A Country Doctor Writes:

Jeremy Doyle’s house is perched high on a knoll with peaceful meadows and a distant ocean view. I had been there a few times before, a dozen years ago, when our teenage daughters were friends. Tuesday evening I went there for my first house call.

Jeremy is a couple of years younger than I am and slowly dying from two forms of cancer. He has his family curse; I also tended to his brother, who died less than a year ago. Jeremy’s Hospice nurse had called earlier in the day and suggested it was time I went there.

The change in Jeremy since I saw him last was profound. He had been under the care of several specialists, so I hadn’t seen him for a few months. Now, with no further treatment options, Hospice nurses are going in several times a week. He is on a morphine drip for his pain, breathes through a tracheostomy and gets his nourishment through a feeding tube.

The last time I was there, we were on opposite sides of 40, he just under and I just over. Yesterday I was there to see for myself how we might change his medications to ease his final journey. Both Jeremy and his wife, Samantha, are rock solid. They have been through enough ups and downs in his cancer battle that they have learned to endure more than most people could imagine, and they have tackled each new obstacle slowly and methodically. Samantha has learned to do absolutely everything the Hospice nurses do.

Sitting in their kitchen in the bright early evening light with friends stopping in for a brief visit and a young dog at their feet, I clearly had the sense that Jeremy and Samantha were in the moment, accepting and appreciating each hour of life and relative comfort. The scene was peaceful, and somehow more significant as a sign of life than one of impending death. We went through his medications, checked on all the issues raised by the Hospice nurse, and I took care of his new medication orders.

As I patted Jeremy’s elbow when I left, I said “I’ll see you soon”. Both of us knew that “soon” might never happen.

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.