A Country Doctor Writes:

Specialists in orthopedics and general surgery often want us, the primary care doctors, to manage postoperative pain. I don’t like that.

First, I don’t know as much as the surgeons about the typical, expected recovery from their procedures. My own appendectomy in Sweden in 1972 was an open one that I stayed in the hospital for several days for (and nobody mentioned that there were such things as pain medications). I’m sure a laparoscopic one leaves you in less pain, but I don’t personally know by how much.

Postoperative pain could be an indicator of complications. Why would a surgeon not want to be the one to know that their patient is in more pain than they were expecting?

Pain that lingers beyond the postoperative or post-injury period is more up to us to manage. I accept my role in managing that, once I know that there is no complication.

I have many patients who hurt more that most people every time they have an injury, a minor procedure or a symptom like leg swelling, arthritis flare or toothache. The common view is that those people are drug seekers, taking every chance to ask for opiates.

I believe that is sometimes the case, but it isn’t that simple. I believe that people have different experiences with pain. We all know about fibromyalgia patients or those with opioid induced hyperalgesia, but pain is not a binary phenomenon. Like blood glucose, from hypoglycemia, through normoglycemia to prediabetes and all the degrees of diabetic control, pain experience falls on a scale from less than others to more than others.

I reject the notion that pain is a vital sign. When I was Medical Director in Bucksport I discouraged the use of numeric pain ratings. But I did encourage talking about the experience of pain as a subjective, nuanced and very valid consideration. We started a comprehensive pain education module for all our chronic pain patients.

I saw a patient just the other day with leg edema, who illustrates what I’m talking about:

Jim Gogan has had brief courses of hydrocodone over the years from different providers for everything from back strains to stress fractures to toothaches. Now he has very modest leg swelling that hurts him so much that he asks for pain medication.

He winced when I palpated his legs.

“This degree of swelling doesn’t usually hurt that much”, I said. “I don’t think I’ve ever seen someone needing hydrocodone for something like this.”

I went on to check the typical fibromyalgia tender points. About half of them were positive.

“Are you familiar with what’s called fibromyalgia? It’s a neurological condition where our pain sensitivity is tuned higher, like the volume of a radio. You are more sensitive to pressure and irritation in some of those spots, like you may have a touch of that phenomenon. There are treatments for that, but the scary thing about using hydrocodone or any other opiates for that is that we now know that they usually make it worse.”

I explained about opioid induced hyperalgesia. My short take is that the fast pain signals in our human nervous system give detailed information, like my left big toe hurts. If we suppress that signaling, an old remnant evolutional “lizard nervous system” gets ramped up. It is less precise, and may only tell us that there is tissue damage but it doesn’t know exactly what kind and where.

In my simple but, I believe, quite accurate explanation I then list the medications that work better when the pain signaling is in the ramped up slow nerve fibers at work in people on what I call the fibromyalgia spectrum.

If that isn’t a recognized term, like autism spectrum, perhaps we should all consider making it one.

Lo and behold, searching for “fibromyalgia spectrum disorder” there are many articles using that term, ranging from a 1993 editorial in Arthritis and Rheumatism, when the pathophysiology of fibromyalgia was still poorly understood, to a more recent 2008 review in The Journal of Clinical Psychiatry and current inferences in Pinterest and Facebook posts.

I have written before about how it can often be helpful to think of presentations that may not meet all the criteria of a given disease as still reasonable to approach as if they are milder forms on a spectrum. The longer I’m in this profession, the more sense that makes to me.

Shadow Syndromes

Fifty years ago this summer I traveled by turbo-prop plane to this country for my exchange student year. I landed, delayed, at Logan airport around 2 am. My host family drove me to their home in a boxy white Studebaker wagon with a bale of hay in the back where I also put my suitcase and guitar. I had just found my musical hero that spring: James Taylor, whose songs have followed me ever since.

The impressions that year provided have shaped my life, from the optimism and the ideals of self expression of that era to the vision of the family doctor that the Marcus Welby, MD television series gave me. I traveled to New York City during that school year and was halfway up one of the twin towers then under construction. After graduation I got a Greyhound pass and saw 30 states in 30 days. Visiting my host family’s older children, I slept in an Adobe hut in New Mexico and in a hippie environment in Mendocino, California. I was smitten with the diversity and vastness of this country that seemed to have room for everybody’s American dream.

And, sometimes through planning, sometimes by circumstance, my American dream unfolded. Now, fifty years later, I find myself marveling at all those events that put me in Swedish country in northern Maine as a country doctor and a writer – the two things I always wanted to be.

Every day I live now is filled with joy because of my children, my animals, this little farm and the work I love. I no longer have the hunger of the younger man I once was.

I’ve had many gloriously happy moments and they’re only memories now. I have gradually shifted from striving for new experiences to cherishing the ones I have had. I have also, perhaps later than some, come to stop ruminating about what to do next.

From Horace’s Carpe Diem to Eckhart Tolle’s The Power of Now to James Taylor’s The Secret of Life, we must remember to live in the moment. Because only the moment is real, everything else is only memory or imagination.

So, once again, I say to myself Happy Birthday, Country Doctor.

Happy Birthday, Country Doctor

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?