A Country Doctor Writes:

This summer I have been a doctor for thirty years, and I just realized I missed the anniversary of my medical school graduation. Actually, it almost seems fitting that I did, because of how it all happened.

I had one of the best medical educations you can get, but there was a total lack of pomp and circumstance at Uppsala University. Any form of celebration of academic achievement occurred after hours and off campus, usually within the highly regulated social clubs called “Nations”. They were started hundreds of years ago when students from all over Sweden came to Uppsala to study and needed ways to stay in touch with people from their own provinces. Students traditionally found room and board with private families in Uppsala, and the “Nations” were meeting places and social support providers for them.

As far as I know, students still have to register with one of the “Nations” when they enroll at Uppsala University.

When I started medical school I was a very serious young man – too serious, I have since realized. When it came time for me to choose which “Nation” to register with, I chose the one that was only perfunctory, charged only a nominal fee and never had any events. Instead of spending my free time with other students, I sat in my one bedroom apartment and read books from the “Doctor in the house” series, which follows a zany group of British medical students through school and internship.

At the end of my last semester, a hot summer day in 1979, I remember putting the contents of my locker in a plastic grocery store bag and riding my bicycle home to my apartment at the outskirts of town. Instead of the kind of diploma my American colleagues proudly display on their office walls, a brief letter arrived in the mail a few weeks later, stating that it was proof of my medical license. In one corner was a red stamp, certifying that the three-dollar administrative fee had also been collected.

It wasn’t much of a ceremony, so it never stuck in my mind. I’m not even sure how to answer when I occasionally get asked for my medical school graduation date – the day I emptied my locker or the day I got the certificate in the mail?

I guess the glory in my case comes from doing what I set out to do when I was about four years old. I never counted the days or the years. I just carry on.

My mother, who lives in Sweden, has been suffering from gout again. It has been a few years since her last attack. She told me on the phone this morning that the medicine her family doctor prescribed didn’t seem to be working. Last time she had an attack a covering physician had given her an anti-inflammatory medication, naproxen. When she saw her regular doctor the other day, he read her chart and voiced his disapproval of his colleague’s choice of treatment that time.

“You should not be taking naproxen when you are also taking a blood thinner”, he declared. “I’ll give you something else.” 

Four days later there was no sign of improvement. I asked what medication her doctor had put her on. “A-L-L-O-P-U-R-I-N-O-L 100 mg”, she spelled from the bottle.

I advised her to stop taking it and explained that allopurinol isn’t indicated for acute gout, but instead is used to prevent attacks. It can often precipitate an attack when first started.

Her doctor is a board certified generalist, who works part time at her neighborhood clinic and does research part time. From what I have heard, he is a decent fellow, who generally takes good care of my mother’s health issues. In this case, however, I felt compelled to intervene.

“Why don’t you call tomorrow and ask for some prednisone,” I suggested. “That’ll stop the attack fast and it won’t upset your blood thinner. Then, when everything has settled down, you might be able to start the allopurinol.”

I don’t remember how nervous Swedish doctors are about short-term use of steroids, but not using allopurinol for acute gout is fairly basic.

I did some more thinking this afternoon. One does need to be careful judging others with regards to what is basic knowledge as opposed to esoteric. I don’t know quite how old my mother’s physician is, and I know the diseases he encounters in my mother’s urban clinic in Sweden are vastly different from what I see in rural America.

I went to medical school before AIDS/HIV, hepatitis C, fibromyalgia and many of the diseases that now fill the workdays of many of my colleagues, and I work in an area without much ethnic diversity. I have only had one patient with AIDS, and I haven’t seen a gun shot wound in a decade. I remember thinking when I took the test to renew my Family Medicine board certification a few weeks ago that the choice of questions was not representative of what I see most days in my practice.

Perhaps we have arrived at a point where physicians’ knowledge base even in primary care isn’t universal.

Just a quick note to wish you a Happy Birthday.

I appreciate all you have done for me over the past fifteen months. I remember thinking I was just run down and fighting mono or something similar when I came to see you last spring. Little did I know then that I had Stage 3B non-Hodgkin lymphoma.

I remember last summer, kayaking down the river in front of your house between chemotherapy sessions, my port-a-cath smarting with every paddle stroke.

This summer I have my old stamina back, and Dr. Schwartz told me last week that my CT scans look excellent!

I know my lymphoma will likely come back some day, but right now I feel great. Life is good at the moment, and I am grateful.

Thanks for being there,

Jane W.

Twenty-four hours ago, as my wife and I finished supper, I told her I wanted to change from my work clothes into my barn clothes and join her as she fed the horses their evening meal. We had spent a rainy but still relaxing three-day Fourth of July weekend, and by Monday night I was already missing our new barn and the horses.

Caleb and our newly adopted Arabian princess nickered as we entered with their grain mash. We watched them eat with obvious pleasure, said goodnight and returned to the house to make it an early night.

As I got in bed, my wife asked if I could hear a noise. There was a clanging and a thumping outside somewhere.

I stepped outside and immediately heard that the noise was coming from the barn. Caleb was down, thrashing around in his stall. I ran in to get my wife and we called the large-animal veterinarian and a neighbor up the road who also owns horses.

It looked like a case of colic, and we administered the Banamine after speaking to the veterinarian on his cell phone. We walked Caleb around his paddock. He went down a couple of times, but we managed to get him up each time.

By ten o’clock the vet was there and puzzled over the situation. He has been at it a few more years than the twenty-eight I have been in Family Medicine, but he is limited to the technology he can fit in his Dodge van.

We went over our options. Caleb looked like he had colic, but his pulse was slow and strong. He also had a long history of unexplained neurological and constitutional symptoms. Exploratory surgery three hundred or more miles down the road on a twenty-year-old horse isn’t undertaken lightly.

We listened to the vet as he shared his assessment. We agreed to treat Caleb’s pain and observe him for a while. The vet left, and we stayed with Caleb for several cold and windy hours in the pasture as a thunderstorm passed in the distance. Now and then he would get up and walk around, but there wasn’t much improvement in how he seemed to feel.

As the vet returned at dawn, we could see that Caleb was giving up. He lost his battle right there in his brand new pasture this morning as the first birds began to sing. I cut a few strands of hair from his mane for a keepsake, and we removed his leather halter.

It was only two weeks ago we all moved into our little red farmhouse with ten acres of land and a brand new Amish-built horse barn right outside the kitchen window. We left our house in the village partly so Caleb could be with us, instead of being boarded. We also adopted our little Arabian princess as a companion for Caleb.

After the cold, sleepless night out there in the pasture, we buried Caleb at the highest spot, overlooking our miniature farm. I stripped his stall and covered the orthopedic floor mat with new shavings.

As we stood there in his empty stall and walked through his empty paddock, we talked of what a big presence he was – a gregarious horse with a sense of humor and a taste for mischief, a thousand pound teddy bear, who loved to cuddle. It is humbling to have earned the affection of such an animal. In just a few hours we lost our biggest pet. We now have his empty stall right outside our kitchen window. We also have our new little Arabian princess, who just lost her new companion. We all feel a little lost.