A Country Doctor Writes:

George Dutton walked in again yesterday. He never calls for an appointment. He asks politely if I have time to see him and never demands to be seen right away. Cindy at the front desk always works him in. He doesn’t drive and never seems to have a ride. Driving around town and the nearby countryside, I always see him out walking.

George is a man of few words. Most of his medical issues are straightforward – a chronic hand eczema, an occasional cut that gets infected, some arthritis. His walk-in visits usually run all of five minutes. He always seems eager to leave, almost in a rush.

More often than not, once we have covered the problem that brought George to the clinic, he asks me the same question:

“Hey, Doc, can you give me something for my nerves?”

George has a terrible case of Benign Essential Tremor, a hereditary condition that causes his hands and neck to vibrate with a high frequency. He has seen two neurologists and tried all the appropriate medications, at least for a few days, but nothing has seemed to help him.

When I first met him, I took his question literally. I started asking him all kinds of questions about how he was feeling. He gave me a blank stare.

“I feel fine,” he insisted. “It’s just my nerves, see?” He held his trembling hands out in front of him.

No matter how many times I tried to explain that the root cause of his tremor is not “nerves” in the sense most people refer to them, George remained steadfast in his belief that deep down, his nerves must be real bad for him to shake like that.

During one of my vacations a colleague prescribed an anxiety medication for him, and George insisted it helped his shaking quite a bit. If I sometimes smell his noontime beer on his breath, I have noticed that his tremor seems better than usual.

Yesterday I had my usual impulse to contradict him and explain again that bad shakes don’t necessarily mean bad nerves, but I caught myself and instead asked him if he thought people ever shake when their nerves are okay. He didn’t think so.

That got me thinking. George is such a laconic man, that perhaps his deepest emotions are non-verbal. I often see patients who struggle to find the right words to describe their feelings, but what if he feels something that he never even imagined finding words for? What if he is grappling with feelings so strong that they make him shake? Benign Essential Tremor certainly can get worse with anxiety.

Prescribing a tranquilizer for George always seemed like treating a symptom without the proper diagnosis, and the only one I had for him was Essential Tremor. Tranquilizers aren’t really the best treatment for that diagnosis. George had told me his nerves are bad, but I had demanded explanations and elaborations about his feelings to me.

How fair is it to insist on hearing just the right words to fit my diagnostic template for generalized anxiety disorder? If George had been a child I would not have done that. If he suffered from dementia or a stroke, I would have had to go on what I have seen for myself – a hurried man who seldom speaks, plagued by terrible tremors, helped by tranquilizers or beer.

I hadn’t listened all those times when he literally spelled out his diagnosis for me:

“Hey, Doc, can you give me something for my nerves?”

As Family Physicians today we each take responsibility for a panel of patients. Some of them are healthy and only come to see us for physicals and episodic illnesses, but more and more of our patients have chronic illnesses like diabetes, heart disease, depression, fibromyalgia and chronic lung disease. Such problems don’t go away between visits, and as primary care doctors, our involvement with these patients doesn’t stop when their office visits are over.

We track these patients’ care in our disease registries in order to ensure that recommended testing and follow-up is offered at timely intervals.

As clinical reports and test results from specialists and emergency rooms trickle in, we review them to see if we need to make any changes in each patient’s care plan.

When lab results come in before a scheduled visit, we look them over to make sure they are normal enough that any needed action can wait until we meet with the patient.

We answer questions, verify and refill prescriptions, and we file countless reports with insurance companies and Quality watchdog organizations that grade us and probably some day will pay us for our patients’ blood pressures, cholesterol and blood sugar values.

Still, we – or in most cases our employers – essentially only get paid for the time we spend face-to-face with the patient, even though medicine these days involves a lot more work behind the scenes and in between visits. This mismatch between payment system and patient needs has made it harder for doctors to be generous with their time.

Health Maintenance Organizations (HMO’s) were supposed to revolutionize health care in the U.S. through capitation – paying doctors a monthly fee per member, based on the expected cost of taking care of various age groups. Today, almost none of our patients have this type of insurance.

What, then, do doctors get paid for in the office? Most get paid according to how many questions they ask patients, how many organ systems are reviewed and examined, and how complex or risk-filled the clinical situation is. Under that system, a doctor who needs to ask a lot of questions and do a detailed general exam gets paid more than a doctor who quickly reaches a diagnosis.

Some clinics get paid a fixed rate, so that a five-minute visit for a sore throat brings in as much money as 45 minutes spent with a complex, very ill patient. There, the temptation is to keep visits short in order to see as many patients as possible.

Face-to-Face time is what we get paid for, but it is part of a package where the other pieces may seem undervalued. We always have to watch how we spend our time. The challenge for all of us is to make the time we have with our patients, be it five minutes or forty-five, productive and therapeutic.

We can’t blame our patients for our lack of time. They didn’t create the system. They come to us for help with their fears and their ailments. They don’t generally ask for a certain number of minutes. They want and deserve technical competency, caring and compassion.  Those things aren’t measured in minutes. 

Neither is Quality.

Lorraine Walker saw her daughter get married and her son finish high school. Not long afterward she was at it again. She and her husband, Ted, adopted two young boys.

Six-year-old Sam and his four-year-old brother Tobias had been in foster homes for two years when Ted and Lorraine adopted them. Sam has a low IQ and is generally a quiet, introverted boy, except when he gets into it with little Tobias, who has a genetic mosaic with several minor physical abnormalities along with attention deficit–hyperactivity disorder and some anxiety.

Tobias had gone through a comprehensive evaluation at a child development clinic just before I became the boys’ family doctor about a year ago. Reading between the lines of the massive report, you could sense the reviewer’s concern for his future; Tobias seemed to have challenges in every sphere, yet being around him you couldn’t help being smitten by his exuberant personality.

I remember the exam room was bedlam the first few times I saw the two boys, but Lorraine was calm and dispassionate. She made it perfectly clear what was acceptable behavior and what was not. With admirable consistency she made Sam and Tobias take the consequences of their actions.

Tobias’ most visible physical abnormality consists of a flexion deformity of his fifth finger on both hands. The child development clinic reviewer thought he would need surgery and recommended an evaluation by a pediatric orthopedic surgeon. Fortunately, the hospital we refer our patients to has a very seasoned specialist, who was wonderful with Tobias. He reassured Lorraine that Tobias would have enough dexterity, in spite of his deformity, that it wouldn’t limit his career options, even if he wanted to be a concert pianist or a pediatric orthopedic surgeon.

We once got chatting about how common it is for parents not to follow through on their threats, like “we won’t go for ice cream if you tease your brother again”. Watching Lorraine Walker, you know she means every word she says, and the boys don’t take very long to mend their ways when she reminds them.

Just about old enough to be their grandmother, she is secure enough in her role as an adult and a parent that she doesn’t take responsibility for things the boys themselves are old enough to be accountable for.

“I made a lot of mistakes with the first two that I’m not about to make again”, she once confided. “Anne and Jeremy are turning out okay, even though Ted and I were a little too lax with them. Sam and Tobias have enough challenges that we need to help them develop their character and their common sense so they can reach their highest potential. I’m not helping them by compensating for them – I need to help them grow up to be solid citizens.”

The last time they were in, little Tobias started to spin out of control, egged on by Sam, who sat in a corner and made faces at him. Lorraine had been talking to me. With a quick turn of her head she caught their attention. It took three little words in a quiet voice for her to change the energy in the exam room into one of peace and order:

“Choices, gentlemen – choices…”

There is a debate going on about whether doctors’ neckties can and do transmit resistant bacteria to unsuspecting patients. Some people are trying to prohibit doctors from wearing them. So far, the evidence has not supported the notion that ties actually spread disease, but this is an emotionally charged issue. 

In my part of the country you see maybe half the doctors wearing a tie and they often also wear a lab coat. The other half tends to wear open-collared plaid shirts and no lab coat. From an infection control point of view, wearing your street clothes without a lab coat when seeing patients all day in the office seems like a more questionable practice than sporting a tie tucked inside a white lab coat.

A fellow Swedish physician doing his residency in New York pointed something out in his Swedish language blog that I also found striking when I first got here: A lot of nursing personnel wear their scrubs not only in the office or hospital, but they wear them on their way home in the family car or on the subway. They wear them when they stop at the grocery store, and they wear them when they greet their children after work. That is probably a bigger infection control problem than physicians’ neckties.

One thing that even the plaid-wearing country doctors carry around the neck is quite possibly a real infection hazard, but I seldom hear anybody worry about it: Our trusted stethoscopes go everywhere we go, dangling from our necks or tucked into our lab coats and our sport jackets. We use them on people’s chests and abdomens and also when we listen to arteries on their necks and in their groins.

When did you last see a doctor sanitize his or her stethoscope?

More important than physicians’ choice of clothing is the alarmingly low rate of hand washing among physicians – 40% to 60% of the instances when they should, depending on which study you read.

The benefit of hand washing isn’t exactly breaking news. One of the earliest stories of medical discoveries I read in medical school was about hand washing. Semmelweiss noticed that midwives seemed to have fewer cases of postpartum womb infections among their patients than the physicians-in-training at his hospital. The difference seemed to be that the midwives and their hands stayed on the labor wards, while the residents went back and forth between anatomical dissections of corpses and the delivery room. Vinyl gloves weren’t invented, and hand washing was until then entirely optional.

In my office we have alcohol hand gel dispensers in every room and in the hallway. I use them on my hands and my stethoscope. I wear a lab coat that stays at the office, and, yes, I always wear a tie. So did Sir William Osler.

Arsène Voisine, my first patient this morning, rose from his chair as I entered the exam room. At 89, he has a strikingly energetic way of moving and speaking. His eyes squinted as he vigorously shook my hand and said “Good Morning, Doctor”.

“How are you?” I inquired.

He flashed a grin that quickly reverted to a frown, shrugged and turned his forearms outward, exposing the palms of both hands in a Gallic-looking gesture.

“I stayed up all night trying to think of something I could complain to you about, but I couldn’t think of anything. I am quite well, thank you. I feel like forty-five.” His pretended frown turned into his usual grin again.

Arsène is a slender man with deep facial wrinkles and large, knotty hands. I see him often in the office; he is a Senior Volunteer, who brings other, less mobile seniors to appointments and helps them with their shopping, banking and other errands.

He is an informed health care consumer, who always reads up on any concern or symptom he might have before deciding to contact our office. His favorite reference is the Mayo Clinic.

There is no mistake, this man is proud of his vigor and good health. He often points out how he lives well and practices moderation, although I sometimes think he expends more energy than I do. He thinks nothing of driving on snow-covered roads an hour each way through moose country to go ballroom dancing on a Saturday night. As he talks about his favorite dances, his shoulders rise, his elbows and knees bend and he looks like he is getting ready to jump.

He never did seem to retire; a master plumber and electrician, he still seems to be the one people around here call on to fix things, and he revels in telling me about his diagnostic triumphs.

“I could have been a doctor”, he sometimes tells me. “I love solving problems.”

He may not be a colleague in the classic sense of the word, but when I hear him talk I do think of him as a mentor and role model. He loves his life, is grateful for his good health, enjoys fixing things and helping those less able-bodied than himself, and he still does the cha-cha at 89.

Arsène – I want to be like you when I’m 89; I’d like some of that attitude!