Posts Tagged 'Progress Notes'

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”.


CONDITIONS, Chapter 1: An Old, New Diagnosis

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