A Country Doctor Writes:

My last patient the day after Thanksgiving wasn’t happy with her two-pound weight loss. Everyone else who got weighed in that day had gained some weight, and each person had an excuse.

Cheyenne Mott is a striking young woman of twelve, going on seventeen. She has some of the features of her tall, reddish-blond father, yet seems like a spitting image of her dark, fiery-eyed mother. Like both of them, she is big-boned, but unlike her concrete-laboring father and her highly disciplined mother, Cheyenne has not been able to keep her weight under control.

Cheyenne has been on antidepressants for a couple of years. I have known her parents for years, but her for only a few months. It quickly became clear that her weight is her biggest issue. Last year her parents sent her to a camp for overweight girls, and during a few short weeks of strict dieting and rigorous exercise, she lost an impressive twelve pounds, yet gained it all back very quickly.

We talked about her efforts at self-discipline and her two-pound weight loss over the Thanksgiving week. She wasn’t able to see losing two pounds as a modest victory, but thought of it as a frustrating experience.

She pointed out that other girls eat more than she does, and are thinner. “It’s not fair,” she exclaimed. “I can’t even look at food without gaining weight,”

I tried to reach through her frustration.

“You are what we call an easy keeper,” I began. “You have a genetic ability to survive starvation, and that may have been a really great thing a thousand years ago, but now it means that if you eat like everybody else you will somehow gain more weight than they do on the same number of calories. And if you cut down your calorie intake, your body will slow down enough so you won’t lose as much weight as other people do when they go on a diet.”

She rolled her large, deep-set eyes.

“It’s like everybody else drives a Hummer with a 32 gallon tank and you drive a Toyota Prius that holds 12 gallons. What happens if you try to put 32 gallons of gas in a 12-gallon tank? It overflows, and when that happens it doesn’t matter if you think it’s fair or not, it’s just the way it is!”

She nodded with understanding, and I continued: “You’re just more fuel-efficient than your friends, and that can be a good thing in some ways, but it means you can’t keep comparing yourself with them,” I repeated.

She seemed to get it, and her mother acknowledged how hard she always had to work to keep her own weight in check, yet she threw in: “So you don’t think there is a medicine that could help Cheyenne?”

“No,” I answered, adding, “You already know you lost twelve pounds at camp. I know I sound like an old fuddy-duddy, but you don’t need a pill to do what you already proved you could do last year at camp. And look at what you just did; you are the only person I saw today that lost any weight over Thanksgiving!”

“I did lose two pounds,” she said with just a hint of a smile.

“Biff” Mitchell at 6 foot four and 265 ponds is all muscle. He is a firefighter/EMT who drives the ambulance and regularly enters burning buildings to save lives. He teaches students at a nearby military college how to fight fires, and on the side, he repairs heavy equipment and also acts as our town’s Animal Control Officer.

I saw “Biff” this morning for an impromptu visit because of a finger laceration. I was curious, and asked what heroic act he had been performing when he cut himself.

He grinned, and answered: “I was making a chocolate cream pie for Thanksgiving.” He looked a bit uncomfortable, and added: “I haven’t told Debbie yet that I cut my hand on the broken pieces of her favorite glass bowl.”

“Biff” had rinsed out the cut thoroughly, and he was already up to date on his tetanus shots. I did a digital block with buffered lidocaine and stitched him up, dressed the wound and sent him home with my best wishes for dealing with the loss of his wife’s favorite bowl and “Happy Thanksgiving”.

Around four o’clock today a chocolate cream pie appeared at Autumn’s desk. It was from “Biff”, and I invited everyone to have a taste. Everybody politely declined, so I brought an intact pie home for our Thanksgiving dinner tomorrow.

I thought this was such a quaint little incident that after dinner I started to write it down, thinking it might make a post for my blog. I was interrupted by the telephone. The caller ID informed me that it was a local number belonging to “B. Mitchell”.

“Was there any left of that pie for you to taste?” he asked.

“The nurses left it all for me”, I told him. “It’ll be the crowning jewel at our Thanksgiving dinner tomorrow”.

I could almost see him beaming at the other end of the receiver.

He seemed more proud of this pie and more grateful for my squeezing him in the day before Thanksgiving than anything more glamorous either one of us has done all year.

This country doctor lost power today in more ways than one.

During dinner tonight, with a hard rain beating against the windows and skylights of our family room and the wind howling outside, the lights flickered a couple of times and then went out. We always eat dinner with a kerosene lamp on the table, so we were not in complete darkness, and I quickly lit other kerosene lamps and the candelabra on the mantle of our Swedish ceramic tile stove.

Moments before this dramatic turn of events I had recounted for my wife this morning’s exchange with our clinic administrator, who had called me into his office to tell me that another physician at our clinic, five years my junior and with an internal medicine background, was vying for my role as Medical Director.

The way the administrator sees things, the future of our clinic depends on our ability to serve an aging population with increasingly complex medical problems. My colleague, the internist, prides himself in his ability to take complex internal medicine cases further before calling in specialists. Ironically, the way we get reimbursed is essentially at a flat rate, making longer visits a drain, while shorter visits are profitable for us.

The administrator told me in a roundabout way that my skills as a Family Physician in handling large numbers of acute visits involving pediatrics, GYN, minor trauma, orthopedics, ear-nose-and throat, ophthalmology and infectious diseases were needed to offset the costlier but less well reimbursed visits of the internist, but that I would be playing second fiddle to him because he deserves the title I’ve held for a dozen years.

My first reaction, I admit, had been one of anger. I helped build this clinic; in the first few years after I came here, our census doubled, and I created most of the programs and protocols in place today. After thinking about it some more, though, I admitted to myself that for any employed physician today, rural or urban, the non-medical people who run the clinics and medical offices we work in are free to bestow titles and “power” upon whomever they choose, and that is usually whoever serves the management’s purposes best.

I may not know what the ultimate purpose of our management is, and, as I was telling my wife just as we lost our electric power, the power I may have had as Medical Director was fickle, and subject to managerial whim, while my power as a physician and healer is something no administrator can take away from me; whether I see acute or chronic illnesses, I am following my calling in meeting my patients, one by one, where they are in their moment of need.

The one thing I will fight for isn’t the title, but my right to see my patients, the ones I have cared for almost a quarter of a century, as long as they choose to see me as their physician.

Leslie Dubrovnik turned sixty-five a few months ago. She has been an infrequent visitor at our clinic because of her lack of health insurance. Her husband is a disabled veteran, who runs a small used car dealership in the next town, and although they seemed fairly well off, she was always very cost conscious about her health care. She would come in once a year for a routine physical and she always got her mammogram, but when I suggested big-ticket items like a screening colonoscopy, she always declined.

“I’ll wait until I’m sixty-five”, she would always say.

At age sixty-five in the U.S., you qualify for Medicare, the government-sponsored health insurance. For many non-working and self-employed Americans, this is the only option for affordable health insurance. Many, like Leslie Dubrovnik, hold out until their Medicare benefits take effect. Soon after she turned sixty-five we scheduled her colonoscopy.

Tuesday I got Leslie’s report in the mail. She had a 3 cm tumor in her proximal colon. Thursday afternoon I got a call from the gastroenterologist who had done Leslie’s colonoscopy.

“I got the pathology report”, he said, “and it’s an adenocarcinoma. I’ve ordered her CT scans and I’ll have Dr. Beach see her for the surgery, but I thought I’d let you know right away so you can get her set up with oncology for possible adjuvant therapy.”

I called her up to go over what needed to happen. She sounded shaken, but okay.

“Doctor,” she said, “I want to thank you for nagging me about having a colonoscopy. Do you think I waited too long?”

Physicians play different roles for different people and in different situations. We fix, educate, nurture, counsel, and sometimes just comfort. We inevitably broadcast our own feelings and values through our words, gestures and physical appearance.

Sometimes patients put us in the same sort of role as clergy; sometimes we take on a parental role.

I often see colleagues who insist on being called “Doctor”, even in non-medical situations. I also have colleagues in nearby towns that dress very casually and insist that patients call them by first name.

In the past few years I have read several articles about patients’ expectations and preferences in physician dress and titulature. The message seems to be that patients tend to prefer their doctors to be a bit on the conservative side.

Since I work in a small clinic, and also because I have been here for a long time, most people I see in my capacity as a physician know that I am a doctor. When I walk into the exam room, dressed in cuffed wool slacks, a crisp shirt and tie and an embroidered, long white lab coat with a stethoscope sticking out from my right coat pocket, I introduce myself by first and last name. I have never had anybody ask me if I really was a doctor in that situation. When I introduce myself to a child, I say, ” I am Doctor X—-“.

Some patients respond to my first-and-last-name greeting by repeating my first name and their pleasure in doing so doesn’t offend me. I simply let the patient decide how to address me, just the way I have to deal with what role they need me as a doctor to play in their illness or in their life.

I have found that even the most sophisticated patients appreciate when I speak plain English. I only use technical terms when I can introduce them and explain them; I never assume my patient is familiar with them.

I have found that comparing the workings of the human body to motors, household appliances and other everyday things helps establish a rapport with my patients and ensures I don’t get misunderstood.

One pet peeve I have is when doctors call patients by first name and themselves “Doctor”. I always found that to sound very disrespectful. We must be respectful of patients, who entrust us with their bodies and allow us to see their suffering and their fears.

Most patients are very respectful of me in return, except for the fact that many have trouble pronouncing my name; many adults and children alike call me by the initial of my last name, which, I guess, is a term of endearment in a way.