A Country Doctor Writes:

Doctors hate it when patients say: “Doc, I don’t want to take this medicine, because it causes all these side effects – just look at this list I got from the pharmacist (or off the internet).”

As allopathic physicians, we are at a disadvantage because our medicines come with warnings about every side effect ever reported, even if no one has ever proven it was actually caused by the medication.

Everyone knows about the placebo effect, the healing caused by a patient’s expectation that a medication will work. The package inserts we get today bring on the nocebo effect, which is the creation of discomfort by negative expectations.

Practitioners of alternative medicine have it easy; they can take full advantage of the placebo effect without the nocebo effect caused by pharmacists, the FDA, the legal climate or the Internet.

Adverse effects can be very real and frightening, though. I have seen plenty of them, and it does make me careful. This is the age of information and Informed Consent, and we have to be very careful to tell patients about possible adverse effects when we prescribe.

I have seen a woman’s bone marrow almost shut down from a week of sulfa for a urinary tract infection. One man lost the use of his right arm for months due to rotator cuff inflammation after taking Cipro for a sinus infection. Another man developed horrendous sunburn while taking doxycycline for a prostate infection. Several patients have developed allergic rashes and tongue swelling.

I have seen people go into heart failure from Avandia, a once-popular diabetes medicine and I have seen people use my prescriptions to try to do themselves in.

But adverse effects can be caused by non-pharmacological treatments also. Sometimes a doctor’s words or demeanor can have unintended, even devastating effects.

One successful business woman told me once that she had felt terrible the whole time between two appointments because she had got the impression I thought she was foolish, and I couldn’t even remember what had happened. A few times I have had to undo damage I caused by being in a hurry when dealing with a patient who was afraid or anxious. 

A physician’s demeanor is part of the treatment. I know they teach empathy in medical school these days – to the extent this is something that can be taught.

William Sykes was told by his pulmonologist that he had eighteen months to live when he was diagnosed with alpha-1-antitrypsin deficiency. He became severely depressed. The antidepressants and steroids I prescribed made him manic for a while, but we got through it. I promised him the pulmonologist didn’t really know how long he would live. The specialist did fire William as a patient because he cancelled a couple of follow-up appointments, so it was “him and me” and the occasional Hospitalist for a few days of “pulmonary toilet”.

William lived almost ten years longer than predicted, even got married and adopted an old parrot, which learned to imitate the sound of the oxygen truck backing into the driveway. But he never got over the words of the pulmonologist.

I had some down time in New York this past weekend and spent some of it looking at what Swedish physicians are writing in their blogs. (I am a Swedish physician, too, but I have lived most of my professional life in the U.S.)

I came across a brief little piece by a 25-year-old Swedish resident. She connected with a patient on her ward in his fifties (her father’s age), who seemed to be doing OK, but died overnight while she was off duty.

I tried to remember the first patient I lost, but I couldn’t. There have been so many in my 29 years as a doctor, some lost prematurely, but most in their old age and after a long illness.

A few months ago, a former patient who no longer lived in our town, died. He was only a few years older than my own children and the news of his death affected me deeply, even though I hadn’t seen him for years.

Bobby Smith was a normal, rambunctious, ten year-old until one day, my second winter in town, when we got a radio call from the ambulance. In those days we had all volunteer EMT’s, and none had any advanced training, so the doctors at our clinic would get called to go on ambulance runs.

It had snowed heavily that morning and school was cancelled. By noon the snowfall had stopped, and the sun came out.  Bobby went sledding right in front of his house. At first, the new powder slowed him down, but every time Bobby followed the same path down the hill he went faster and farther. The last time, he ended up in the middle of the road.

Samuel Trumbull, the town selectman, didn’t have a chance to avoid hitting Bobby as he lay on his sled in the middle of the road.

The ambulance had twenty miles to go on the winding, slippery road to the hospital. Bobby was unconscious, not breathing, but with a good pulse and blood pressure. I maintained his airway and bagged him the whole way.

He pulled through, but with severe brain damage. He never spoke again. He would make grimaces and smile or poke at you. He was bed bound and incontinent. I did house calls there for a few years. Eventually they wheeled him into his old classroom, mainstreaming him, as they called it.

His parents split up, and Bobby ended up moving away from town. I would still often think of Bobby, and poor selectman Trumbull – his life was never the same after that day, either.

Suddenly, one day this spring, a patient whose maiden name was Smith – something I never reflected on – cancelled an appointment because her brother had died. When I saw her a week later, she mentioned who her brother was. All of a sudden I was back in that ambulance, bagging this little boy, who could have been my son. I lost Bobby all over again, but this time I lost him forever.

The other night we stayed in Brookline on our way to New York.

Boston and Brookline are reference points for this country doctor. I go to Harvard courses for updated knowledge and continuing education credits, and I occasionally refer patients to specialists at Massachusetts General, The Brigham, or Mass. Eye and Ear Infirmary.

When down there, we often stay in Brookline, down the street from the Longwood medical area. There is a row of inns that offer housing for families and patients undergoing treatments at the major hospitals. We ended up there once ourselves, referred by Angell Memorial Hospital, when we took our sick dog there, first for a consult, and then for an extended period of radiation therapy.

Angell referred us to the Bertram Inn, which allows dogs (and our Persian cats). Since those first two stays, we have been back to stay at least half a dozen times.  Walking the tree lined streets just a few blocks from Beacon Street and Coolidge Corner, I feel like I am in a small town, yet minutes away by car or taxi, we can be at the Symphony or a downtown course or restaurant.

On our early morning dog walks we see residents and medical students hurrying to work with stethoscopes around their necks. There are joggers everywhere. We pass the Lown Cardiovascular Center, named after Dr. Bernard Lown, who pioneered cardioversion for atrial fibrillation. His book “The Lost Art of Healing” from a dozen years ago is a must-read for doctors, particularly now. My patient and mentor, Clarine, who told me from her sick bed to write, and who gave me Thomas Moore’s “Care of the Soul“, also gave me a copy of “The Lost Art of Healing”.

Actually, Thomas Moore himself – a humble man – has said that even titles of books you haven’t read yet can be an inspiration. We attended his seminar on Cape Cod last summer, entitled “Care of the Soul”.  We missed a day of that course because of our dog’s illness. That was the summer our dog died, and what we learned from her passing paralleled what we learned from the course.

Sometimes, just spending one night in Brookline gives me a sense that I, living and working in New England, am connected to the Boston medical community. Doing the work we do, day in and day out, especially in a rural community, can make us feel isolated. A night in Brookline is like glancing at the titles of the books on my shelf. You are quickly reminded of what’s inside and it changes you a little every time you reconnect with it.

Sally is about sixty. She was widowed a couple of years ago. I usually only see her once a year for her routine physical. She and her spry eighty-four year old mother always go together for their annual mammogram.

When Sally came in for her physical a while ago, her blood pressure was up. I didn’t act on it then, but did some blood work and brought her back a few weeks later for a recheck. Her pressure was still up. I made the judgment call to pursue this further instead of just treating her pressure, and ordered an ultrasound of her kidneys with an office follow-up. A blood pressure that suddenly goes up can be a sign of an underlying problem such as poor circulation to the kidneys. We often look for “secondary hypertension” when the clinical picture isn’t typical for “essential hypertension”.

Sally’s renal ultrasound showed normal size of both kidneys, but one kidney had two suspicious areas in it, which could be either benign or malignant. The radiologist recommended a CAT scan. Sally wasn’t thrilled when I called her to let her know the results; she generally doesn’t like to have a lot of tests done, but now we had the possibility of kidney cancer versus something harmless. She agreed to the CAT scan, which required intravenous contrast.

A few days later the report came in. My heart sank. The larger of the two kidney lesions was benign looking, but the smaller one looked suspicious and was too small to completely characterize on the scan – follow-up was suggested (how soon, I wondered…). But there was more: The head of the pancreas looked a little enlarged, and the bile ducts were a hair wider than usual. A dedicated pancreas CAT scan was suggested in order to rule out pancreatic cancer.

The follow-up appointment we had scheduled at the beginning of this process was three days after the CAT scan. I looked her straight in her eyes and told her about the small suspicious area in her kidney and the suspicious looking area in her pancreas. She moved her head back in slow motion and moved her hands up toward the ceiling and said:

“You know my husband died from pancreas cancer? I watched him go from a big, strong man to nothing in five months, and his sister died from the same thing! If this could be pancreatic cancer, I don’t think I want to know!”

“And if it isn’t, wouldn’t you want to know if you have a small, curable kidney cancer?” I asked.

“I don’t know,” she said, “what would I tell my mother? I don’t know if she can handle this.”

“Would you be OK with getting an opinion from an oncology surgeon before you say no to the pancreas scan?” I asked. She agreed, reluctantly. I have a call in to Dr. G.

Sally needs more answers than I can give her right now.