A Country Doctor Writes:

We buried my wife’s cousin Ruth last week. She had a strange mole on her arm a couple of years ago. The doctor told her it wasn’t anything to worry about, but he was wrong. By the time she got to the cancer clinic in Chicago, her melanoma had spread to her lungs, and in spite of chemotherapy and radiation, it continued to spread through her spine and, finally, her brain. The somewhat tired looking Ruth we saw at Christmas died last weekend in a nursing home, where, in the end, she had been unable to speak or feed herself. This seems such a horrible and unnecessary tragedy, and Ruth’s family is still in shock. As we sat around her parents’ living room the night after the funeral, some bitter thoughts were voiced about the doctor who misdiagnosed her melanoma. Someone said he should be sued, but Walter and Ellen said they wouldn’t consider it; that would not bring Ruth back. Someone else said he should be stopped from ever practicing medicine again, so he wouldn’t be able to make any more serious mistakes. That’s where I found myself having to defend him. Of course we need ways to monitor the quality of medical care, and to discipline negligent physicians, but “one strike, you’re out” is three times stricter than the controversial laws that impose life sentences on habitual offenders in California and some other states.

To watch over your fellow human beings’ health is a tremendous responsibility, especially on the front lines of Primary Care. Every bellyache is a possible appendicitis, every headache a possible brain tumor, every case of indigestion a fatal heart attack, and every mole a potential melanoma. We have the technology to correctly diagnose these conditions, but can we use all of it in every situation? Does every bellyache require an exposure to the high doses of radiation of a CT scan or the risks involved in an exploratory laparotomy? Does every headache justify an MRI, and does every case of indigestion warrant an admission to the cardiac intensive care unit to rule out a myocardial infarction?

Is it humanly possible to never ever be wrong? And if we punish mistakes by barring doctors from practicing medicine, will there be enough doctors left to treat us? Is it possible to learn and gain experience without ever making a mistake in judgement? I have 63 small “birth marks” on my upper body. They all look harmless, but think of all the spots on all the people out there.

The only way I can think about these questions, without wishing I were already retired, is in the context of a healthy doctor-patient relationship, where the doctor shares knowledge and information with the patient, and every clinical decision is explained in such a way that the patient knows what to expect if all goes well, signs of trouble to be on the lookout for, and when to come back for reevaluation. An authoritarian doctor who gives a categorical answer without explaining his or her diagnosis, and a patient who doesn’t question the doctor’s assessment when things seem to be getting worse are a dangerous combination. We need to communicate better with our patients, and that is where Ruth’s doctor failed her.

After talking about it some more, Ruth’s family agreed that the doctor deserved a chance to learn from his mistake. I hope he does.

Every now and then a patient visit prompts me to look back over my almost 25 years at this clinic.

Bill Maloney is applying for a job in the mental health field. He came in yesterday for an immunization update. He needed to start his Hepatitis B series, get a two-step tuberculosis test, and also needed proof that he has had chicken pox, either through a blood test or a note from a medical provider.

Bill brought his daughter, Brandy, a petite, four-year-old brunette with serious, blue eyes. She is the apple of her father’s eyes, and he calls her his miracle baby. He has chronic health problems, was in and out of the hospital as a child, and was not easy for his single mother to raise. I met Bill and his mother Sheila shortly after I came to town in 1985. Her health was poor, and Bill was orphaned in his late teens.

“I know I had the chicken pox when I was about six. I still have a scar on my leg”, he said. I turned back the pages of his chart. There, a note from 1986 in my own handwriting, but much neater than my current scribble, indeed documented that Sheila had brought little Billy to the office with a typical case of varicellae. It was with a sense of both sadness and satisfaction I pulled out my prescription pad and wrote:

“I diagnosed William Maloney with chickenpox in August, 1986.”

Sherman Waltz had been through a lot since I saw him just before his 83rd birthday in late November to review the results of his CT scan. He had a large tumor in his liver. The cancer surgeons at our referral hospital sent him on to Boston because of the type of surgery he needed and because of his age and underlying medical conditions, dominated by severe emphysema. He is oxygen dependent even at rest. He pulled through the liver surgery without complications, but on the second postoperative day he fell and broke his hip.

Poor Sherman ended up in the Operating Room again, this time for a new hip. Again, the operation was a success. He was transferred to a rehabilitation hospital, where he caught pneumonia, which brought him to the brink of respiratory failure, but he pulled through again.

Finally back home, and with concerns that his new hip was still painful and stiff this long after the surgery, he came to see me. He wasn’t keen on going back to Boston to follow up on his hip surgery if I could help him get that taken care of closer to home. We agreed to have him se an orthopedic surgeon nearby.

We reviewed his medications, his level of functioning at home now, and the follow-up plans for his cancer. We also established that his pneumonia had cleared.

“You’re amazing,” I told him. “Three life threatening conditions in less than three months, and I couldn’t tell just looking at you!”

He smiled his typical shy smile as he adjusted the oxygen prongs in his nose and cautiously rose from the exam room chair. He turned toward the door, then back again towards me as he cleared his throat.

“Oh, By the way, Doc,” he said with his hand on the door handle. “Do you think I could try some Viagra?”

I twice had a priest for a patient and I have been the personal physician of a handful of protestant ministers of various denominations. In each of these doctor-patient relationships I have found myself entering a ministerial role vis-à-vis my pastoral patient.

I have had reason to temper the hypochondriachal tendencies of one man of the cloth, and I have cautioned another that taking care of one’s body is a form of stewardship, and as such, just as important as taking care of one’s spiritual health. I have urged a minister to quit smoking and a priest to temper his sweet tooth.

Each time I have done one of those things I have been reminded of the apostolic nature of both our professions. People come to each of us, clergy or physician, with hearts and minds that are at least to some degree more open to hear what we have to say because of the office we hold, the cloaks we wear, that make our words somehow carry more weight than those of friends, relatives or family members.

As physicians, we need to be very careful with the authority and weight people grant our words, actions, even intonations and gestures. We need to be careful not to completely disregard that aspect of our interactions, because we may not always know what need we may fill in any given encounter. It may seem politically incorrect to encourage people to put you on a pedestal, but we need to be careful to keep separate the office we represent and the human beings we are. When a judge speaks to us from the bench, we assume he is not speaking as a private citizen, and the same is often true when a physician speaks to his patient behind a closed exam room door.

Imagine someone going to confession to reveal their innermost, secret weaknesses, only to hear the priest volunteer that his own weaknesses are even worse. In the moment of administering the sacrament of confession, the priest isn’t interacting with you only as a fellow human being, but as an apostolic officiant in an ancient ritual. This may seem outmoded, but, like it or not, as physicians we also fill that kind of role some of the time, and we don’t always know in advance when we are asked to save someone’s pocketbook, someone’s life or someone’s soul.

We haven’t all taken an oath to do what we do (not all countries hold their physicians to the Hippocratic Oath), but we are all part of an ancient fraternity that has cared for the sick and injured for thousands of years, and we need to show humility and let that calling and that tradition work through us, or we will only be technicians. When even clergy come to us for advice that goes beyond the technical, we need to be humble and accept that, now and then, what we do is greater than what we know.

Three asthma inhalers for my wife cost us $90 in copayments this week. Not long ago, generic albuterol inhalers were about seven dollars each. The main reason for the price increase is the new U.S. law that banned the use of fluorocarbons in prescription asthma inhalers this winter. The old-fashioned inhalers are harmful to the ozone layer. This new law prompted the development of novel, brand name, delivery systems, which drove up the cost to levels many of my patients have trouble affording. It does seem ironic that people around here often have remote starters for their gas-guzzling, high-polluting Sport Utility Vehicles, so they don’t have to drive to work in a cold car, but we make our asthmatics help take care of the environment by giving up their inexpensive inhalers for newer, more expensive and not necessarily better devices.

As far as I know, you can still buy old-technology, ozone-depleting inhalers with adrenaline (epinephrine) over the counter for under $10. By the way, we use the name epinephrine in the U.S. because somebody (Parke-Davis) patented the name Adrenalin in 1900 (without the “e”, but still similar enough to force the introduction of a new generic name, epinephrine, different from what the rest of the world uses).

I remember when I was a resident in Sweden in 1981, we had asthma medicines that were years ahead of the American products. We used so-called beta-2 selective inhalers and injectables like terbutaline (Bricanyl), which had fewer side effects, as they acted mostly on the lungs without stimulating the heart the way adrenaline does. In the U.S., adrenaline (epinephrine) in injectable form is commonly used for asthma attacks and allergic reactions. It is even available in auto-injectors for personal use by allergy sufferers.

My Swedish teachers and mentors had little or no experience with adrenaline. In fact, one night in a community hospital where I worked, we had an asthmatic in the emergency room with a stubborn attack, and the senior physician decided to use straight adrenaline since the patient wasn’t responding to injections of terbutaline. We actually transferred the patient to the intensive care unit before injecting the adrenaline, more because of our fear of side efecs from the drug than fear of respiratory failure from the asthma attack.

A couple of years later, new here in town, I met Elwood “Woody” Black.

Woody Black was almost seventy when I met him, and he lived for a good many more years in spite if his bad asthma. The first day I met him, he pulled a beat-up metal case from his shirt pocket with an ancient syringe, a well used needle and a couple of vials of adrenaline. When his asthma kicked in, he would roll up his sleeve and give himself a shot in the arm with adrenaline. It was with great trepidation I agreed to refill his prescription, but he had obviously used it many times without coming to harm.

Driving home from the pharmacy with three inhalers worth about $150, I wondered if generic injectable adrenaline might see a resurgence in this country…