A Country Doctor Writes:

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Thanksgiving Potpourri

Published November 26, 2009 Progress Notes 2 Comments

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.

See You Next Time

Published November 22, 2009 Reflections Leave a Comment
Tags: Evidence Based Medicine, kidney stones

Can you imagine a doctor telling a heart attack survivor:

“That was a close call, but I’m glad you made it. I’ll see you next time you have one. Oh, by the way, you might want to watch that cholesterol.”

I thought not. Yet, that is how most of the one million kidney stone cases are handled every year in the United States at a cost reported to exceed four billion dollars.

Kidney stone pain is said to be one of the worst pains a person can experience. In medical school we were taught that patients with a ruptured appendix are likely to lie perfectly still on the exam table whereas kidney stone patients are in such agony that they are unable to stay long enough on the table for you to examine them.

We have all kinds of technologies available for kidney stone removal, all of them expensive. Prevention, on the other hand, is cheap but seldom done. Cynics may say that there are no incentives in this country to prevent diseases that provide steady work for physicians who treat them.

Over the years I have seen public awareness and special interest groups crop up for just about every disease, even rare ones like SCID, Asperger’s and Rett Syndrome. Common things like avoiding recurrent kidney stones seem to get less media attention.

Kidney stones are made up of uric acid (the same compound responsible for gout) or salts containing calcium and another ingredient like oxalate, phosphate or struvite. Regardless of stone composition, recurrences can be partly prevented by simply drinking more water, which dilutes the stone-forming chemicals. Interestingly, there is a “kidney stone belt” in the southern part of the United States that is said to be expanding northward as a result of global warming, with projections of a 25% increase in kidney stone cases by the year 2050.

The Calcium Paradox

Depending on the chemical composition of kidney stones and levels of urinary excretion of key ingredients, specific dietary interventions and medications can help reduce a patient’s risk for recurrent stones. Doctors, like everyone else, however sometimes jump to conclusions. Some things seem so obvious that nobody questions them. Then, when scientific research proves our assumptions to be wrong, we refuse to believe, or perhaps we just forget what we have learned. This is at the core of what we call Evidence Based Medicine.

It was long assumed that if you restricted a person’s intake of calcium, the risk for kidney stones would decrease. The New England Journal of Medicine reported in 1993 that the opposite was true; a low calcium diet increases kidney stone risk. I seem to remember hearing the same thing during my training in Sweden long before then.

The reason for this calcium paradox seems to be that a low calcium diet causes more ingested oxalate in the intestine to exist in a free form, rather than attached to calcium. The free intestinal oxalate is more easily absorbed, leading to more oxalate in the urine, where it can combine with even small amounts of calcium to form a kidney stone.

Yet, I often hear that kidney stone patients are told by their doctors to restrict their calcium intake. I also hear both doctors and patients make general statements about the effects of fluid pills (diuretics) and vitamin C. Without knowing what type of stone a patient has, such generalizations are simply not helpful.

Physicians have an obligation to help patients avoid illness when there is good evidence available to guide us. Kidney stone prevention is not as glamorous as blasting stones with lithotripsy. As with any disease prevention, the way you know it works is that nothing happens. Any physician who has faced a kidney stone patient writhing with excruciating pain can appreciate that nothing happening is more humane than “See you next time”.

Starting Over

Published November 13, 2009 Progress Notes 2 Comments

Mrs. Jarvis seemed almost exasperated with my questions. She had told me all her symptoms a couple of times and I had asked several follow-up questions. Between our first and second visit she had gone for several tests, but I could not make a unified diagnosis. I was beginning to think she had several things going on, but I couldn’t make sense of her nausea.

“I am stuck,” I said. She sighed as I continued: “I must be missing something in your story.” Then, in a moment of inspiration, I got up from my stool and walked over to the exam room door as she followed my movements with suspicion and disbelief in her eyes.

With one hand on the doorknob I turned toward her and explained what I was doing:

“Pretend I’m an amnesiac and you never met me or told me what you are feeling. I need to hear your story again from the beginning and without interruptions.”

She giggled as I walked back across the room, shook her hand and introduced myself. Her husband grinned from his chair in the corner.

Nausea is a lot like dizziness. I remembered the lecture on dizziness Dr. Martin Samuels had given at a Continuing Medcal Education course I attended years ago. Dr. Samuels is Professor of Neurology at Harvard Medical School and one of the most captivating lecturers I know.

Don’t ask a dizzy patient any questions, because with that particular symptom, all questions are leading questions. If you ask a dizzy patient a single thing, they’ll say: “yes, that’s what it’s like” and you are doomed, Dr. Samuels cautions.

In order to evaluate a dizzy patient, you need to lean back in your chair, touch your chin, take some deep breaths and look out the window, not at the patient. Then you need to just sit there for a while and finally say: “Dizzy…?” You then must wait as long as it takes for the patient to tell you more.

Mrs. Jarvis smiled as I did my Marty Samuels impression. Her husband leaned forward from his chair.

With renewed resolve to avoid any leading questions that might derail her story, I said in a reflective tone of voice:

“Nauseous…?”

Five minutes later, without asking a single further question, I knew what to do.

Who Needs a Physical?

Published November 9, 2009 Progress Notes 1 Comment
Tags: health maintenance

Last week I saw an elderly woman whose daughter brought her in with a long list of symptoms, including palpitations, chest pain, fatigue, forgetfulness, dizziness, headaches, chronic leg swelling, abdominal pain and irregular bowels.

“She needs a complete physical,” the daughter said.

I disagreed. In my opinion, she needed a thorough evaluation of her symptoms and concerns, starting with her most urgent symptom of chest pain. She was simply not well enough for a routine physical.

This is no joke: A routine exam is essentially for healthy people. Patients with alarming symptoms need to have them evaluated promptly in a focused way, and not wait until their next routine physical, where the urgent issues would have to be dealt with in conjunction with immunization advice and all kinds of health maintenance issues.

Not everybody believes in the annual physical. Medicare doesn’t cover it, and most of the things doctors do during such an exam are of little or no proven benefit, as the proponents of evidence-based medicine remind us.

Those routine tests that are supported by the evidence are not usually recommended on an annual basis, but rather at different intervals for different age groups.

As far as the old-fashioned head-to-toe physical, there is simply no scientific support for it if you listen to the U.S. Public Health Task Force or the big insurance companies.

I have always shied away from the term “complete physical”, because there really is no such thing in clinical practice. There are always more things you could do, but don’t – we all have to budget our time as well as all other resources in our profession.

For many years now I have preferred the term “Annual Review”, because, in preventive medicine as in clinical diagnosis, you can usually accomplish more by simply talking to your patient than by delving into examinations and procedures right away.

In my practice, I see the Annual Review as my opportunity to ask patients things that they may not have thought of bringing to my attention. It is my opportunity, just like in the “well child visit,” to offer what we call anticipatory guidance – addressing things that might become problems in the future, and how to avoid that happening.

I am more likely to find a patient with angina by asking him how he feels when he splits and stacks firewood than by auscultating his heart or doing an annual resting EKG in my office. I also think I am more likely to spot a depressed patient if I have a chance to ask a few open-ended questions about how things are going than if I only rely on questionnaires.

There is no doubt that certain parts of the routine physical exam are valuable. I tend to talk my way through the exam, asking questions while I touch the patient, explaining what I am looking for, and encouraging the patient to do their own breast exam, lymph node or testicular exam.

And, getting back to auscultating the heart, it is necessary to do. A physical without listening to the heart is like a dinner without a main course. People expect it, and you never know what you’ll hear if you stop and listen for half a minute or so.

I didn’t need an EKG to diagnose my elderly chest pain patient with atrial fibrillation.

A Hero’s Pain

Published October 27, 2009 Progress Notes 2 Comments
Tags: pain management, veterans

“I don’t know if you understand, Doc, what kind of man this is.”

The man who spoke appeared to be a few years my junior. He was speaking of his father, who is one of my patients at the local Veteran’s Home, where I am a relative newcomer.

“This man fought in two wars and earned two Medals of Honor. He is not going to tell you how much pain he is in, even when you ask him, because he isn’t even going to admit to himself how much he hurts.”

He made a point I actually hadn’t considered before during my tenure at the Veteran’s Home. My patient has metastatic cancer, and the nursing staff asks him every day to rate his pain. His answer is always 2 on a scale from 0 to 10.

As doctors and nurses we estimate our patients’ discomfort through their words and also through their vital signs, facial expressions, posture and other nonverbal clues. But when it comes to treating war heroes, do our usual instruments fall short?

I remember thinking when I admitted the ailing veteran that he seemed so humble and plain spoken. The words “true hero” came across my mind then. I didn’t consider that I might not be able to accurately assess his cancer pain or his level of distress over his terminal diagnosis.

There is a lot of talk about cultural competency in this country. Today I even read in one of the publications of the American Medical Association that several states are mandating that physicians take courses to improve their skills in dealing with patients from cultural and ethnic minorities.

Somehow I think we oversimplify the issue of cultural competency if we focus on only those we think of as minority groups. Our challenge in caring for all our patients is to meet them where they are, to step out of our own world long enough to at least get a glimpse of theirs. We must first meet as human beings before we can begin our medical assessment.

War heroes are a minority, too.

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