A Country Doctor Writes:

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.

Jack Frommer has been my patient since last fall. He has high blood pressure and high cholesterol and he had a small heart attack six years ago.

Jack hates to take pills, and that was one of our topics when I first met him. He needed some changes in his regimen, based on his history, lab work and physical exam.

We had a lot of ground to cover in that first visit, but I don’t remember feeling particularly rushed. Other than his blood pressure, his cardiovascular exam was normal. I re-read my notes the other day. His heart sounded regular without murmurs, his neck veins weren’t engorged, his carotid arteries didn’t have bruits, and the pulses at his ankles were good and strong. I remember him pointing out as I listened to his neck that nobody had done that before.

His three-month follow-up was encouraging. His cholesterol had dropped below his target level with the new medication I had prescribed, and his blood pressure was almost normal. I spent some extra time on his smoking and the importance of taking aspirin.

I didn’t do much of an exam that day because it was a brief visit with a lot of numbers to talk about.

At his six-month follow-up all the numbers looked good. We talked about the 3-4 cigarettes he was still smoking. I listened to his lungs and repeated his cardiovascular exam.

Suddenly, there it was: A loud, harsh scraping bruit in the lower portion of his right carotid artery.

An ultrasound suggested a stenosis greater than 80% and an MRA clinched the deal. Within weeks, Jack had surgery to remove the buildup in his neck artery.

In follow-up he and his wife showered me with praise for saving him from a stroke by listening and noticing the abnormal sound in his carotid artery.

I felt humble. I had not heard it the first time I listened.