A Country Doctor Writes:

Dinner conversations in medical families can be less than ordinary. Tonight we were talking about how to choose antidepressants for different types of patients. My wife, who worked side by side with me for many years as a Nurse Practitioner, is now doing other things, and her time away from practice has heightened her awareness of how clinicians often reach for their prescription pads very quickly when faced with patients, whose lives have presented them with more losses or sorrows than they can handle in the moment.

As we talked more, we realized that it was this very weekend – Columbus Day – eight or nine years ago that we attended probably the most profound Continuing Medical Education event of our careers. It was one of several parallel seminars offered by Harvard Medical School and Massachusetts General Hospital’s Department of Psychiatry.

The title of the course was “The Shadow of the Object”, which is a quote from an enigmatic passage in “Mourning and Melancholia” by Freud. It was held in an old, slightly run-down family resort in the Catskills in upstate New York, very similar to the setting of the movie “Dirty Dancing”. In its heyday, this resort was a summer haven for middle class families from New York City – a chance to experience nature and participate in organized activities while mingling with people of their own kind.

The central idea of the conference was that we never “get over” loss or trauma – we just have to find ways to carry it with us in a fashion that makes sense for us. It is a simple notion, but it has profoundly affected how I have counseled patients from that moment on. There is such a tendency in our society to focus on the “positive”, to downplay the importance of sadness in a healthy and balanced life.

One particular thought we brought with us from “The Shadow of the Object” is the concept of moving through grief by finding ways to honor the legacy of the lost loved one. I have found that to be one of the most healing things you can teach those left behind after someone they respect and love passes away.

On our way home from the course, we spent one night at the Equinox Mountain Inn in Manchester, Vermont. It was another magical experience, dining and sleeping high above the clouds in a quirky 1960’s building at the site of an old charterhouse, or Carthusian monastery. It only seemed fitting that we ended our Continuing Medical Education weekend there – high above the ordinary places we usually frequent for such affairs, a place for quiet contemplation before stepping back into the normal practice routine, albeit a little bit changed.

Working with students always makes you think about why you do certain things the way you do them and why you may feel more strongly about some things than others.

Today, in talking with one of my students about how to do a history and physical exam, I admitted for the first time something that has plagued me for most of my career:

As an intern in Sweden during one of my first surgical subspecialty rotations I had to do the admissions of patients who came to the hospital the afternoon before elective procedures. Those were the days when nobody had to get up before the birds in order to check into the hospital at seven a.m. for same-day major operations and procedures.

I remember dutifully documenting the history of a man who mentioned in passing as I went through a Review of Systems that his bowel movements were getting narrower in diameter – a possible sign of colon cancer.

My attending physician was the head of his subspecialty department and a very busy surgeon. I must have had five or six admissions to do that afternoon.

I remember thinking that this patient’s altered bowel movements were significant and needed some type of follow-up. The attending was not on the ward, but doing a clinic at the other end of the hospital and the resident was seeing patients in the emergency room, so with several more admissions to take care of, I did what I thought was the best I could do and carefully documented the patients symptoms for the attending physician to read and presumably act on the next day before surgery.

The next morning when I arrived at the hospital he had already been in the O.R. for almost an hour and I didn’t get around to asking what he thought we should do about the patient, whose name I didn’t even remember by then.

It could not have been long afterward that I realized that attending physicians with busy surgical or clinic schedules don’t necessarily read their interns’ charts closely enough to find pearls of information deep inside paragraphs that document mostly normal findings.

I realized today why I feel so strongly about making clinical notes clearly distinguish between normal and abnormal findings. This has become an even bigger challenge with the seemingly ever-increasing need, at least in my adopted homeland, to document even perfectly normal exams in great detail for the sake of higher reimbursement and protection from lawsuits.

A macabre example of documentation just for the sake of documentation came to me a couple of years ago in the form of a four page printout of a cardiologist’s office note, which must have involved all of ten minutes of face-to-face time between doctor and patient. Most of the information in the office note was repeated Past, Family and Social History. The exam followed a template, and the Review of Systems had been imported from a patient questionnaire on an optical reader form, similar to ones we used for tests in school – I have seen that particular electronic health record in use.

Deep inside the four page document was a notation that the patient admitted to suicidal and homicidal thoughts. The busy cardiologist didn’t comment on it, and I dare say he never noticed it was there.

Ultimately, whether we are nurses, interns or Board Certified specialists, if we are the first or only ones to know about something important in a patient’s history or physical exam, we own it, at least until someone better suited can take over.

Emily Green knew there was a lump in her right breast. She was a new patient I saw a few weeks ago. Her previous doctor had sent her for a mammogram last year, but she had not come in for a clinical breast exam. She was a busy professional, who admitted she sometimes cut a few corners with her own health care.

I remember signing the order for her annual mammogram even before I met her. At that point in time, she had not made an appointment to see me, but I signed the order anyway.

In years past I used to stick to my guns and not order a mammogram for patients who had no intention to come and see me for a breast exam.

We all know that a mammogram is best done after a clinical breast exam, so that women with abnormalities on their exam can have a more comprehensive, or diagnostic, mammography study with an ultrasound examination to distinguish between solid and cystic masses.

Purist that I was, I insisted on doing the job right, and on my terms – exam first, then mammogram. I don’t know how many patients ended up having nothing at all done because of my stubbornness. After a lot of thought I decided to authorize mammograms for any woman who wanted one, whether she came in for a breast exam or not, since doing something seems better than possibly doing nothing to screen for cancer.

When I finally met Emily Green for her first appointment, she told me she was concerned about a small lump in the lower portion of her right breast. I agreed with her – the lump was a little larger than a pea, nontender and freely movable against the overlying and underlying tissue. Another, larger, irregular cluster of lumps toward her breast­bone in the 3 o’clock position seemed like typical fibrocystic disease.

At the end of her appointment we agreed on getting a diagnostic mammogram followed immediately by an ultrasound. Whether these tests showed anything or not, we also agreed to have her see a breast surgeon in consultation because of the suspicious nature of the lump at 6 o’clock. We also decided to get some updated blood tests and change her blood pressure medication.

I signed off on her normal radiology reports and added “cc: Dr. Fowler” at the bottom of each page.

When I saw Emily Friday to follow up on her blood tests and new medication, she had already seen the breast surgeon the day before. She was quite animated when she said:

“I can’t believe the tests didn’t show anything. I mean, I felt the lump, you felt it, and Dr. Fowler found it instantly. She’s set me up for a biopsy in less than two weeks! I never realized doctors might disagree with an x-ray.”

“A test is only a test” I mused. “Mammograms are probably best at finding little microcalcifications we can’t feel with our hands.”

“I guess so, but I still feel like I had a near miss”, she said. “What if I had just trusted the mammogram and not bothered to come and see you until the lump had grown some more?”

I reminded her that the biopsy may still come out negative, but agreed that it was very good she had taken the time to come in with her concern.

I still wonder, which is the better thing to do, authorizing screening mammograms to any and all or start insisting again on seeing patients for a clinical breast exam first.

Yesterday afternoon I sat in a dark room with a couple of doctors and several mental health professionals and participated in a video conference about integration of primary care and behavioral health. Outside, the late summer sun shone brightly just like it did September 11 eight years ago.

The case for integration is obvious; 85% of the time the ten most common symptoms brought to the attention of primary care doctors (chest pain, dizziness, fatigue, back pain and so on) have no known somatic explanation – the cause for the symptom appears to be psychological.

Yet, the words we use to interview patients, to document the history and physical examination findings, and to present our thoughts to our patients and to our behavioral health consultants are often extremely unhelpful and sometimes downright insulting to the patient.

It seems the place to start integrating primary care and behavioral health is with our everyday choices of words we use to describe the patients we see in our offices.

The days are essentially gone when doctors spoke in technical terms to each other and other medical professionals with the purpose of keeping the patient in the dark. For example, very few of the old prescription-related Latin phrases are still being understood and used by doctors and pharmacists, and most preprinted prescription pads no longer feature the optional “label” box, which in a bygone era gave the prescribing physician the option of not revealing the name of the drug to the patient.

We are nowadays cautioned to clear our vocabulary of words which we as physicians have used and understood to mean something perfectly neutral in clinical language, yet can be offensive to patients, who increasingly often end up reading their own medical records.

In my years as a physician I have read many chart entries that read something like this:

“This pathetic 57 year-old woman returns with a litany of complaints, and seems to completely lack insight into the real cause of her misery…”

Those are words that, perhaps, may insulate a doctor from bad feelings about his/her inability to help such a patient, but they aren’t likely to help the patient manage their symptoms or psychological issues, and they ultimately don’t belong in a therapeutic relationship.

This is not Orwellian Newspeak; our words can heal, and they can hurt. These are some examples of conventional doctorspeak and suggested alternatives from the video presentation by Alexander Blount, Ed. D.:

Chief Complaint = Main Concern

Suffers from = Struggles with

Refused to take = Decided against

Was noncompliant with = Didn’t see the value of

Didn’t keep appointment = Wasn’t able to be here

Arrived late = Was determined not to miss

There is a lot of talk these days in the U.S. about the Patient-Centered Medical Home. It begins here; with the way we see our patients as the center of the clinical work we do, indeed the justification for our own existence as doctors in our communities.

Mrs. McCann greeted me at the door. “Thank you for coming”, she said in a hushed voice. “Gerry thinks I’m a worry-wart, but I’d feel better if you looked him over again. He sounds a little congested and I’d like you to see his wounds again.”

Gerry McCann sat in his favorite chair in the sunny living room. His wife handed me a piece of paper with his recent weights, blood sugars and blood pressure readings.

I checked his heart and lungs without finding anything unusual, and then Mrs. McCann proceeded to expertly change his dressings, so I could inspect his diabetic ulcers.

“They’re coming along great”, I said, and added, “You are doing a superb job”.

“I do my best”, she answered, beaming.

I wrote some new prescriptions and we agreed on the timing of my next house call. She followed me to the door.

“Thank you, Father”, she said, and then quickly corrected herself.

“I mean, thank you, Doctor. Father Harris was here yesterday to see him.”

It struck me that Father Harris and I had come on similar errands, giving our blessing to the care and commitment we see in that house, neither one of us delivering much more than reassurance that the McCanns are doing their part and whatever happens next is in God’s hands.