A Country Doctor Writes:

William R. Winters, Jr. was in for his 18 month Well Child Visit today. He brought his mother with him. I had done a weight check halfway between his one-year visit and today, just to make sure his weight didn’t slip. At a year old, I even checked his basic labs, lead and thyroid studies – all normal.

He is a tiny thing, not quite on the growth chart, but his mother is only 4’10”. Will also isn’t a voracious eater. Last time I saw him, he wouldn’t eat anything with texture to it – he would spit out jar baby food if it had lumps in it, and wouldn’t eat Cheerios or crackers. 

Today, as I walked in the room, Will was reading one of my car magazines while stacking blocks on the exam table. His little face was serious and determined-looking as he greeted me with a block in the air while repeating the word “block”.

I brought a peace offering – an age-appropriate book about a duck. He glanced at it, tossed it on the floor and went back to his/my car magazine. I turned to his mother for more history.

Will still nurses at night, but he has started to explore foods with lumps. He drinks from a cup, although he doesn’t show any interest in using a spoon. His weight is up a little. He knows twenty words, although he doesn’t combine them yet. Sometimes in public places like the supermarket he starts screaming just to get attention, and he’s enjoying the power of saying “no”. He is clearly working on soon being a healthy two-year-old.

After the physical exam, and after hearing me announce that no shots or blood tests were needed today, his mother said:

“You’ve got to help me with his dad.”

“What do you mean?” I asked.

“He’s threatening to buy Will a dirt bike as soon as his legs are long enough to reach the pedals”.

“But he doesn’t even know how to ride a tricycle!” I was at least as bewildered as she expected me to be.

We talked about how dirt bikes and ATV’s aren’t safe at any age, and how fathers, no matter how loving, sometimes don’t know how to handle babies.

The physical exam was straightforward. Will let me check his ears, throat and all the other required body parts. He is clearly just a very normal boy with a diminutive mother and a macho dad. I gave his mother some pointers on how to deal with an over-compensating father. I left the room to let them get his clothes and their stuff back in order. A few moments later they emerged into the hallway.

“Can I borrow this car magazine, he won’t let go of it?” she asked.

“Keep it!” I said.

I’m not sure what happened to the age appropriate duck book. I thought to myself:

“What a little man…”

The medical record of another young man in our practice went into the office basement Friday after being stamped “DECEASED” across the front of the manila folder.

In all my years of practice in this community I cannot remember a single young male patient of mine who died from a disease like cancer or AIDS, but I have known over a dozen who shot themselves, jumped off the bridge, took a deliberate or accidental overdose, or died as a result of a motor vehicle accident.

This time it was a self-inflicted gunshot wound in the context of a failed marriage and a troubled new relationship that ended a young life. Several staff members knew Thursday morning what had happened to the young man I only met once about a year ago.  Someone had even heard it from an eyewitness, but the “DECEASED” stamp didn’t go on the record until the obituary appeared in Friday’s newspaper.

When adolescent or preadolescent males come in for physicals, we don’t often find new diseases. We’re certainly on the lookout for boys who might be developing hypertrophic cardiomyopathy and are at risk for collapsing during vigorous exercise. We also preach the importance of testicular self-examination. This is extremely important, since the majority of testicular cancers are discovered this way. I still remember the last case I saw, probably four years ago now. The young man felt a lump I wasn’t sure I could feel. I ordered an ultrasound, which identified the cancer and confirmed his self-diagnosis.

The most important part of the adolescent male physical is talking about the things that most often threaten or end the lives of young men. I have no illusions that we as physicians can stop suicides or deaths from risk-taking behaviors or accidents in even a fraction of cases, but what if some of us can do that even once? We don’t know when we might indirectly save a life by nudging someone toward better conflict resolution skills or away from situations like getting in a car with an impaired driver behind the wheel.

The young man who ended his own life Wednesday seemed like a decent fellow. I’ll probably never know what made him do what he did, but it does sensitize me to my role as a fiftysomething physician who has the privilege and responsibility of sometimes, however briefly, being in the position of elder or mentor for young men making their way into a complicated adult existence. Am I open and aware enough to offer my ear or my hand when it is wanted?

Sweden, Saturday night: 

Sitting in my aunt’s living room on the eleventh floor as the late summer sun set and the sky turned dark, the conversation over after-dinner-coffee and cognac turned to her recent stroke and emergency carotid artery surgery. My mother had a small stroke a couple of years ago, which fortunately only affected her peripheral vision to her right. My aunt’s sequelae are less specific, affecting a few fingers, her balance and some parts of her memory. I let my gaze wander to my right from the coffee table to her windowsill with several blooming orchids and the city lights below.

“How funny”, I thought to myself, “there’s a spider web between those two orchids”.

A perfect, round spider web sat between the two orchids with a distant light source illuminating it from behind. I tilted my head to make sure; my aunt was always a good housekeeper and it seemed unlikely she would have cobwebs on her orchids. “Maybe the stroke did even more things to her”, I thought to myself.

With my head tilted I saw another spider web of the exact same size and appearance, between the next two orchids on the windowsill, also illuminated by a bright light in the distance. “No way she would have two cobwebs”, I decided. “It must be my eyes”.

As the conversation continued I drifted off with my own project. Closing one eye at a time and discretely tilting and turning my head, I determined the spider webs were only visible with my right eye. Sudden cataract of one eye seemed an unlikely diagnosis, so I figured it must be something else, probably a vitreous detachment. I saw no flashing lights, which can be a symptom of either a vitreous or a retinal detachment, and there certainly was no curtain over any part of my visual field or any loss of peripheral vision.

With no ominous diagnosis immediately apparent to me, and not wanting to ruin the evening, I beamed myself back to the conversation and finished out the evening without saying a word about my vision.

Driving back to the hotel, I knew for the first time what people mean when they describe the difficulties of night driving with cataracts. The spider webs seemed more like small haloes around streetlights and headlights of oncoming cars. This is a classic symptom of cataracts, but this was too sudden. Squinting with my right eye allowed me to drive comfortably.

After parking the car outside the hotel I continued my exploration. What looked like a halo with a spider web configuration was also a circle filled with a swirl of movement, like water circling a drain. Inside this swirl of water were squiggly, small worm-like shapes, similar to the small, unobtrusive floaters I have had for years.

I went up to my room and pondered my fate. I wanted to be a doctor from about the age of four, ever since as a sickly child I had our general practitioner come for house calls. When I became severely and progressively nearsighted starting at age seven, I became fascinated with ophthalmology. My first eye doctor was a thin, old man with an office in an ancient apartment building with marble stairs, oak doors and a musty smell. As he leaned into me with his bright lights, he spoke with great concern about my worsening eyes. Every year I would get new, thicker lenses, and every year he would seem more concerned. After puberty, things seemed to slow down, and the old doctor seemed to be more content with my situation. He was so wise and kind. I wanted to be just like him.

In medical school I flirted with the idea of becoming an ophthalmologist; I learned everything I could about refraction, and as an avid photographer and dark room enthusiast, it seemed like a natural fit. I took electives in ophthalmology and thought this would be my life’s work.

Then one thought, one factoid, stopped me in my tracks: As a severe myopic, I might be at increased risk for suffering a retinal detachment – then where would I be as an eye doctor who couldn’t see well? The rest, as they say, is history. I decided to become the kind of general practitioner I first identified with as a young child. 

Fast forward to 2008, a middle aged Family Practitioner, sitting in a hotel room with a self-diagnosis of a vitreous detachment in a country where I no longer have any medical connections – do I have a harmless condition with no need for intervention? Do I trust what I think I know about ophthalmology beyond my own specialty training? Do I trust whoever is on duty at the small hospital nearby? Or do I call my wife back home in the States and ask her to pull some strings and get me an appointment Wednesday with the best ophthalmologist I know back home?

Times are tough for most airlines. Scandinavian Airlines used to offer a choice of entrees even in economy class.  That ended a year or two ago. I found out when the steward handed me my food with a grumpy face. “I thought there was a choice”, I said. His grumpiness deepened, and he quipped “You have a choice whether to eat it or not”.

The Stockholm newspaper I read shortly after takeoff from Newark had side-by-side articles on Swedish health care. One piece described the waits for elective surgery within Sweden’s socialized system. At Stockholm’s Karolinska, the wait for knee replacement surgery is currently 20 weeks, down from 52 weeks in 2005. The smaller Södersjukhuset makes patients wait 32 weeks to have their gallbladder out, which is better than suburban Danderyd Hospital’s 44 week wait.

Other than going to one of very few strictly private hospitals, patients have few options but to wait. Right now, they can’t seek elective care at a hospital other than the one near where they are legally residing. That will change in 2009, but the new freedom to choose hospitals will only apply to certain surgical procedures.

The second article mentioned that until recently in Stockholm, patients were not able to choose which primary care clinic to use. Now patients can choose freely, but their new freedom has not yet resulted in enough resources going to the clinics with the most needs and highest volume.

Of course I remember working under this system, but I hadn’t been thinking about the waits and the lack of choice for a while. The private option wasn’t available when I practiced in Sweden. It is a nice luxury option for those few who can afford it, just like flying business class. However, the majority travels economy class through life and has the choice between waiting many months for elective surgeries like knee replacements, and not having them at all.

Maybe Sweden needs to learn from American insurance companies about medical tourism – sending elective surgery patients abroad for what is touted to be high quality, low cost care.