A Country Doctor Writes:

The hackneyed windows phrase, about what a domestic employee will and will not do for an employer, represents a concept that applies to the life of a doctor, too.

Personally, I have to do Windows, the default computer system of corporate America, even though I despise it. But in my personal life I use iOS on my iPad and iPhone and very rarely use even my slick looking MacBook Pro. I use “tech” and machines as little as possible and I prefer that they work invisibly and intuitively.

In medicine, even in what used to be called “general practice”, you can’t very reasonably do everything for everybody. Setting those limits requires introspection, honesty and diplomacy.

In my case, I have always stayed away from dealing with machine treatments of disease. But I do much more than just prescribe medication. Since the beginning of my career, and more and more the longer I practice, I teach and counsel more than I prescribe.

I have decided not to be involved with treatment of sleep apnea, for example. It may sound crass, but I don’t find this condition very interesting: The prospect of reviewing downloads and manipulating machine settings is too far removed from my idea of country medicine.

Worse than CPAP machines are noninvasive respiratory assist devises. I won’t go near those.

I similarly defer to my local hospital’s diabetes nurses to manage insulin pumps. This, too, is too much of a mechanical task for my temperament.

In my personal life, I have done wound care for horses many times, but I have never changed the oil of any of the cars I have owned and loved.

I have also found it more and more interesting and rewarding to engage with patients in what might be called nudge therapy. The word microtherapy is already taken and stands for using low levels of electricity on people, which is not my cup of tea. Microcounseling is also already taken, and stands for briefly coaching non therapists about techniques they can use.

Nudge therapy is when I in a brief appointment can apply cognitive therapy principles to gently and quickly nudge a person towards a different interpretation of their symptoms or circumstances. I find this incredibly powerful sometimes. In my Suboxone clinic, for example, I often deliver these kind of messages, which in some cases have a direct result on my patient’s outlook and sometimes sells them on the idea of adding individual counseling to their regular group therapy.

Changing how the mind, or the body, works without drugs, dials or electricity – now that’s inspiring!

(P.S. As I searched for previous use of “Nudge Therapy”, I came across “Therapeutic Nudging“, which basically consists of reaching out between appointments, something I have also found to be incredibly powerful.)

“I worry, so you don’t have to”, is how I explain to patients when something about their story or physical exam makes me consider that they may have something serious going on.

The worst thing you can do is give false reassurance without serious consideration. And the next worst thing you can do is be an alarmist and needlessly frighten your patient. Finding and explaining the balance between those two extremes is a big part of the art of medicine.

A few times in my career I have struggled with doubt or worry after a patient visit. Did I miss anything, did I order the right test? We all have those moments, but we have personal limits as to how much of such doubt we can handle in the long run.

During my training and early career in Sweden there was more tolerance for physician fallability. Doctors have not been sitting on any pedestals for a couple of generations there. Here, the climate is different: We may not be revered like we were in the past, but if we make errors in judgement, the personal consequences for us can be devastating.

The way to navigate this treacherous territory is first of all to not travel alone. Everything we do is for our patient, so we must maintain a partnership. We are the experts, but we should not make decisions that aren’t shared. I keep coming back to the notion that today’s doctors are guides.

I try to gauge my patient’s degree of worry and match my choice of words and actions to some degree to that. If a patient mentions a symptom and then trivializes it, I often cloak my concern with the words “I worry, so you don’t have to”. That works better than “I don’t want to scare you, but you could have a brain tumor”. The way I say it, I suggest to the patient that my recommendation is a safety measure and I quietly suggest that I just might be worried for nothing. My use of the word worry shows a degree of emotional involvement, partnership and guide responsibility.

If a patient seems overly worried, we must be very careful not to brush off their concern. It is easy to seem callous and to make the patient think we aren’t listening. I may ask point blank what their biggest fear is if I can’t tell and if they name one, I say it back to them and talk about how that condition usually does or does not present. If there is a test that could rule out the life threatening condition they worry about, what’s the point in not ordering it?

In the busy flow of any clinic day, I try not to ignore that little inner voice, that clinical instinct, which tells me something could be dreadfully wrong. If it appears after the visit is over, or after I have already formulated a plan, there is nothing wrong with correcting your course. Those few times when I have said “I’ve been thinking about your symptoms, and maybe we should just have you go to the emergency room and get that scan done so neither one of us has to worry tonight”, nobody has faulted me for changing my mind.

When I worked at MedNow, Dewey Richards’ walk-in family practice in Orono, a part time transcriptionist worked in the break room.

She would sit down in front of her old fashioned computer monitor, put a doctor’s micro cassette in her player, the ear phones in her ears and start typing. The screen in front of her was completely empty except for the cursor in the upper left corner. When each office note was finished, she would print it and start again with a completely blank screen.

Most word processors today are full of icons with formatting options. The only time I use that kind of writing platform is when I actually do some formatting, like a pamphlet or layout of a completed book manuscript.

I write on my iPad because it lets me work anywhere, and I prefer a blank screen in front of me as I choose the right words to express my thoughts. Just like I prefer to write in the early morning, when life has fewer distractions, I find the big white space of my favorite writing app helps me open my mind and be inspired. I don’t usually start with a topic already in my head until I see the empty screen in front of me.

The free program I use for creating blog posts and personal correspondence is called Simplenote. It was created by WordPress, which is the backbone of probably the majority of websites, from A Country Doctor Writes to The New York Times.

Simplenote synchs seamlessly between all my devices every time I close a document, so I can open what I created on my iPad minutes later on my iPhone or my MacBook.

This way of writing is as close to a blank page in a typewriter that you can get. I have heard some people are intimidated by sitting down in front of a blank page. I find it inviting and inspiring, because it suggests that anything is possible.

For blog posts, I copy the finished piece and paste it in WordPress, where I can insert graphics, italicize or make text bold, insert links or indents for quotes.

For book chapters, I paste my text into Scrivener, which synchs (although they spell it ‘syncs’) with Dropbox across devices. This is a writing program that lets you create, format and organize chapters. The last step is then to convert the whole project to a Pages, pdf or (if necessary – ugh) Word document.

As I now finish writing this post on my white iPad screen, my eyes also take in the whiteness of the new snow on the trees and the red cedar fence of the horse pasture outside my bedroom window. It is a silent, sunny Sunday morning.

Time to feed the horses.

People don’t like to be outsmarted by someone else. They don’t like to have their actions questioned. And they really don’t like to have their mistakes or transgressions pointed out to them.

But that’s what we as doctors have a tendency to do. We need to curb those natural impulses if we want to influence people. Unless we are invited by a patient to render our opinion, we are better off not overemphasizing our insightfulness or expertise. If invited, a radical opening statement may be a very effective attention grabber, but not when our opinion may come as an unwelcome surprise to our patient.

Whether it is contradicting a patient’s misperception of the laws of nature or exposing their misuse of prescriptions, food or other substances, we need to tread very carefully if we expect to maintain a therapeutic relationship with our patient.

I often “think out loud” by asking a question, like “I wonder if you’re doing something different now that your weight is going up”. That is a lot less confrontational than “you must be doing something wrong”. Equally effective is to simply ask for the patient’s analysis and then gently probing it for loopholes. This creates a give and take atmosphere where our restraint in the opinion department may even nudge the patient into realizing for themselves what we might have been tempted to tell them in the first place.

The balance we constantly strive for is to be a trusted and credible guide for our patients in their own journey, without trying to replace them as heroes in their story. We cannot assume what all their priorities are when it comes to choosing how to handle medical circumstances and their treatment options. We may think we know what is best for them, but—if we can’t let go of that notion—should at least say that we don’t have all the answers. Otherwise, their success or failure will be entirely on our shoulders. And that can be a perilous spot to be in.

I seldom choose confrontation in my practice, or outside for that matter.

If a patient who is receiving a controlled substance fails a urine drug test, I don’t say, “I know you’re abusing meth/heroin/cocaine”. I just say “There is X in your urine sample and that means I can no longer prescribe controlled substances for you”.

When the patient says they don’t understand how the test could show that, I explain that they definitely had the substance in their urine but that it isn’t my job to figure out how. I suggest it could even have gotten into their system without their knowledge if they accepted a puff of marijuana or a headache pill from someone else. But that doesn’t even matter: I just follow the rules while still allowing my patient a graceful way to accept my decision without having to confess anything.

That way, in this doctor shortage area, I make it possible for my patient to continue getting general medical care from me if they choose to.

Walter Brown’s blood sugars were out of control. Ellen Meek had put on 15 lbs. Diane Meserve’s blood pressure was suddenly 30 points higher than ever before.

In Walter’s case, he turned out to have an acute thyroiditis that caused many other symptoms that came to light during our standard Review of Systems.

Ellen, it turned out, was pretty sure her husband was having an affair with one of his coworkers. And, since this wasn’t the first time, she was secretly working on a plan to move out and file for divorce. She admitted she’d always had a tendency to stress eat.

Diane’s daughter had just announced that she was pregnant by a man she wasn’t sure wanted to be around in the long run.

How do we know whether a patient’s subjective symptoms, laboratory values or even their vital signs are caused by their known medical conditions, a new disease or their state of mind?

We are often tempted to proceed down familiar tracks and tackle seemingly straightforward problems with medications: More insulin would take care of Walter’s blood sugar. Ellen could use a couple of months of phentermine. Diane needed a higher dose of lisinopril or perhaps some hydrochlorothiazide.

As Sherlock Holmes said, “there is nothing more deceptive than an obvious fact”.

There are all kinds of algorithms and guidelines that are supposed to inform clinicians in situations like these, but I wonder how often they are helpful and how often they might actually cause harm.

Medicine is part physiology and part psychology. Are we giving both aspects of our craft the attention they deserve? And, of course, do we make choices and treatment decisions according to probability or by time available to stay on time in our clinic schedules?

Asking “what else is going on” can open up the dreaded, proverbial floodgates, can of worms or Pandora’s box. We don’t have all these cliches in our language for nothing.

Do we avoid asking the questions that will reveal the real answers we need in order to help our patients, or do we dare to?