Posts Tagged 'Progress Notes'

A Doctor’s Advice

My friend, Dr. Barbara Brennan, who gave up her practice because of her CFS, or Chronic Fatigue Syndrome, told me a very touching story about her last conversation with her gynecologist.

Dr. Brennan worked hard, and seemed to be inexhaustible until her illness stopped her in her tracks. In this medically underserved area we all work hard, and many of us looked to her as someone to admire, because she didn’t seem to tire of what she did day after day.

Barbara Brennan told me that there was one colleague who had told her to take a hard look at what she was doing.

Samuel Baumgarten was Barbara’s gynecologist for many years. He had delivered two of her children and when she came in for her annual checkup he always took time to ask how she was doing as a physician. She confided in him that she wished she wasn’t working quite as hard.

Sam had stopped delivering babies a couple of years earlier as his patients grew older, and focused more on gynecologic surgery. He had also cut his workweek from four to three days a week. He told Barbara that five days a week was too much for any doctor.

In his mid sixties, Samuel Baumgarten was youthful and always seemed relaxed and in perfect health. He was an avid skier, tennis player and sailor. He never wore a tie. He followed the Red Sox and gave the impression that medicine was important to him but never kept him from being a human being also.

The last visit Barbara had with Sam he had urged her to think about changing her situation.

“You’re working too hard” he lectured her. “No one is indispensable, not even you or I.” He looked very serious, almost stern as he spoke to his younger colleague and patient.

“People may say that only you can help them, but after you’re gone, they’ll say ‘She was good, but who do I see now?‘”

She often heard those words echo in her mind on days when fatigue started to creep up on her. She did start to think about what she might want to – or need to – do in the next few years in order to avoid burnout.

Two months after that appointment Samuel Baumgarten died suddenly while skiing down his favorite slope.  Barbara heard one patient after another say what a good gynecologist Dr. Baumgarten had been and in the next breath ask whom they should see now.

Barbara herself had to do the same thing, choosing to see Sam’s younger partner Sandra, who was ten years his junior and a nice enough woman, but not a mentor the way Sam had been.

His words came back to her often during the first weeks of her illness as she struggled with her guilt over not showing up at the office. They helped her make her final decision to quit her practice. And she imagined her own patients, one by one, wrapping things up the same way:

She was a great doctor, but who do I see now?

Physician, Heal Thyself!

Dr. Barbara Brennan practiced Family Medicine in a nearby town for a decade. She was busier than most of her colleagues. Her patients adored her and she had earned a solid reputation as a crackerjack diagnostician. She worked long hours at the clinic and she ran a tight ship at home, managing a large household and even found time to be active in her community. She would be up at five to get everyone in her house on their way, and when she arrived at her office at eight, she always looked beautifully put together and on top of the world.

She never seemed hurried or harried. People wondered how she did it. Her husband, also a physician, admired his wife both as a woman and as a colleague. He had more years behind him as a doctor than she, but he often found himself asking for her medical opinion.

Dr. Brennan had many patients who appreciated her razor sharp diagnostic skills. She diagnosed a pheochromocytoma, a case of fallopian tube cancer, and several other rare medical conditions. She was also well known for her psychiatry skills. In rural America, primary care physicians deliver the majority of psychiatric care. Barbara Brennan moved comfortably between crisis intervention, brief psychotherapy, antidepressants, mood stabilizers and ADHD prescriptions.

There were two kinds of clinical problems she avoided. She didn’t enjoy doing the minor surgical procedures some primary care doctors see as bright spots in their day, and she didn’t enjoy treating fibromyalgia and Chronic Fatigue Syndrome. Suffering from some arthritis herself, she found it draining to work with patients she thought sometimes dwelled too much on their symptoms. It saddened her to see fibromyalgia patients focused on what they couldn’t do, instead of making the most of their physical abilities.

One Friday morning, at the end of an unusually busy week that even Dr. Barbara Brennan thought would never end, she noticed a strange tingling sensation over her right eye. As the day progressed, the tingling turned into a burning pain down most of the right side of her face. She became nauseous and developed a migraine. She had worked in spite of having migraines before and steeled herself to make it through the day. A slight dizziness set in, and she had trouble concentrating.

Finally home, she put dinner on the table, but didn’t eat anything herself. She looked in the mirror for a rash on her face. She asked her husband to double check closely for her. By eight o’clock she went to bed, exhausted and with a throbbing migraine.

Saturday morning her shingles rash was there, subtle at first. Her husband confirmed it and called the pharmacy with a prescription. Her headache was still there and she was still nauseous and lightheaded. She had to move slowly to avoid vertigo and she noticed it took her longer to find words, even to figure things out. As a physician, she knew she must have developed a touch of encephalitis – brain inflammation.

She expected to be out of work for a week, but complications set in. She broke out in hives from the antiviral medication and had to stop taking it after only three days of treatment. Without the medication the shingles flared up again and she became profoundly tired. Over the next few weeks she developed joint pains and muscle aches. She got a sore throat. She felt as if her mind and body moved in slow motion. All she accomplished was to get everybody off in the morning, and by the time she got the dishwasher loaded it was already almost noon. She didn’t take naps, she didn’t even sit down much – it literally took her so much longer to do the simplest things.

She cried in frustration: “What’s wrong with me?”

Her husband looked into her eyes, the right one still framed by the slight scars left by the shingles, embraced her and said what she knew but didn’t want to believe: “You have a post-viral syndrome, maybe early Chronic Fatigue Syndrome”.

Months have passed and Dr. Brennan has not returned to work. She is convinced that she has CFS. She didn’t like it in her patients and she is fighting to beat it in her own case. She now knows first hand how real and devastating this condition can be. She is learning to listen to her body, always doing as much as she can, pushing ahead just a little, so that eventually she can get her stamina and her health back. Sometimes when she pushes herself too hard the sore throat, body aches and tingling over her right eye remind her to slow down again. 

I asked Barbara the other day if she would ever resume her practice. Her answer was: “I can’t afford to ignore my own health. In that job, and at that pace, I did just that.”

Dr. Brennan is living by her own advice – Physician, Heal Thyself!

(Here’s to you, Barbara! With respect and best wishes…)

The Correct Diagnosis – Ten Years Later

Wanda has been my patient for over ten years. She has these spells that nobody could figure out. She had seen a couple of the doctors in our clinic and at least two neurologists. She was even admitted to a hospital a hundred miles away for EEGs and videotaping of her spells.

When I first met Wanda, she described spells of confusion accompanied by a slight headache, severe anxiety, nausea made worse by the smell of food and abdominal cramps. Her husband wouldn’t be able to talk with her, and she would have trouble remembering the entire episode after it was over.  The episodes often occurred during her period. The neurologists suspected seizures, but the video-EEG showed rather bizarre moaning and groaning with a normal EEG, so the conclusion was that she had pseudoseizures. This is a condition that basically falls under anxiety disorders.

None of the anxiety medicines did anything for Wanda and she insisted she wasn’t anxious. She is an accomplished businesswoman who travels, gives presentations and generally seems to be at ease with everything she does.

Wanda is not a complainer, so years went by without her bringing up her spells. She would come in for routine things and occasional minor illnesses, but she never spoke much about the spells.

Then one busy Friday she turned up as my 4:30 patient with the purpose of the visit stated as “spells”. Looking at my schedule that morning I had remembered how none of her doctors had been able to help her. I was tired and running late because of a couple of late-day emergencies, so it was about fifteen minutes of five when I knocked and entered her exam room. I was not in high hopes of solving her problem before 5 pm.

When you get stuck in a diagnostic dilemma you have two ways of approaching the problem. You can dig deeper and meticulously go over all the tests that have been done so far, looking for anything that could have been missed. You can also do the opposite, step back, clear your mind and listen to the patient’s story all over again. It is a little bit like those pictures in psychology class; the more you stare at them, the less likely you are to see the hidden image. Sometimes if you squint, you can see it right away.

Given the time available and also the amount of time that had passed since Wanda had anything done to figure out these spells, I chose the latter course. Instead of acting frustrated that I had an unsolvable problem at 4:45 on a Friday afternoon, I sat back, took a deep breath and asked Wanda to start from the beginning.

As I listened, I started to think that all of these symptoms sounded a little like migraines, except that the headaches were mild and sometimes absent. Some people have neurological symptoms with migraines. The nausea and abdominal pain, which she now described as bloating, sometimes followed by diarrhea, can be seen with migraines. There is a rare form of migraines called abdominal migraines or Cyclic Vomiting Syndrome, usually found in children. Her spells were getting a little less severe as she was approaching menopause, but they were interfering with her work, especially as she had to travel more in recent years. Migraines are more likely to occur when people aren’t following their normal routines – missed meals, lack of sleep and jet lag are all migraine triggers. There is also the phenomenon of “weekend migraines”.

I told Wanda that her story made me think of migraines. She lit up. It made sense to her and she was pleased that I was willing to go in a different direction. I gave her samples of Imitrex to be taken with attacks and a prescription for a common blood pressure medication that is often used for migraine prophylaxis. 

Within a month Wanda was almost free of the severe attacks, and she had stopped a couple of spells by taking the Imitrex. With her permission I sent copies of her records to a migraine specialist in Boston for his review. He confided in me that he had always been sceptical of abdominal migraines in adults, but agreed that I seemed to be on the right track. We are now adjusting her preventive medication because of side effects.

It took ten years to make the correct diagnosis – or, should I say, ten years and fifteen minutes. I can certainly not pat myself on the back for getting it right without feeling very humble about how we all missed what was going on for so long. Sometimes when you’re tired your mind can work more intuitively, and I think that is what happened here.

Adverse Effects

Doctors hate it when patients say: “Doc, I don’t want to take this medicine, because it causes all these side effects – just look at this list I got from the pharmacist (or off the internet).”

As allopathic physicians, we are at a disadvantage because our medicines come with warnings about every side effect ever reported, even if no one has ever proven it was actually caused by the medication.

Everyone knows about the placebo effect, the healing caused by a patient’s expectation that a medication will work. The package inserts we get today bring on the nocebo effect, which is the creation of discomfort by negative expectations.

Practitioners of alternative medicine have it easy; they can take full advantage of the placebo effect without the nocebo effect caused by pharmacists, the FDA, the legal climate or the Internet.

Adverse effects can be very real and frightening, though. I have seen plenty of them, and it does make me careful. This is the age of information and Informed Consent, and we have to be very careful to tell patients about possible adverse effects when we prescribe.

I have seen a woman’s bone marrow almost shut down from a week of sulfa for a urinary tract infection. One man lost the use of his right arm for months due to rotator cuff inflammation after taking Cipro for a sinus infection. Another man developed horrendous sunburn while taking doxycycline for a prostate infection. Several patients have developed allergic rashes and tongue swelling.

I have seen people go into heart failure from Avandia, a once-popular diabetes medicine and I have seen people use my prescriptions to try to do themselves in.

But adverse effects can be caused by non-pharmacological treatments also. Sometimes a doctor’s words or demeanor can have unintended, even devastating effects.

One successful business woman told me once that she had felt terrible the whole time between two appointments because she had got the impression I thought she was foolish, and I couldn’t even remember what had happened. A few times I have had to undo damage I caused by being in a hurry when dealing with a patient who was afraid or anxious. 

A physician’s demeanor is part of the treatment. I know they teach empathy in medical school these days – to the extent this is something that can be taught.

William Sykes was told by his pulmonologist that he had eighteen months to live when he was diagnosed with alpha-1-antitrypsin deficiency. He became severely depressed. The antidepressants and steroids I prescribed made him manic for a while, but we got through it. I promised him the pulmonologist didn’t really know how long he would live. The specialist did fire William as a patient because he cancelled a couple of follow-up appointments, so it was “him and me” and the occasional Hospitalist for a few days of “pulmonary toilet”.

William lived almost ten years longer than predicted, even got married and adopted an old parrot, which learned to imitate the sound of the oxygen truck backing into the driveway. But he never got over the words of the pulmonologist.

Losing a Patient Twice

I had some down time in New York this past weekend and spent some of it looking at what Swedish physicians are writing in their blogs. (I am a Swedish physician, too, but I have lived most of my professional life in the U.S.)

I came across a brief little piece by a 25-year-old Swedish resident. She connected with a patient on her ward in his fifties (her father’s age), who seemed to be doing OK, but died overnight while she was off duty.

I tried to remember the first patient I lost, but I couldn’t. There have been so many in my 29 years as a doctor, some lost prematurely, but most in their old age and after a long illness.

A few months ago, a former patient who no longer lived in our town, died. He was only a few years older than my own children and the news of his death affected me deeply, even though I hadn’t seen him for years.

Bobby Smith was a normal, rambunctious, ten year-old until one day, my second winter in town, when we got a radio call from the ambulance. In those days we had all volunteer EMT’s, and none had any advanced training, so the doctors at our clinic would get called to go on ambulance runs.

It had snowed heavily that morning and school was cancelled. By noon the snowfall had stopped, and the sun came out.  Bobby went sledding right in front of his house. At first, the new powder slowed him down, but every time Bobby followed the same path down the hill he went faster and farther. The last time, he ended up in the middle of the road.

Samuel Trumbull, the town selectman, didn’t have a chance to avoid hitting Bobby as he lay on his sled in the middle of the road.

The ambulance had twenty miles to go on the winding, slippery road to the hospital. Bobby was unconscious, not breathing, but with a good pulse and blood pressure. I maintained his airway and bagged him the whole way.

He pulled through, but with severe brain damage. He never spoke again. He would make grimaces and smile or poke at you. He was bed bound and incontinent. I did house calls there for a few years. Eventually they wheeled him into his old classroom, mainstreaming him, as they called it.

His parents split up, and Bobby ended up moving away from town. I would still often think of Bobby, and poor selectman Trumbull – his life was never the same after that day, either.

Suddenly, one day this spring, a patient whose maiden name was Smith – something I never reflected on – cancelled an appointment because her brother had died. When I saw her a week later, she mentioned who her brother was. All of a sudden I was back in that ambulance, bagging this little boy, who could have been my son. I lost Bobby all over again, but this time I lost him forever.

A Country Doctor Stops In Brookline

The other night we stayed in Brookline on our way to New York.

Boston and Brookline are reference points for this country doctor. I go to Harvard courses for updated knowledge and continuing education credits, and I occasionally refer patients to specialists at Massachusetts General, The Brigham, or Mass. Eye and Ear Infirmary.

When down there, we often stay in Brookline, down the street from the Longwood medical area. There is a row of inns that offer housing for families and patients undergoing treatments at the major hospitals. We ended up there once ourselves, referred by Angell Memorial Hospital, when we took our sick dog there, first for a consult, and then for an extended period of radiation therapy.

Angell referred us to the Bertram Inn, which allows dogs (and our Persian cats). Since those first two stays, we have been back to stay at least half a dozen times.  Walking the tree lined streets just a few blocks from Beacon Street and Coolidge Corner, I feel like I am in a small town, yet minutes away by car or taxi, we can be at the Symphony or a downtown course or restaurant.

On our early morning dog walks we see residents and medical students hurrying to work with stethoscopes around their necks. There are joggers everywhere. We pass the Lown Cardiovascular Center, named after Dr. Bernard Lown, who pioneered cardioversion for atrial fibrillation. His book “The Lost Art of Healing” from a dozen years ago is a must-read for doctors, particularly now. My patient and mentor, Clarine, who told me from her sick bed to write, and who gave me Thomas Moore’s “Care of the Soul“, also gave me a copy of “The Lost Art of Healing”.

Actually, Thomas Moore himself – a humble man – has said that even titles of books you haven’t read yet can be an inspiration. We attended his seminar on Cape Cod last summer, entitled “Care of the Soul”.  We missed a day of that course because of our dog’s illness. That was the summer our dog died, and what we learned from her passing paralleled what we learned from the course.

Sometimes, just spending one night in Brookline gives me a sense that I, living and working in New England, am connected to the Boston medical community. Doing the work we do, day in and day out, especially in a rural community, can make us feel isolated. A night in Brookline is like glancing at the titles of the books on my shelf. You are quickly reminded of what’s inside and it changes you a little every time you reconnect with it.

Sally’s Dilemma

Sally is about sixty. She was widowed a couple of years ago. I usually only see her once a year for her routine physical. She and her spry eighty-four year old mother always go together for their annual mammogram.

When Sally came in for her physical a while ago, her blood pressure was up. I didn’t act on it then, but did some blood work and brought her back a few weeks later for a recheck. Her pressure was still up. I made the judgment call to pursue this further instead of just treating her pressure, and ordered an ultrasound of her kidneys with an office follow-up. A blood pressure that suddenly goes up can be a sign of an underlying problem such as poor circulation to the kidneys. We often look for “secondary hypertension” when the clinical picture isn’t typical for “essential hypertension”.

Sally’s renal ultrasound showed normal size of both kidneys, but one kidney had two suspicious areas in it, which could be either benign or malignant. The radiologist recommended a CAT scan. Sally wasn’t thrilled when I called her to let her know the results; she generally doesn’t like to have a lot of tests done, but now we had the possibility of kidney cancer versus something harmless. She agreed to the CAT scan, which required intravenous contrast.

A few days later the report came in. My heart sank. The larger of the two kidney lesions was benign looking, but the smaller one looked suspicious and was too small to completely characterize on the scan – follow-up was suggested (how soon, I wondered…). But there was more: The head of the pancreas looked a little enlarged, and the bile ducts were a hair wider than usual. A dedicated pancreas CAT scan was suggested in order to rule out pancreatic cancer.

The follow-up appointment we had scheduled at the beginning of this process was three days after the CAT scan. I looked her straight in her eyes and told her about the small suspicious area in her kidney and the suspicious looking area in her pancreas. She moved her head back in slow motion and moved her hands up toward the ceiling and said:

“You know my husband died from pancreas cancer? I watched him go from a big, strong man to nothing in five months, and his sister died from the same thing! If this could be pancreatic cancer, I don’t think I want to know!”

“And if it isn’t, wouldn’t you want to know if you have a small, curable kidney cancer?” I asked.

“I don’t know,” she said, “what would I tell my mother? I don’t know if she can handle this.”

“Would you be OK with getting an opinion from an oncology surgeon before you say no to the pancreas scan?” I asked. She agreed, reluctantly. I have a call in to Dr. G.

Sally needs more answers than I can give her right now.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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