A Country Doctor Writes:

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

My Swedish morning paper had an article about the increased use of tramadol by criminal gang members. When an investigator asked if there was anything special about tramadol, she was again and again told that this drug made it easier to commit crimes. Maria Almazidou, quoted in the article, said “the chemical has a double effect. You can get turned on and feel more focused, while at the same time it blunts your emotions. That is one reason it fits in with the criminal lifestyle”.

I was intrigued, but not surprised. After all, tramadol hits the opioid mu receptor and also has serotonergic properties, making it reduce anxiety as well as blunting affect.

Although I don’t think I have come across tramadol addiction here, I realize its potential to destabilize mood in bipolar disorder. I have seen florid psychosis and tremors in combination with duloxetine. But have never seen it cause full blown serotonin syndrome.

There are many case reports and news articles, like this one, of people with tramadol addiction and overdoses committing violent crimes. But then, there are also FDA black box warnings about traditional serotonergic drugs causing suicidal ideation.

I started looking for more information on the link between tramadol and murders. The connections are all there, in many countries.

First of all, it is a more common drug of abuse in many countries, especially in Africa, and as such, the trade of it is linked with crime. But its use by criminals to enhance their unscrupulousness is actually well documented.

Here are some quotes I ran across:

“Tramadol is regularly found in the pockets of suspects arrested for terrorism in the Sahel, or who have committed suicidal attacks.” – The United Nations Office of Drugs and Crime

AP NEWS writes:

“One woman said children stumble down the streets, high on the opioid; parents add it to tea to dull the ache of hunger. Nigerian officials said at a United Nations meeting on tramadol trafficking that the number of people there living with addiction is now far higher than the number with AIDS or HIV.

Tramadol is so pervasive in Cameroon scientists a few years ago believed they’d discovered a natural version in tree roots. But it was not natural at all: Farmers bought pills and fed them to their cattle to ward off the effects of debilitating heat. Their waste contaminated the soil, and the chemical seeped into the trees.

Police began finding pills on terrorists, who traffic it to fund their networks and take it to bolster their capacity for violence.”

So, by now I have even more respect than I used to for the dark side of this unique (next to tapentadol/Nucynta) analgesic and all other drugs that work on so many neuroreceptors at the same time.

The World Health Organization has a comprehensive summary on Tramadol here.