A Country Doctor Writes:

Laura is about 25, a sweet kid with a doting husband, Mike. She was in the office yesterday to follow up on a weekend emergency room visit for vomiting and diarrhea. She wasn’t getting any better. Her liver tests were off the scale, but her pancreas numbers were pretty good. Her hepatitis profile was still pending. I got an urgent ultrasound on her to make sure she didn’t have her family curse – unusual and dramatic presentation of gallstones. This test was normal.

Today she was back for a follow-up visit. She wasn’t getting better. Her hepatitis profile from this weekend came back negative. Her liver tests from yesterday were unimproved from the ER visit. Overnight she had run a fever. She was vomiting more, her diarrhea was worse, and the pain was getting worse. She needed to go back to the hospital for some IV fluids and a CT scan.

Laura was alone in the room today. I asked if Mike was in the waiting room, which would have been unusual. No, her father had brought her, but he was waiting in the car. I must have looked puzzled. She said: “He’s a chiropractor, remember, and he has problems with doctors’ offices…”

I made the arrangements and Laura went back to the hospital with her father at the wheel.

I have had reason to think about physician-chiropractor relationships before; my brother-in-law is a chiropractor. We have never talked shop. I have always been a staunch allopath but have sometimes seen patients who were helped, dramatically, by chiropractic. Recently, Caleb, our horse with an unexplained limp, seemed to be very much improved after acupuncture and chiropractic treatments.

The practice of medicine in America is flavored by the malpractice climate. I have a form letter on my computer, stating that I as a patient’s primary care physician agree to authorize insurance payments to their chiropractor, but I don’t assume any responsibility for the chiropractor’s diagnosis or treatment.

When patients ask me if they should see a chiropractor, I usually answer their question this way:

“You wouldn’t ask your rabbi how often you should go to confession, would you? Chiropractic and allopathic medicine are like two religions. We don’t speak the same language and we use different tools. But even though our practices are different, we ultimately work for the same higher purpose, and it may be that our differences are smaller than we were taught. We don’t know enough about each other’s practices to make specific recommendations, but support you, our patients, in your pursuit of better health and wellbeing.” 

I wished Laura’s father had been more present as she sought allopathic care for a potentially serious, maybe even life threatening condition, and I wish my brother-in-law and I could sit down and talk about what it means to be in two different, yet similar healing professions…

I have been away from the office for more than two weeks. After two days back at work I am finally able to catch my breath and think about writing again.

I had intended to write a post about the fact that our clinic has a system where providers who have been away for more than a week have half a day dedicated to catching up on incoming laboratory tests, consultant and hospital reports as well as x-ray reports.

Instead, I am marveling about how hard we work. As doctors in rural America, we really do work hard. When I lived in Sweden and when I went back there to work as a locum tenens (“temp“) for one summer, there were regulated coffee breaks and a leisurely pace throughout the day. Swedes are a patient bunch; you can only call your doctor during certain hours, and you never expect anybody to respond in real-time. In America, people expect instant action.

I spent half a day going through reports. My hospice lymphoma patient is still hanging in there. Sally, the woman with a possible pancreatic tumor did go for her pancreatic CT, in spite of her misgivings, and the test was normal. Now she “only” has to deal with a possible kidney cancer; her urology appointment isn’t until next month. Sumner Bell, one of my regulars, died suddenly during a quick trip out to his shed – we don’t know what happened. He had angina and some heart failure and was on warfarin because of a prior history of a blood clot in his lungs.

My first two days back (one and a half seeing patients) have been more hectic and demanding than I anticipated. Today I had three patients go to the city hospital by ambulance – two with breathing problems and one with a broken femur. On top of that, my wife took our second car for a short trip to the post office and lost the brakes due to rusted-out brake lines (replaced only a couple of years ago in a hilly town in Canada – another adventure worth writing about some day). Between the tow truck taking six hours to get here and the hassles of picking up a rental, we haven’t quite landed yet, but life is expecting us to be present.

Moses, our puppy who took the big city by storm, is learning how to deal with the cats and the beagles all over again; I think he enjoyed being an only animal.

I was on call last night; tonight I am off. Now I know why it always takes a couple of days to wind down when I go on vacation – it is a matter of switching between two realities. But, I have to admit, even with the pressure we’re under, I couldn’t imagine myself doing anything else besides what I’m doing. I always wanted to be a doctor, and that’s what I am.

We are settling in back home tonight after a two-week trip to New York City and one of the Mid Atlantic states. We stayed at one hotel for twelve nights and it started to feel like a home away from home. This was the first trip for our puppy, a black German Shepherd, who actually turned one year old while we were away. This dog makes friends everywhere we go.

I am not as gregarious as our puppy, but at this particular hotel I made friends (sometimes because of the dog) with all the desk clerks and the newly hired maintenance man and his helper. I also had a quiet understanding with the woman who ran the complimentary breakfast buffet. I never took the dog there, but he contributed to my multiple trips to the free buffet every morning. This dog doesn’t eat dog food; we feed him human grade food, so I made a few trips every morning to the breakfast buffet to load up on eggs and bacon for the dog and me, as well as pastries and yogurt for my wife.

Every morning the breakfast buffet supervisor seemed to look me over as I heaped a generous amount of eggs and bacon on my plate and disappeared to our room, only to appear minutes later for another big helping. She always smiled at me and said with an East-European accent: “Have a nice breakfast”. Whenever I ran into her somewhere else in the hotel, she smiled as if she knew my little secret and always said something nice.

Early this morning, after three trips downstairs to pack the car, as we passed through the lobby on our way out for the last time, it seemed as if they were all there. The night desk clerk, just coming off duty, the daytime desk clerk, the maintenance man, even the breakfast lady showed up, seemingly to say good-bye to the puppy. The breakfast lady was the last one to do so, and she spoke to Moses in Russian.

I said, in Russian, mustering all I could remember from thirty years ago: “I understand a little Russian“.

She beamed, exclaimed ” Ochen chorosho (very good)!” and went into something long and complicated, of which I understood nothing. I reverted to English and told her why I came to learn some Russian at all when I did my military service back in Sweden.

She smiled and said softly “I am doctor in Russia, here – ” and she shrugged “housekeeping”.

I wanted to say something more profound and supportive, but the puppy was starting to get impatient, we were already an hour behind schedule and we had a very long drive ahead of us. All I could do was mumble something about reading somewhere that there are many foreign-trained doctors who are having trouble getting their license here. Then I drove back home to my life as a doctor in America while she went back to check on the breakfast buffet.

Doctors have a reputation of making bad patients. Many of us even hesitate getting a personal physician. Years ago it was common for doctors to treat themselves and their families. The Latin vocabulary used on prescriptions includes the phrase “Ad Usum Proprium”, which means “For Personal Use”. This is now considered inappropriate, except in emergency situations or for occasional minor illnesses.

When I turned fifty, after years of neglecting my health, I decided to get my own Family Doctor. I thought about it for a long time. I decided not to see one of my partners, but someone in the city 20 miles from here. It should be a physician with more years of experience than I had, not someone who was young and “aggressive”.  In medicine we use that term for doctors who order lots of tests and prescribe multiple medications. My choice of Family Doctor for myself was Wilford Brown, III, MD, a tall, gray haired man with a solid reputation as a thoughtful, conservative clinician.

Our first meeting went well. I told him which things I was interested in looking into and which ones I didn’t worry about. He obliged, did a brief but appropriate physical exam and treated me with utmost respect. If he disagreed with me, he didn’t say so. I really liked him. We had another visit a year later, and I thought things were going well until he told me he was retiring. My heart sank. I asked him if there was another doctor in his office he would recommend for me. He didn’t hesitate before suggesting Dr. John Royson.

My first and only meeting with Dr. Royson did not go well. I sat in a bare exam room, fortunately not bare myself, for an hour. The exam room door was open and I overheard the medical assistant call Dr. Royson on the phone. Her end of the conversation went:

“Hello, Dr. Royson? Did you forget you had office patients today?”

“Yes, for over an hour.”

“So when will you be here?”

I had taken a half-day off, so I declined the assistant’s offer to reschedule the appointment. After another twenty minutes or so Dr. Royson appeared. He was in his early thirties, sported a flat top and didn’t apologize or even mention anything about me waiting almost an hour and a half.

D. Royson seemed a bit flustered about having an older physician for a patient. He mumbled to himself about perhaps checking my prostate etc. The whole visit lasted ten minutes.

I didn’t have to fire Dr. Royson; he left the practice to become a full time Hospitalist, doing what he was doing when he forgot that he had me and other patients to see at the office.

Dr. Royson’s replacement at Cityside Family Practice was another interesting experience. Dr. Joe Washburn looked like he’d rather be surfing, started me on a new blood pressure pill with a prescription good for a whole year and didn’t say a word about how to follow up. I got the impression he was so uncomfortable treating a colleague that he wished I’d go away and do my own follow-up.

Not long ago our clinic had a new patient register. We have a preliminary registration sheet come to the doctors for approval, because we are at near full capacity. This patient  registration sheet caught my eye:

Name: Wilford Brown, III, MD. 

Reason for choosing our practice: Payback.