A Country Doctor Writes:

Mary and Joseph Washburn are moving back to Massachusetts tomorrow after a dozen years in our little town. They were active retirees from the big city, involved in the community in several ways. Joe was a baseball coach, Mary was on the board of more than one charitable organization, and their home was a beacon on the local cocktail circuit; Joe was the best amateur bartender our community had ever seen.

Over the past few years, Joe’s faculties failed him rapidly, and Mary came down with rheumatoid arthritis. For a while, between his strong body and her sharp mind, they were able to hold things together, but as his dementia worsened, Mary’s ability to reign in his confusion lessened and a few weeks ago she told me the time had come for them to leave their adopted home town and move back to Massachusetts in order to be closer to family.

Today I saw Mary for her last visit and it was a profound ten-minute encounter.

As I entered the exam room, Mary was writing out a deposit slip for ten thousand dollars.

“I sold Joe’s truck,” she explained, “but he doesn’t know yet. He thinks it’s in the shop. He is so much worse just since you saw him last. He doesn’t even know who I am. Sometimes he thinks I’m a friend and sometimes his sister.”

“I can’t do this paperwork in front of him, so I had to do it now”, she continued. “We bought this little row house so I can continue to take care of him because we promised each other a long time ago that we’d never put each other in a nursing home, although we have long term insurance.”

I found myself counseling a woman about the same age as my mother.

“We sometimes make promises without ever imagining what circumstances we might end up in,” I began. “Don’t be hard on yourself. Do the best you can, but if you find that the situation isn’t safe for one or both of you, do what is best at that time. If he is restless or agitated and you can’t keep him safe with just the power of your wit and your love for him, you will need to find another way.”

She nodded and sighed.

“It’s gone so fast.”

Shrugging, she added: “Do you know we got a thirty year mortgage on our new home – at our age. Who knows how long we have together.”

Stopping into our local supermarket during a surprise snowstorm yesterday, I found myself in the checkout line observing some of my young patients in action.

Darcy Devereaux was the cashier. I watched her quick hands scan the groceries of the person ahead of me while she chatted away cheerfully.

A casual observer might have missed the skin grafts on her hands and forearms. Knowing they were there, I marveled at her speed and agility as I remembered her trips to the Shriners Hospital for a long series of surgeries for the burns she suffered at age two. Her mother was in and out of the picture, and ultimately she ended up living with her father.

Danny Pierson was our bagger. His nametag said “Shift Leader”. He is a full time college student, who lives with his father and stepmother here in town. Every day he commutes to college, and every weekend he pulls long shifts at our supermarket. A few years ago his biological mother arrived in town after being away for fifteen years, and sought him out in an effort to reestablish a relationship with the son she hadn’t seen for such a long time. Then, just as suddenly as she had appeared, she fell ill and died. Danny didn’t miss a day of school or work. I happened to see his father around that time, and we had talked about Danny’s resilience.

Darcy had just finished scanning the groceries of the woman ahead of me, and Danny had bagged them with more care and proficiency than anybody else when Sarah Daigle came storming in from the parking lot, her blonde hair dripping and her blaze orange vest covered with snowflakes.

“Some old guy almost ran over me out there”, she exclaimed, her voice quivering.

Danny made sure the customer ahead of me was all set, then quickly whisked Sarah across the exit isle and into a small staff area. Her voice was shrill as she recounted what had happened. I couldn’t hear more than a word here and there as I stood there and watched Darcy’s scarred hands flick my groceries across the scanner.

Danny was calm and professional. He debriefed Sarah as if he had done that sort of thing a hundred times before. I heard him say that Sarah could take some time-out or go and see the Manager on duty. She seemed to be okay with just her talk with Danny and disappeared into the store.

I had started bagging my own groceries, and Danny quickly finished the job for me. He explained briefly that an older gentleman backing out of his parking space had not seen Sarah and had almost run into her. Danny looked straight into my eyes and wished me a good night.

I wished him the same, drove home carefully through the heavy snowfall and called the Manager on duty.

“I just wanted to let you know I saw Danny Pierson in action tonight debriefing Sarah Daigle after she almost got run over in the parking lot. He really seemed to handle the situation in a very professional manner”, I said.

“Thanks, Doc”, he said. “I’m really glad you called to tell me that. Usually when somebody calls about my crew, they call to complain about something. It’s nice to hear when somebody is doing something right!”

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.