A Country Doctor Writes:

Mitch Tapley was not your ordinary preacher. He was a burly man in his late sixties with massive, tattoo-covered arms, a stubbly, broad face and hair that always looked like he might have arrived by motorcycle. He smelled of cigarette smoke and his powerful baritone voice had a gravelly edge to it that reminded me of Johnny Cash.

He became my patient just a few months ago after he ended up in the hospital and almost died from a respiratory illness. Mitch had worked hard to get back in the pulpit and out among his congregation, and every time I had seen him he had spoken of trying to find a balance between helping others and taking care of his own health.

Our last visit, the day before yesterday, seemed particularly profound. He spoke of his walk with his Lord by his side, and a new level of clarity he had experienced since facing his own mortality, then interrupted himself and said:

“I don’t even know if you are a believer, but I think you know what I mean.”

I responded by telling him what my father had said about my choice of medicine as a career many years ago – that I could have been a lawyer but I was too honest, or a preacher but my faith was too weak.

He laughed heartily and said:

“God bless you, man, you are a healer and a friend.”

I asked him again about his smoking, and he said he was almost ready to quit.

Early this morning the shrill sound of an ambulance tore through our little village and the news reached me as I walked through the clinic door: Pastor Mitch had suffered a massive heart attack and died from cardiac arrest.

This afternoon I dialed his home number to give my condolences to his wife. The phone rang four or five times, then there was a click, followed by his familiar, powerful, resonant voice. A chill went up my spine as the recording played:

“I am not here to take your call,

Please try again later, and

May the Lord always be with you.

May He bless you and protect you.

May His face smile on you and be gracious to you.

May the Lord show you His favor and give you His peace.”

I said no when Nora Williams asked me to order a CA 125 blood test the other day. She is worried about ovarian cancer, not because of any family history, but because she, in her own words, just has the worst luck. She is an anxious woman, and I would have loved to help relieve her anxiety, but I couldn’t.

I said no when Mark Michaud asked for an antibiotic, even though he was miserable after several days of cold symptoms which had by now turned into a severe and productive cough with thick, yellow sputum.

I even said no when Jim Westerdahl asked for an MRI of his back after his sciatica attack cleared on prednisone. “I just want to know what’s going on in there”, he said, “so I know what to expect.”

I seem to be saying no a lot lately. More and more often, patients present with requests for specific tests or treatments, sometimes as a direct result of searching online for ways to screen for, diagnose or treat disease.

Nora Williams’ fears of ovarian cancer cannot be allayed by a CA 125 test. Women often ask for it, but the sad truth is that for an average risk woman without a family history of the disease, a positive test means ovarian cancer only 20% of the time, and only 50% of early ovarian cancers cause a rise in this particular tumor marker. The real usefulness of this test is to follow an already advanced ovarian cancer for recurrence after treatment.

Mark Michaud, like many other people, wishes antibiotics would work on viral infections, but they don’t. Twenty years ago I might have treated his type of bronchitis with an antibiotic, but now we know that colored phlegm does not necessarily mean an infection is bacterial.

Poor Jim Westerdahl. Whether an MRI showed a herniated disc or not, that would not help predict his risk of recurrence. It has been said that 10% of healthy people have MRI evidence of significant disc disease, but no symptoms. His symptoms were already gone, so he didn’t need any treatment, and a $1500 MRI would not help predict future symptoms any more than flipping a coin.

Sometimes I say no when patients want disability parking placards, electric scooters or narcotic pain medications when it really is in their best interest to push themselves a little harder.

I say no when patients ask me to write prescriptions in their name for an uninsured family member, and I say no when patients ask for expensive, new medications they have seen advertised on TV when there are effective, tried-and-true generics that work just as well.

I also say no when patients call in with a request for a prescription when they have self-diagnosed something I haven’t seen them for many times in the past.

Saying yes is often faster in the moment, since a no requires a thoughtful explanation, but my job is to consider the long-term consequences of every clinical decision. As a physician I have the freedom to ignore the guidelines and the scientific evidence that’s out there when I think my patient doesn’t fit the usual pattern. We need to be careful with that power if we want to keep it.

Several patients Wednesday made me reflect on how fortunate I am to be doing what I do for a living.

There was the young man with chest pain, skin problems and unusually long fingers. Could it be that he had a syndrome I have never diagnosed before?

There was the woman with a platelet disorder and new onset atrial fibrillation. The cardiologist had recommended against using blood thinners because of the woman’s low risk for stroke based on her CHADS score, but had deferred to her hematologist and me because of her thrombocytosis. The hematologist couldn’t be sure that her hydroxyurea treatment completely neutralized her risk for blood clots, and wanted to defer to the cardiologist and me. I was able to pull it all together for her by showing her the NNT, or number needed to treat, for patients with her CHADS score. She chose to go with aspirin alone and left the office visibly relieved that nobody was trying to make her take warfarin.

There was also the young mother who wept about the loss of her grandmother a few days earlier. “Gram was my best friend”, she said, adding “I need to keep it together for my two-year-old daughter”. The woman’s presenting complaint of cough and shortness of breath didn’t seem to be a sign of anything dangerous. At the end of our visit I pointed out how fortunate she was to have been that close to her grandmother while growing up. I encouraged her to help her little girl know the importance of family the way she did.

My last two patients were a husband and wife, both around eighty years old. He had almost crushed his lower leg in a farming accident, and came in for a wound check and some pain pills, which he had declined on his first visit.

“I’m too stoved up to wrestle with my cows now. The shape I’m in, I couldn’t even wrestle the rooster”, he muttered in his thick local accent.

His wife’s blood pressure checked out okay, and I asked her to come back in the spring for a recheck. She looked me square in the eye and said:

“I’ll call you if I need you”.

There was enough time left to take care of all the incoming laboratory and x-ray reports, prescription refills and other chores well before five o’clock.

I wished my nurse, Autumn, “Happy Thanksgiving” before calling my wife to tell her I was on my way. I turned out the office lights and locked the clinic door behind me. My Thanksgiving was already well under way.