A Country Doctor Writes:

I had a clue what this might be when Autumn asked me “can we squeeze in Sally Smith for leg numbness and a groin rash”, although I didn’t know the extent of the numbness or the specifics of the rash.

So we double booked her and I listened to her story. The numbness was only in the front of her left thigh and started somewhere around the groin. Her strength was normal and the sensation below the knee was perfectly normal. When I touched the numb area she told me it hurt, so it wasn’t just numb, it was numb and painful at the same time. Looking at the rash, it was a cluster of blisters in her left groin about the size of my fist and she also had a small patch of smaller blisters around the corner in the upper left gluteal area.

Sally had had a couple of outbreaks of painful blisters before. A couple of years ago I gave her valacyclovir for what looked like herpes simplex in her face. She became violently ill on a modest dose. She is also intolerant of gabapentin, which she had tried for sciatica in the past. She has a history of chronic back pain.

She has had the shingles vaccine, both doses of the newer one, so supposedly shingles isn’t likely to happen to her but it was clear to me that her numbness with pain qualifies her for the diagnosis of meralgia paresthetica.

This condition is usually caused by pinching of the lateral cutaneous femoral nerve as it exits the pelvis in the groin. People with large bellies are more likely to get this. Sally is a slender woman. But she was too tender and sensitive for me to feel for a hernia or lymph nodes in the groin. Even the slightest touch was unbearable for her.

So in this case I think her meralgia paresthetica isn’t caused by a big belly. Rather, I suspect the virus itself and possibly any associated swelling of lymph nodes or other soft tissues are the culprit.

So I reassured her I thought this would go away by itself. But, in the meantime, what could I do?

She is already on hydrocodone for her chronic back pain. And she confirmed when I said hydrocodone doesn’t usually do much for nerve pain. Lyrica would be too similar to gabapentin to try and duloxetine would probably take too long to help her. So I offered her low-dose amitriptyline and a burst of prednisone.

She will call me in a couple of days to report how she is doing and she already has a routine visit in a week and a half.

Time is a precious commodity in today’s healthcare. Visits are short and agendas can be far reaching. The concept of previsit planning has penetrated our world in recent years, but what is it, and what should it be?

Supposedly our patients are our patients every day of the year. Why then does everything have to happen the few times they show up for an appointment?

Clinics like mine actually have staff members research “care gaps“ and save them up for us providers to deal with in each patient’s glorious 15 minutes in our presence: Depression screening, colonoscopy, immunizations and on and on and on.

There was a time when previsit planning meant making sure that we were ready to deal with the clinical issues: Are the test results and consultation reports available to discuss in tomorrow’s appointment? This task is no longer prioritized. So that means I have a long list of things that could have been done by somebody else some other time while I have to scramble to do what the patient expected and deserved to have done in our visit.

How hard would it be for those people who create our work list of care gaps to also be the ones to contact the patients, leaving us to be doctors, NPs and PAs?

We are supposed to be teams, working together for the benefit of our patients. Why do we have this crazy system that funnels, absolutely bottlenecks, everything through the medical provider?

“Hello, this is so and so from X health services, calling to remind you flu shots are out, and we noticed you haven’t had a colonoscopy since 2011…”

That would be teamwork. Having a bunch of people telling me what to do does not feel like teamwork, but more like having too many bosses.

The morning huddle has been hijacked and the role of previsit planner of what the doctor should do is becoming more and more prominent. There are better ways to provide public and preventive health in primary care offices.

I’m taking a little time off around the holidays. Meanwhile, here are the top five posts from A Country Doctor Writes in 2021.

I had this long New Year’s post planned but… Sometimes a picture is worth 1000 words. I am where I’m supposed to be. I’m looking forward to 2023. Happy New Year!

It is the evening of Christmas Day. The day did not turn out the way I had planned. But I made it work. Those who follow me on Facebook know that I was one of the quarter million people in Maine who lost power Friday night.

Because I follow the weather, like most Mainers, I pulled my large, portable $1,300 generator out of my walk-in basement early Friday evening and connected it to the outlet outside. When, after several blips, the house finally turned dark, I just turned it on and manually switched from utility power to generator power for my little house and my Amish minibarn, infrared heater and all.

Christmas Eve, generator humming in the back yard, I fed the generator gasoline a few times, stashed more hay and water in the horse barn, made sure to replenish any water the horses drank, and went to town for a few extra groceries and to refill my gasoline tanks.

Some friends and neighbors didn’t fare as well as I did. Many don’t have generators. I could have installed a more permanent whole house germerator for $6,000 or more, but my portable unit runs everything electric on my little farm; I just have to fill’er up now and then. It is dual fuel, so maybe I’ll get a honking propane tank some day.

Feeling a little smug, I cherish the fact that for way under $2,000 I have what it takes to weather a storm like this without jeopardizing my horses or myself and my dogs. People around here spend much more than that on snowmobiles, ATVs and other toys. And then they freeze or have to check into a motel in situations like this one.

As Christmas Eve turned into night, it was obvious that I could not go to Bangor to celebrate Christmas Day with my children and grandchildren. I had to stay home with the animals and feed the generator. We were already planning for everyone to come up here for New Year’s so we will do another Christmas then.

Because I always think about Medicine, this incident made me again reflect on how, on the front lines, the practice of medicine is never predictable or straightforward. It is always full of surprises and obstacles that have to be creatively approached or circumvented. It always bothers me that the people who evaluate us have little or no understanding of the fact that primary care medicine is never predictable, that no two patients are ever the same, and the same patient may seem different on two different occasions.

Cookbooks are great learning tools, but show me a master chef who always follows a recipe.

I thought of watching a Christmas movie tonight, but I’m not yet feeling quite in the Christmas mood. Sitting by the fire, I instead decided to read from Pulitzer Prize winning Maine writer Richard Russo’s book, The Destiny Chief – Essays on Writing, Writers and Life.

In Getting Good, he writes:

Indeed, a good hint that you’ve entered the realm of art is that you immediately feel like giving up. You become overwhelmed by the astonishing complexity of the task, the sheer number of moving parts over which you have less – than – perfect control, the perversity of happenstance, the impossibility of predicting outcomes. In Life on the Mississippi, Twain describes learning to pilot a steamboat as an art because the river you steam up this week isn’t the same one you’ll navigate after a week of rains on your return trip. It’s still the Mississippi and eventually you’ll end up in New Orleans, not some unexpected city, but each trip is different because the river is. You have to know everything about it, know it without having to think, and be certain of your judgments, which will have to be made quickly on the basis of incomplete information, and at night you’ll have to do all this and more by feel. It would be nice if the river were a science because in the sciences there are controls, and if you’ve been careful your results can be replicated. What worked on Tuesday will work on Thursday, a claim that cannot always be made when what you hold in your hand is a paint brush or a camera or a pen. What was exactly right for your last painting will be completely wrong for this one. Creative people love to claim they know what works but in reality all they know is what worked. Fortunes are lost and hearts broken in that shift of tense.

Medicine, perhaps mostly in the muddy waters of primary care, is at least as much art as science. The number of variables is beyond at least today’s artificial intelligence to consider. Only a well educated and seasoned clinician has a fighting chance to do well by patients with messy histories, messy lives, multiple comorbidities and unclear genetic and epigenetic predictors of outcomes.

Once again, I find myself learning and borrowing from other disciplines as I muddle my way forward in the practice of primary care medicine.