A Country Doctor Writes:

I read an article last weekend in Allmän Medicin by my Swedish colleague, Christer Petersson, who once wrote a piece titled “I worked as a doctor for 20 years. Then I became one”.

He again writes about the difference between academic knowledge and experience-based intuition and how each is necessary to acquire and cultivate in order to be a good physician. He draws from Russian author Mikhail Bulgakov and American Nobel Prize winner Daniel Kahneman (I now have both books).

In A Young Doctor’s Notebook, Bulgakov describes how his obstetrics textbook made no sense to him until he, with the help of a seasoned midwife, performed a version of a transverse fetus in the middle of the night. After that, he returned to his textbook and wrote:

It was just after one o’clock when I got home. In a patch of lamplight on the desk in the study Döderlein lay peacefully open at the page ‘The Dangers of Version’. I sat with it for another hour or so, gulping tea that had grown cold, leafing through its pages. And now something interesting happened: all of the formerly obscure bits became completely comprehensible, as though they had filled with light, and there, in the light of the lamp, at night, in the back of beyond, I realized what real knowledge means. “There’s great experience to be gained in the countryside,” I thought, falling asleep, “only I have to read, read a lot… read…”

Kahneman, an economist, writes in Thinking, Fast and Slow about the value of clinical intuition, and explains it as a result of learning:

We have all heard such stories of expert intuition: the chess master who walks past a street game and announces “White mates in three” without stopping, or the physician who makes a complex diagnosis after a single glance at a patient. Expert intuition strikes us as magical, but it is not. Indeed, each of us performs feats of intuitive expertise many times each day. Most of us are pitch-perfect in detecting anger in the first word of a telephone call, recognize as we enter a room that we were the subject of the conversation, and quickly react to subtle signs that the driver of the car in the next lane is dangerous.

The psychology of accurate intuition involves no magic. Perhaps the best short statement of it is by the great Herbert Simon, who studied chess masters and showed that after thousands of hours of practice they come to see the pieces on the board differently from the rest of us. You can feel Simon’s impatience with the mythologizing of expert intuition when he writes: “The situation has provided a cue; this cue has given the expert access to information stored in memory, and the information provides the answer. Intuition is nothing more and nothing less than recognition.”

Petersson Writes:

As family physicians we are next-door neighbors to uncertainty. Not infrequently do we have to make decisions without suspenders or a belt (Swedish expression for leaving your comfort zone). Our judgment is constantly being tested. Without intuitive sensitivity we become paralyzed and without analysis we become reckless. Only in our encounters with individual patients’ concrete problems and by connecting those to our profession’s collective knowledge, textbooks and databases can our judgment evolve.

For the general practitioner it is primarily the patient encounter that creates experience. Communication between colleagues, one on one or in a group setting, is in my opinion a necessary ingredient for growing that knowledge.

He writes that there is much to be done with that in Sweden. Here, too, is what I think. Professional isolation in American primary care is possibly worse. And primary care providers are often thought of as interchangeable. Experience and intuition are not valued the way they might be in other fields or in other practice settings, like academic medicine.

Editor’s (that’s me) note:

I sent Christer my draft for this post and he gave me some names, and synopses of writings by people who have written eloquently about intuition. I will be doing some more reading and thinking. Stay tuned for another post about the science behind clinical intuition.

A while ago I recognized myself in one of the five newspapers/sites I check during my morning coffee in bed. I don’t remember where I read about what I thought was something unique I had not been able to put into words before: You can be introvert and extrovert at the same time. So-called ambiverts actually often make better leaders than either of the two opposites.

A quiet only child, I could sit for hours with pen and paper or just a toy Bentley or some Legos. I had few friends, played no sports and I actually remember my mother’s anger and frustration that I didn’t want to be like other children and play outside.

But at the same time, I recited Luke in church for Christmas and took every other opportunity I came across to speak in public. When I taught myself to play guitar, I had people (girls) smile and sing along with me but I seldom felt comfortable making small talk or more with them.

I was president of my class in my Swedish high school but hardly ever socialized. I taught photography to 9th graders as a school project. I spent a summer at the Boy Scout Center in Kandersteg, Switzerland, teaching scouts from all over the world how to build shelters and bridges using rope lashings. And I spent a semester between the army and medical school as a substitute teacher and thrived standing in front of both enthusiastic and uninterested students.

And I became a doctor, a “docere” – educator, therapist, life coach in today’s vernacular. But I had no social life to speak of until I became a ballroom dancer. Then, I was out there, so much that he dance floor always seemed too small for my fancy swing and Lindy Hop kicks.

And here I am, all alone on the farm with just the animals, not spending any of my personal time with other human beings, writing blogs that are read all over the world, getting royalty payments from several countries for my books and networking online to market them to more doctors, students and medical educators. And I’m even recording and posting videos with ad-libbed patient education talks.

I even reactivated my dormant Facebook account and found an outlet for my creativity outside medicine. I post pictures and stories and feel quite content with my virtual friendships that occur without spoken words. Once I leave my clinic, I don’t speak, basically.

For years now, I have felt increasingly content just being who I am but there is a sense of ordinariness to know that I am not as much of an aberration as I thought I was. Sure, we are all unique, but I like knowing that there is a name for people like me.

It’s a little bit like my dietary preferences: I went from being a picky eater to a vegetarian (just for consistency) and on to what I now call recovering vegetarian (embracing two opposites). Now I am not an introvert trying to be an extrovert. I am an ambivert, plain and simple.

I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time.

Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, and there is more and more of a mismatch between what we were envisioning and trained for and what we are now being asked to do. Our specialty is often the first to see a patient and also the last stop when no other specialty wants to deal with them.

We have also been required to do more public health, more clerical work, more protocol-driven pseudo-care and pseudo-documentation like the current forms of depression screening and followup documentation. And don’t get me started on the Medicare Annual Wellness Visit. How can we follow the rigid protocol and be culturally and ethnically sensitive at the same time?

We are less and less valued for our ability – by virtue of our education and experience – to take general principles and apply them to individual people or cases that aren’t quite like the research populations behind the data and the guidelines. The cultural climate in healthcare today is that conformity equals quality and thinking out of the box is not appreciated. The heavy-handed mandates imposed on our history taking and screening constantly risk eroding our patients’ trust in us as their confidants and advocates. The finesse and sensitivity of the wise old fashioned family doctor is gradually being squeezed out of existence.

The call to primary care medicine, if it isn’t going to pave the road straight to professional burnout, today needs to be a bit like the call to be a missionary doctor somewhere far away:

To go into a sometimes hostile environment, without the right kind of resources, where people don’t speak your language, where you never feel you can do everything you hoped to do for your patient, and where some of the things you want to do might even encounter cultural or political taboos.

In other words, to do what we can in the moment for each patient, regardless of the system and the circumstances.

That is a very noble call, but not one for the faint-hearted.

One might say I’m on a roll. Halfway through the year I have already broken my 2017 record for best year. I have published three of my most read ever blog posts in the past three months. But, even combined, they don’t surpass my 2015 piece “Normal Blood Pressure”. If that one was a movie, it would be characterized as a sleeper. It describes a housecall on a snowy day in Van Buren. And I guess it is a fair little snapshot of the essence of rural medicine at the northern edge of my adopted homeland.

Normal Blood Pressure