A Country Doctor Writes:

Mrs. Maguire never followed my advise completely or took my prescriptions exactly as prescribed, but she kept coming back for all her scheduled appointments. After her pulmonary function test came back abnormal, I gave her a sample of an anticholinergic inhaler two weeks ago and had her take her first dose as I watched. Today I entered the exam room a little bit hopeful that we were getting somewhere.

“I have to be honest with you”, she said. “I haven’t been using the inhaler you gave me, except I tried it again yesterday because I was coming here today.”

“That’s probably not long enough to know if it might help you”, I summed it up. I didn’t ask why she hadn’t really tried it. I sat quietly for a while and then she continued:

“I don’t know what’s wrong with me. I just don’t do anything anymore, only the absolute necessary. I just have no ambition, and the depression pills you had me try before didn’t help me.”

“Right, you wanted to taper off your Lexapro. How long ago did you actually stop them?”

“Last week, and I see no difference.”

I said nothing.

“You know, ever since Brian and his wife moved to Connecticut two years ago, I haven’t had the ambition to do anything. Babysitting for them was my job, and now I feel so useless. They wanted me to come live with them, but I didn’t like it there at all. I have lived here all my life.”

She teared up.

“I miss my grandchildren.”

“And you miss having a purpose”, I filled in.

“I do”, she said as she pulled a Kleenex from her purse.

“So, have you thought about what other things you could do that would give your days some purpose and structure”, I asked.

“No, like what?”

“Like the food pantry or thrift store or nursing home, maybe giving people rides, I don’t know? Melinda, our social worker, is connected with a lot of places that need volunteers. Would you like to talk with her?”

“A counselor, a psychiatrist? I don’t think I can open up to a stranger.”

“Well, she’s a social worker. She does do counseling, but she also helps people figure things out and make practical decisions, because she knows the community. And you’re telling me what’s going on.”

“Well, that’s different.”

“You don’t have to tell her anything about your feelings if you don’t want. You could just have her help you brainstorm about things you might start doing.”

“I don’t know.”

“Well, think about it. Let me know if you want to talk with her. Otherwise I’ll just see you in three months for your diabetes. But I think it could be good to brainstorm with her.”

“I’ll think about it”, she said as she got up and left the room.

We, or actually she, had finally nailed down her diagnosis and now it is up to her to decide what to do next. I knew there is nothing more I could do right now, or is there?

When I first lost power and then saw my generator fail during a storm last winter, two other failures struck. As I scrambled to fill my water containers for the horses, the failing generator delivered just enough electricity for dim lights and a slow trickle of water. And then, when the power came back on, I had no water and the furnace didn’t work.

I trudged through the snow to the pump house up in the woods and found the water pump clicking as if it tried to start, but couldn’t. I ended up a day or two later with a whole new water pump.

The furnace had power, but I saw a red light with what looked like a stick figure repair man. Other furnaces I’ve had all had a reset/start button. Not this technical wonder that I never had to mess with before.

The repair man showed me that the stick figure light was, in fact, a recessed reset button. He pushed it and the furnace started instantly. But he didn’t leave. He said he was going to make sure there were no other problems. That took half an hour and I later got a $250 bill for the emergency repair call.

I felt stupid for not having pushed the red light on my own and I don’t mind paying $250 for my stupidity. But did he really have to spend half an hour making sure that a furnace that fired and delivered heat REALLY was working?

This long story makes me think of how we practice medicine these days. Nothing is quick and easy. Everything has to be comprehensive. But some problems are really simple enough that we shouldn’t have to belabor them like my furnace repair man. His job was, or should have been, easier than the plumber’s.

Primary care, with our ongoing patient relationships, is in theory ideally suited for quickly taking care of minor problems. After all, we already have background information on our patients and shouldn’t have to start from scratch.

But, we are disincentivized and downright punished if we do just that. This is because some well meaning bureaucrats imagined that while patients are in our clutches, we might as well screen them for this, that and the other, update their immunizations and, God forbid, not let them leave if their blood pressure should happen to be out of range because they are in pain or in a hurry.

So, instead, our patients end up going to walk-in clinics, seeing providers they don’t know who practice without the shackles of the family doctor of record.

I think we need to stop pretending that today’s primary care is patient centered. It is not. It is a vehicle for top-down government control of people’s care decisions and doctors’ behavior.

Take a lesson from the pandemic:

When this country faced a public health emergency, the directives and recommendations were broadcast by the government and its agencies directly to the public. And when mass immunizations needed to be done, they took place in large arenas, even parking lots and also pharmacies. Primary care offices were deemed a last option, presumably because the Fed realized how stodgy our work flows are because of how they designed us.

We desperately need a public health system in this country. The past year has demonstrated that mass communication and mass interventions are better vehicles for public health than clinics historically geared up for treating patients one by one.

So, please take public health off our plate, because we don’t have the resources for mass education – we have doctors, PAs and NPs working in professional isolation with full schedules. Each provider is aided by one medical assistant. Primary care clinics usually don’t have registered nurses, health educators, PR people or the kind of support it would take to treat entire, even small community, populations.

I’ve got myself a reputation as a technology hater. Nothing could be farther from the truth. I just have no patience with bad or stupid technology, like EMRs.

If I apply the brakes going down a hill and then let go of the brake pedal, my car does not roll a whole lot faster than I wanted it to moments before – thanks to a clever computer system I know nothing about. And often, when I drive past our Caribou clinic (where I only work on Saturdays) on my way home and glance to see whose cars are still in the parking lot, the car makes an alarm sound and a red triangle lights up as if I was almost crossing the center line, even if I’m not: The car KNOWS I’m distracted.

Contrast that with my EMR: If I open a patient’s chart and go to the “medications” sidebar icon and hit the + sign, any reasonable human being would think I am about to prescribe a medication right now. Not my system. It asks me which old encounter I’d like to use, and if not, what category of new encounter I want to create. Excuse me, I’m sending a prescription right now, why do I have to spell that out?

Unless we are computer geeks, most doctors just want our technology to work. HOW is not for us; we like intuitive. We want our computers to know and adapt to how real doctors work, rather than make us work for them.

I can’t tell you how many times, when I print a lab or X-ray order for a patient , I have to walk back to the exam room from the printer in my office to confirm on my laptop that I left behind, that I really DO want to print my order. What purpose does the last confirmation screen serve? I’ve already told the computer I want to print the darn thing.

As I’m writing this outside, on my iPad Pro in my sling chair, watching dogs and horses on a quiet Sunday afternoon, I lament the fact that my clinic here up north doesn’t have an iPad EMR app and my Bucksport clinic’s EMR’s iPad app no longer works because of mysterious incompatibilities between iOS versions, app versions and the installation at the mother ship 200 miles away. Desktops are so Stone Age and laptops are so last century.

In my non-clinical work, the technology lets me work whenever and wherever I want. Most of my 777 (and counting) posts on A Country Doctor Writes were written in bed between 5 and 6 am or somewhere just before midnight!

I can run Zoom clinics from my iPhone and publish books from my iPad. Why are medical applications so far behind?

When I first adopted my black Alabai dog, she had what people call an accident. She went far into a corner of the house and did her business on the floor. She never did that again. Not because of any negative feedback from me, because I never even let her know I found out. But what I did was close off the house so we only lived in the kitchen, bathroom and my bedroom for a while. I also started to walk her as soon as I fed her, morning and night.

I took advantage of two natural phenomena: The gastrocolic reflex that at least human babies are born with, and the power of habit. The dog’s brain and intestine both knew what to expect very soon after she joined me.

Now that I have two Alabais, it is amusing and convenient to have them always pooping in tandem. (As a Swede, I use a child word but I don’t use the euphemism of dogs going to the bathroom – I find that expression silly and confusing.)

I get horses to come inside the barn at night just by whistling and bringing food; then I close the doors while they eat. They even watch for that to happen. I made them want what I want, so this works for all of us.

I have many patients who lead irregular lives: They eat and sleep seemingly at random, not because they are shift workers, but because they never saw the need to follow any given rhythm. After all, television and streaming are on 24/7 and so are many other services and distractions in our society.

Diurnal rhythms exist naturally not just for our digestive processes, but hormones, vital signs, tissue regeneration and more things that I, as a country doctor, am excused from keeping track of. I just know that habits and bodily rhythms are good for us and unless we need to work irregular hours to earn our living in this frantic society, we are better off living like most animals – according to a stable pattern.

I am amused and confused by the opposite extreme of habits I see in other patients: Some people obsess over their habits by monitoring sleep, steps, calories and vital signs on their smartphones. I think overthinking the natural processes of our bodies and our lives can be counterproductive. Our brain is not the supreme control center many people imagine it to be.

We need to avoid over-analyzing what should be automatic functions; start worrying about your blood pressure and it goes up every time you recheck it, for example. Walk your dog, cuddle your cat, listen to the birds instead. Let the light go dim when evening falls and let the sun shine in your window every morning. Plan your meals, schedule your chores, and give your brain the freedom to be creative with something other than constantly reorganizing and reinventing what should be your day and your body on autopilot.

The other day I saw a woman who had transferred her care and then came back to me. There was a time in my life when that used to bristle me. Now I’m not threatened or insulted by such switches.

This patient was struggling with depression and anxiety and had, on her own initiative, tapered off her duloxetine. Some time after that she then destabilized and in that context transferred her care. Six months later she was back in my schedule.

Our “transfer of care” appointment took a while. I’m not sure by how much we exceeded our allotted time slot. But I plodded through our last several notes and read aloud to her my documentation of how the medicine had actually made her feel better, and how she had told me about her decision to taper off it. I listened as she described how her next provider went with the flow and prescribed bupropion, because she had “failed” duloxetine.

Her new medicine didn’t help her at all. I did spend a fair amount of time just letting her tell her own story. I then reviewed my notes aloud with her about how good she seemed to be feeling before her self directed taper. I also listed the things she did that made her feel better: car rides, friends, her therapist.

She cried for a while, sitting at the edge of her seat, then wiped her tears and blew her nose.

“You have felt better than this, I remember, and you do too”, I said.

She agreed to stop the bupropion and restart duloxetine in a low dose.

“I’d like to see you back next week to make sure things are working”, I said, and she agreed.

I knocked on the door, following my usual habit, of the same exam room exactly one week later. I wasn’t even halfway into the room when the serenity, for lack of a better word, struck me.

She was sitting in a relaxed position, wearing makeup, looking straight at me with a contented smile.

“I feel so much better. I’m sleeping at night. My appetite is back, and I don’t hurt everywhere anymore. This medicine is working for me”, she said. She took a deep breath and continued “but I think what did the most was that you took the time to listen. Those 45 minutes turned things around for me.”

I think so too, even though I’m sure we didn’t spend quite that much time together, but I didn’t say it out loud. But I do believe that, not infrequently, the doctor is the treatment, at least to a degree. Connection can be healing.

When the Doctor is the Treatment