headaches or weight issues.

Making another appointment to deal with something the patient brings up at the last minute is not frivolous. It is good medicine. It validates the patient’s concerns and keeps the physician’s next several patients from waiting unnecessarily for the doctor to catch up.

On my way to the hardware store this morning, I saw an old patient waving from her front porch rocking chair. By all accounts, Clair Schultze should not be alive today. Now in her mid-eighties, she suffers from fairly advanced chronic kidney disease and anemia. Two years ago she had a small heart attack and developed atrial fibrillation. Then, just after last Thanksgiving, she had a stroke.

It was a large brainstem infarct. She was in a coma for several days and her three sons flew in from their opposite corners of the country to comfort their father and help him decide whether to discontinue her life support.

The same day they decided to stop all heroics, she started to move her arms and legs a little. Within two weeks she was home, making final plans for Christmas dinner. She was weak, but she was still the same bright, witty Southern Belle and matriarch she had always been.

That is the way things are with brainstem infarcts – you never wake up or you make a full recovery.

In follow-up, Clair’s lab work looked much worse than before her stroke. From her anemia to her kidney function to her protein levels and salt balance, she looked like she should feel terrible, but she was radiant.

As for what to do with all the abnormal lab values, she told me in no uncertain terms:

“If you can’t promise that fixing the numbers would make me feel better than I do now, leave things alone!”

I shook her hand in agreement and we set a time for our next housecall, after the New Year. As I left, I looked back and saw her sitting in an almost Royal pose in her velvet wingback chair next to the decorated Christmas tree by the crackling fire in her tidy living room. I had the strongest sense that her will to live and to enjoy every moment was doing more for her than any of the medical treatments we might offer her.

I remembered the story of Mr. Fish.

When our children were young, they wanted a fish tank. They promised to take good care of it and to never tire of it. We agreed, but decided to put it in the built-in bookcase in my study. That way I figured I could make sure the fish were not neglected, and I would be able to enjoy the soothing movements of the fish when I sat down to write at night.

In the beginning, just as we predicted, the children gave the fish a lot of attention. Even Mindy, the Springer Spaniel, who was crazy about water and frogs, was fascinated with them.

The years passed and so did the children’s interest in fish keeping. Even Mindy ignored the few fish that remained, as age and unknown maladies reduced their numbers.

In the end, there was only one lonely fish left, a dapper, brightly colored fellow my wife and I called Mr. Fish. Whenever I entered the study, he swam up to the glass as if to greet me. I really enjoyed his company.

By that time, the glass walls of the tank weren’t as clean as when the suckers were alive, and the water had taken on a slightly murky quality. We joked that he had adapted to these seemingly unsanitary conditions so well that anything else would kill him. But then, the light and the bubbler both stopped working, and we felt we had no choice but to put Mr. Fish through a major renovation of his surroundings.

We should have known. Mr. Fish didn’t survive the change, even though we saved some of the old water and some of the old plants. The newly redone tank looked beautiful, but that was meaningless to him.

Ever since we lost Mr. Fish I have had a certain trepidation about intervening to correct abnormal lab values when the patient seems to be thriving in spite of them.

I think Clair Schultze is a lot like Mr. Fish in that regard.