A Country Doctor Writes:

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.

I am sitting at Newark International Airport, waiting for a flight to Sweden. Instead of a book I have my laptop with me this time. I think it took longer to log on to the wireless network than it took to fly here.

I am hoping for a quick, quiet flight to visit family for a few days, but you never know. As a physician I have occasionally been called to assist fellow passengers with medical problems.

My last summer sojourn to Sweden ended on a particularly hot day. The economy cabin of the big SAS Airbus was filled to capacity. We were minutes from takeoff from Arlanda airport and the cabin crew was making its way down the double aisles to check seat backs, trays and overhead bin doors.  Just two rows behind us they stopped and I heard them ask, “Sir, are you all right?” and soft voices spoke inaudibly for a while. The purser arrived, and soon that familiar phrase came over the intercom:

“Is there a doctor on board? Is there a medical doctor on board the aircraft?”

I reached over, tapped one of the crewmembers on the shoulder and said: “I am a doctor.”

The middle-aged man was drenched in perspiration. He was American, his wife Swedish, and they had three school age children.

“I don’t feel so good”, he said. His pulse was weak and rapid, but not irregular. The wife described that he had been running high fevers on and off for the past 48 hours. The day before he had gone to a primary care clinic in a distant suburb of Stockholm with no firm diagnosis made. The wife asked him if he wanted to get off the plane and go to the Karolinska Institute. He seemed ambivalent. As I went through a brief review of systems, the Captain arrived. He needed to make a decision and asked for my advice. Should the passenger be allowed to remain on the flight?

It seemed to be my call. On one hand, the man might have had just a garden variety viral illness and might have made it back to the States without losing control of any bodily functions, but on the other hand we could have had a real mess in the cabin. He could also have had something more ominous going on, where his life would be in jeopardy hours later and 30,000 feet in the air. Lastly, imagine if what he had was very contagious – remember the SARS epidemic in 2003, thought to have spread through air travel.

I told the Captain I thought the man should stay in Stockholm. The Captain seemed relieved. The wife decided that she and the children would also get off the plane.

The Captain announced the delay while the family deplaned. The purser brought me some free champagne, and another doctor suddenly appeared from the Business Class cabin with a small box of chocolate for me. He seemed mildly intoxicated at 10:30 am. 

Triage is a crude process. You don’t have to make a diagnosis. You don’t have to be right. All you have to do is choose the course of action that minimizes the harm of any wrong decisions you might make.

Danny Ames was in for a Well Child Visit Friday, and I’ve been thinking about him all weekend. I had not seen him before; he used to see one of my partners, who retired last year. There are plenty of people named Ames in our community, but not all of them are related. 

Danny Ames turned out to be a very resolute young man, just about to enter the eighth grade. He told me he is living with his father in the next town, because that way he has a choice of High Schools. Danny wants to become a professional soccer player, and he wants to go to High School at a nearby private academy that tutors in students from towns without their own High School. 

He has spent the summer learning roofing. He told me with pride in his voice that his father has a roofing business. In the next breath he told me that since age seven he had lived with his mother, because his father went to prison. Now that Danny’s dad is out of prison, the two of them have become close again.

Danny is missing a big chunk of his left ear. He told me matter-of-factly that when he was four years old he happened to be standing behind is uncle, who was using a chain saw. The uncle swung the chainsaw behind him and cut into Danny’s ear. Danny remembered the whole incident vividly – the first two doctors he was taken to wouldn’t stitch him up, so he ended up at the hospital, the anesthesia didn’t take very well, and Danny screamed the whole time. 

Danny was alone in the exam room for his physical. His grandmother was in the waiting room with a younger child. As I went through the usual questions about alcohol, drugs, sex and peer pressure, Danny told me self-assuredly that he had been trusted to take care of himself since he was eight years old with his father in prison and his mother having to work two jobs to support herself and her two boys.

I rattled through the immunizations Danny might want to update, brought the grandmother in for signatures, but basically acknowledged that I was dealing with a very young adult. Danny had clearly not had an easy life up to this point, but he had the character to turn it all into something positive; he was proud of both his parents, he was learning a trade, and he had a dream. I know not many kids from around here become professional soccer players, but if anybody will, Danny Ames just might be the one.