The Dance

Summer Rerun from 2011:

The band members brought their instruments and their small amplifier system into the activity room through the big glass doors facing the parking lot. As they tuned their instruments and warmed up, the residents started to stream into the big, bare room.

Some arrived in their hospital beds, some were pushed in their wheelchairs, some shuffled in with canes and walkers and a few strolled in with the spring of anticipation in their steps.

There had been bands there before, but this was a real dance band with horns, percussion and a female vocalist.

He walked down the long hall with a group of others from the dementia unit. By now he knew the way, even though his eyes failed to guide him because of his advanced macular degeneration. He could see the nurse’s aides in their brightly colored scrubs, but he had trouble making out his fellow residents in the slow caravan.

As they approached the activity room he heard the sweet sound of the vocalist and the wind instruments. The rhythm energized him and he remembered dancing to Glenn Miller and Artie Shaw tunes like “In the Mood” and “Begin the Beguine” in the Forties. He suddenly felt sad. Where was his wife? Why wasn’t she there with him?

One of the aides escorted him to a chair along the sidewall, close to the band. They were playing something Latin he didn’t know what to dance to. He couldn’t see if anybody was dancing yet, but the music was cheerful and made him feel good.

Eyes turned toward her as she entered the room. She felt pretty in her blue dress and shoulder-length black hair. She saw him sitting by the band and quickened her steps, her left leg swinging outward in a slight semicircle and her arm kinked at the elbow. It had been six months since her stroke and this was her first dance since then.

He noticed the blue dress as she approached him, but couldn’t tell at first who she was.

“Have you been waiting long?” she asked.

“Well, hello, dear. I just got here.”

“I’m so glad to see you”, she whispered in his ear before planting a discreet kiss on his cheek. She sat down next to him. She made sure to place herself so she could touch him with her good arm.

The band started playing a new song. He realized after the first few bars that it was “Tuxedo Junction”. Years ago he would have done the Lindy Hop to it, but he couldn’t pull that off now. This would be a nice, slow swing dance.

“May I have this dance?” he asked.

“Well, certainly”, she answered and gave him a slight squeeze.

She led him onto the improvised dance floor with her right arm and they stood there for a few bars, her right hand in his left, both of them just moving slightly to the rhythm. He led her into first the basic step, then a push-out and then an underarm turn. She followed beautifully. They danced the whole song without saying anything at all.

The next tune was a slow waltz. She was able to put her left arm up on his right one and he danced gently with small steps. His eyes strained to see her facial expression, but he didn’t see the tears that had begun to well up in the corners of her eyes.

“I’m sorry I was away for such a long time”, she whispered.

“It’s all right”, he answered, patting her on the back as they danced.

“I was really sick and couldn’t come to see you.”

“It’s okay.”

He didn’t see the scars on her bare arms or the tracheostomy scar over her windpipe.

“I’m so glad I am here with you today.”

“I’m glad you came”, he said and added “I love you.”

By now, two floods of tears were streaming along her pale cheeks and down her neck, across her demon and snake tattoos, wetting her jet-black hair.

“I love you too, Grandpa.”

Less is More, More or Less

Cholesterol is bad. Cholesterol is an essential building block for important hormones.

Eggs are bad. Eggs are a complete protein food.

Salt is bad. Salt is essential for life.

High blood pressure kills people. No blood pressure defines death.

High blood sugar causes eye and kidney damage. Low blood sugar causes falls, fractures and car wrecks.

Low potassium causes heart rhythm problems. High potassium causes heart rhythm problems.

Too little vitamin B-12 causes nerve damage. Too much vitamin B-12 causes nerve damage.

The ancient physicians, from Hippocrates in Greece to the Yellow Emperor in China, to Ekiken in Japan and Charaka in India, all spoke of the virtues of moderation.

Why do we in our culture go to excess in our pursuit of wellness? We always seem to want to classify foods and nutrients as either good or bad. Depending on how we classify them, we go to excess in consuming them or we deprive ourselves of even necessary amounts of them.

There is even a newish disease, defining the extremes of such behavior, “orthorexia nervosa”.

The latest scuttlebutt of this sort is the new findings that low sodium diets are associated with greater risk of ending up dead than moderate salt diets. The editorial about the studies published in this week’s New England Journal of Medicine made me late for my nightly rounds to check on the barn animals Wednesday night. The piece was interesting, but ultimately no more enlightening than reciting the old adages “everything in moderation” and “nothing to excess”.

Somehow, we here in America have been conditioned to seek expert guidance over our own common sense or our Grandmothers’ advice. We listen to Government advice about drinking eight glasses of water per day whether we are joggers in Memphis during August or mailmen in Anchorage during January. We even listen to medical experts in unrelated fields who promote the latest nutrition and supplement fads on TV for their own profit.

The problem with turning the findings of scientific studies into practical advice or medical treatments is that science only produces data. “Data-driven” has become a buzzword today, just like “evidence based”, or a new one I heard recently, “evidence supported”.

What is wrong with both “data” and “evidence” is that neither entity equals truth, value, practicality or “wisdom”, not to mention the “fact” that the scientific “evidence” has changed many times over about a great many things just in the last few decades. If people wearing astronaut-like Ebola suits are less likely to also get the flu, does that mean we should all wear them during the winter months? Probably not. If tall bachelors have more dates than short ones, should we issue platform shoes to the vertically challenged (my very first blog post)? It was tried to a degree in the 1980’s, but never quite worked out.

Data is meaningless without context or “big picture”. Medical research, by its nature, analyzes small and easily defined parameters within the vast systems we call health and disease. What makes perfect sense to do for the well-being of one corner of our anatomy or physiology may have disastrous consequences for another and possibly for the whole organism. Each scientific study only aims at illuminating one small aspect of life. Only with an understanding of the bigger picture can we decide how to use the nuggets of “fact” science produces.

Even more than a view of the big picture is required to truly make use of data: Common sense, trivial as that may sound, is required when making judgements and setting priorities. This is what has gone missing in our collective enthusiasm at the advances of science in the past century. My Grandmother, who would have been 114 this year, but only lived to be 96, already knew that a little salt, fat or sugar never hurt anyone, but eating anything to excess was not healthy.

Both Hippocrates and Grandma, without the advantages of scientific data, knew in their hearts by virtue of their common sense what science has finally seemed to confirm.

We, as a culture, need to take advantage of both our shared, ancient wisdom and the advances of science, but either one without the other is likely to sometimes lead us astray.

Semmelweis’ analysis of why midwives’ postpartum infection rates were only a fraction of doctors’ and medical students’ is an example of science serving to explain what common sense already knew: Touching the dead before delivering babies made bad things happen.

Population studies, on the other hand, where we seek to find out if vegetarians, salt fiends, runners, nurses or yoga practitioners are healthier than others after decades of doing what they do are so fraught with uncontrollable variables that we are likely to be confused; it took twenty years to find out that postmenopausal estrogen treatment didn’t decrease heart attack rates in older women as the experts had speculated. Too many years of a good thing turned out to be bad.

My Grandmother could have told us that taking drugs to thwart aging didn’t make any sense. So could Hippocrates. They both had common sense. We need to cultivate ours in order to properly make use of today’s exponentially increasing amount of data.

Come to think of it, data seems to be a little bit like salt: Either too little or too much can be debilitating. We should let our common sense regulate our consumption.

Calling Mrs. Kafka

“Prior Authorizations, Mrs. Kafka. May I have your name and the patient’s policy number.”

“My name is Country Doctor, and I don’t have the patient’s number but I have her husband’s – it is 123456789”.

“Thank you, Doctor. This is for Harry Black?”

“Well, no, it’s for his wife, Harriet. We asked for a PA for Lyrica for her, but it was approved for him instead, even though the forms we sent you clearly stated her name.”

“I see that Harry is approved for one year.”

“Yes, but he doesn’t need it. He has no diagnosis and no symptoms. Someone at your end reversed the names, because the application was for Harriet. I have a copy right here in front of me. So can we just get this approval switched over to her name instead?”

“I’m sorry, we can’t.”

“But why?”

“She’s a different patient.”

“But everything we sent in was on her. You were the ones who put it under his name instead. It was your mistake and I’m asking that you correct your mistake.”

“I’m sorry, but we have to process Harriet’s Prior Authorization separately. What is her diagnosis?”

(Sigh)

“Postherpetic neuralgia.”

“Is she currently taking Lyrica for this?”

“Yes.”

“I don’t see any pharmacy claims for Lyrica in her profile.”

“That’s because you don’t pay for it. That’s why you and I are talking right now, isn’t it? She’s been using samples.”

“Lyrica is not covered for that diagnosis. Studies have shown that other drugs usually control symptoms…”

“Now, wait a minute, your company already approved it for that indication when you looked at the paperwork we sent in before, all that happened was that you misread the name of the patient! And if you didn’t read her papers and still approved it for her husband with no diagnosis at all, you can’t exactly say you’re following any firm principles there at MegaScripts!”

“I’m sorry, Doctor. We have to process her request from the beginning.”

“This woman has suffered for two months and has taken several other drugs before getting any relief -amitriptyline, gabapentin, and she’s on Effexor, so there is no point in trying Cymbalta. If you can’t or won’t correct your own mistake, and if you can’t accept what I’m telling you now, I just can’t sit here and argue any longer with you. I’ve got patients waiting. Just tell me where to fax the information.”

“The number is 1-888-000-6666. Now, did you say she had tried ga-ba-pen-tin?”

“Yes, that’s what I said, and that’s what I wrote on the form we already sent you!”

“All right, hold on, Doctor. I’m getting an approval here. O.K., I have a number for you. It is 9921465. And it’s good until August 12, 2015.”

“Thank you!”

(Sigh)

“You’re welcome. Is there anything else I can do for you?”

“No, that’s all I have time for today, even if I needed anything more from you.”

“Then, you have a nice day and thanks for calling MegaScripts.”

(Click)

Is it the Devil or God in the Detail?

“We must bear in mind the difference between thoroughness and efficiency. Thoroughness gathers all the facts, but efficiency distinguishes the two-cent pieces of non-essential data from the twenty-dollar gold pieces of fundamental fact.”

Dr. William Mayo

The practice of medicine involves a lot of details, but details without the big picture are meaningless at best and distracting at worst.

The expression “The Devil is in the Detail(s)” implies that the details can trip you up, whereas the original, older, idiom “God is in the Detail(s)” conveys the importance, even beauty or virtue, of paying attention to the details when trying to do good work.

I think medicine has lost sight of the big picture when it comes to its thoroughness and its pursuit of efficiency. And I don’t see much beauty or virtue in today’s medical charts.

This was going on before electronic medical records, but quantum leaped with the switch from transcribed dictation to click boxes and copy-and-paste functionalities.

The root of this problem lies with the Evaluation and Management (E&M) coding that literally gives points for how many questions a doctor asks about a symptom – onset, character, duration, severity and so on. Points are also given for documenting which symptoms a patient doesn’t have. In earlier times, we used the phrase “pertinent negatives” for items a reasonable physician would want to know in order to work through the possible differential diagnoses for a particular symptom

With the reimbursement system we now have, the number of questions and physical exam items, regardless of whether they are relevant or just filler material, drives physicians’ income and practices’ bottom line.

It was often possible when reading an old-fashioned, dictated, narrative to relatively quickly sort through the irrelevant items, particularly if the style and grammar were used to provide emphasis. For example, when dictating, you had the option of grouping all the negatives together and of keeping the positives separate and emphasized. With an EMR, the items in structured data entry fields tend to come in a predetermined order, making it much harder for the reader to find the relevant items.

The forest of details in today’s medical record serves purposes other than the efficient documentation for doctors to remember their own inquiry and thought processes. It also isn’t primarily designed for doctors to communicate to each other what they have observed and how they propose to treat it.

Today, under the new Government edicts, medical records have to contain hoards of details doctors never thought were relevant, but politicians and insurance actuaries do and future generations of researchers might. Plaintiffs’ lawyers and medical boards might need them, and patients need to be able to read them, so we can no longer create notes that efficiently document our findings, conclusions and plans. It is as if the conductor’s sheet music at the Symphony could no longer have musical notes, G-clefs and technical terms like “mezzo forte”, in case a non-musician wanted to follow along with the orchestra.

It is a bizarre situation: Imagine the Ministry of Culture requiring that all poetry contain certain elements about the beauty of America and the threat of global warming. Similar things have happened in countries that shall not be named here.

This is where the religious analogy really plays out: Which higher power decides the relative importance of what details in medical records? I have a theory.

Details, details, details…

Neither Doctor nor Priest

It is the year of Woodstock. The motorcycle accident victim lies quietly in his hospital bed. By all accounts, the surgery has gone well and Richard’s initial prognosis had been good. But his vital signs are deteriorating and he seems distant and despondent.

Marcus Welby knows the trouble isn’t physical. He calls on the parish priest, who seems slow to respond. The priest, twenty years younger than Welby, is also his patient, and has been suffering from asthma attacks. Welby believes they are due to Father Hugh’s struggles with feelings of inadequacy as a priest.

Richard turns the priest away and appears to be dying. The priest feels ready to give up the priesthood.

Marcus Welby, who had been urging the younger priest to take a break because of his asthma, now urges him to get to work. He tells Father Hugh that he has also failed many times, but failures are no excuse for quitting. The gravity of the situation mobilizes new strength in Dr. Welby, and his humanity and passion inspire Father Hugh to admit to himself and the young accident victim that, even though he is a priest, he struggles like all human beings. That honesty makes young Richard open up to Father Hugh and he begins to recover.

What neither doctor nor priest could do alone, the two men working together are accomplishing. This is what happens in a December 1969 episode of Marcus Welby, M.D., “Neither Punch nor Judy”.

The cars seemed more old-fashioned than I remember them from those days, and the 1969 medical standards of care are definitely as old-fashioned as the cars, but the struggles of the three men from three different generations are timeless.

I decided to watch this episode after rereading my post “The Apostolic Nature of our Profession” when I linked to it the other day. The video illustrates many things about medicine that we are no better at today than 45 years ago, or 2,400 years ago, for that matter:

“The cure of the part should not be attempted without treatment of the whole. No attempt should be made to cure the body without the soul. If the head and body are to be healthy you must begin by curing the mind…for this is the great error of our day in the treatment of the human body, that physicians first separate the soul from the body.”

Plato

A Country Doctor in his Sixties


“Once you start studying medicine you never get through with it.”

Dr. Charles Mayo

Marcus Welby, M.D. was 62 in the first episode of the TV series. My father, not a physician, retired at 62. As I am now beginning my sixty-second year, I seem to be thinking a lot about my place in time and in medicine.

Thirty years ago people often told me I looked too young to be a doctor, and I felt I had to work extra hard to seem wise. I developed a habit of carefully explaining what I understood of each patient’s condition, what I saw as the options for further testing and treatment, and what I expected the outcome to be. I also made a point of being respectful and seeking out each patient’s views and preferences.

That is still how I work, but I have found that over time, as my appearance more and more plainly suggests my years in the business, patients are more and more willing to take my advice with fewer explanations. They are also more openly seeking my opinions, support and advice in matters that go beyond the purely medical aspects of life.

It is an honor and a humbling responsibility to be in that position. It comes from not only looking like you have lived through a lot, and I have, but also from being privileged to see up close the joys and travails of so many fellow human beings.

Few professions see as much of the human condition as we physicians, and especially in these secular times, our role can sometimes have similarities with that of the village priest, especially because we deal with matters of birth, life and death.

Early on, I wrote a post titled “The Apostolic Nature of Our Profession”. The older I get in my vocation, the more I see of that; I feel more kinship and indebtedness to the ancient physicians and to my own mentors that guided me to where I am now, and I feel more tangibly the responsibility that goes with years of practice, suddenly graying hair and the earnest requests from some of my patients to fill their archetypal need for the services of a physician.

At the same time, I feel a strengthening of my desire to understand more of medicine. This truly is a lifelong pursuit, and every year I know more, but also wish for deeper and deeper knowledge than I have achieved. Dr. Charles Mayo said it succinctly in the quote above, and Sir William Osler elaborated eloquently:

“The hardest conviction to get in the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.”

Like Osler, I believe medicine is a genuine calling for many physicians, but unlike him, I believe it can be practiced into old age, as long as we have the physical and mental vigor this kind of work requires.

I bring the enthusiasm of a young man and the experience of a sixty-one year old to my remote clinic five days a week, and most nights and weekends I read, think and write about doctoring.

I hold these words by Dr. William Mayo close to my heart as I imagine myself following in the footsteps of mentors like my senior colleague Dr. Wilford Brown, III:

“The keen clinician, as he grows in experience, becomes more and more valuable as age advances.”

In order to be as valuable as I can be to my patients thirty-five years after medical school, I need to read a lot. I need to read the major medical journals not only to learn what applies directly to my everyday work, but also to be cognizant of how the basic sciences are evolving. I need to translate my life experience and what I have learned from well over 100,000 patient encounters into a language with many dialects that I can use in familiar and unfamiliar situations with patients from a multitude of backgrounds. I need to continually learn about psychology, philosophy and religion in order to be a support to patients who face life altering circumstances and diseases.

I need to maintain my equanimity through busy clinic days in our tumultuous national health care environment, so that my patients don’t become pawns in the system any more than they have to. I need to maintain my sense of proportion in everything I do: in differential diagnosis, in helping patients set priorities, in managing agendas imposed on me by “the system”, and in my own expectations as only one mere human.

This is what I hope to continue to bring to work with me every day for as long as I can do it well.

Context, Always

Question: What do you do when presented with abnormal lab results?

Answer: Ask lots of questions.

The nursing home just sent over a urinalysis on a patient of Dr. Carlyle. I am covering his practice for a few days. The test showed that an 82 year old woman had 3+ white blood cells in her urine. “NKDA” was written in the margin, indicating she had no allergies.

I sighed internally and called the nursing home. The charge nurse seemed a little surprised at all my questions.

“What are the symptoms? What is the patient’s kidney function? Is she on blood thinners or any other medications that might interact with an antibiotic?”

The presence of bacteria or white blood cells in the urine should not usually be treated if there are no symptoms. That’s not always been our belief, but most doctors agree with this approach today.

Looking at a test result without knowing the story behind it, we cannot decide whether or how to act.

Last week we got a critically high potassium result on a patient with normal kidney function and no prescription medications in her profile. I did nothing about it, except order a repeat test that was normal. The obvious explanation was hemolysis; red blood cells contain more potassium than the serum that transports them and if the cells break during blood draw or handling of the vial, serum potassium will be falsely elevated.

A seizure patient of Dr. Carlyle had a high phenytoin level. I pestered the nurse to give me several past results and to track any previous dose changes. It turned out this patient had stable levels for a year and a half and suddenly had a low level last month. Dr. Carlyle raised the dose. In retrospect, the patient probably had missed a few doses, and would have been fine staying on the same dose. I dropped the prescribed dose back down and expect the patient to do fine.

A hypothyroid patient, Diane Green, was hospitalized with abdominal distention and constipation. She is nonverbal, and fearful of medical procedures. The hospitalist checked her thyroid function, as undertreated hypothyroidism can contribute to constipation. The test suggested Diane needed a higher dose, so she was discharged on a substantially increased dose of levothyroxine. As soon as I saw her again, I reversed the medication change; her TSH had been normal one week before her admission, and a severe illness or traumatic experience can affect thyroid values. I figured the hospitalist did not notice Diane’s old TSH result in the hospital computer.

Context is crucial when deciding what to do with abnormal test results. But doctors are often pressed for time, and finding the story behind the results takes time. Even when all the data is in our electronic medical records, it takes time to see the patterns: The test results are usually in one place, the prescriptions in another, the office notes in a third, and the phone messages in a fourth. My own EMR can produce flowsheets with lab results, but each test is identified by the date it was ordered instead of the date it was performed, so correlating lab values with prescription dates becomes confusing, for example when following thyroid cases.

In times past, when solo practice physicians cared for their patients in the office, hospital and nursing home, they kept the threads of context and continuity together more easily. Today, with more providers sharing the care, and with other office staff also interacting with patients and their families, there is more room for errors, gaps and confusion. The tools we have right now are not always as effective as we would like, and they certainly can be cumbersome and slow to use. Reading each other’s notes can take a while, as the EMR format is primarily built for coding and not for ease of following the clinical “story”.

A few words doctor to doctor, doctor to nurse or doctor to patient can sometimes do what half an hour on the computer might not. Treatment without context is essentially just random reflex actions: Killing the innocent bacteria, lowering the falsely elevated potassium, treating the lab value and not the patient – none of it does anybody any good, and probably will cause harm to some unfortunate patients.

Our temptation to view test results as obvious facts in a predictable process instead of possibly misleading clues in a complex mystery reminds me of these words from a Sherlock Holmes novel:

“There is nothing more deceptive than an obvious fact.”

Sir Arthur Conan Doyle

Med School, Day One (1974)

The corpse, laid out on a gurney and covered with a white sheet, was wheeled onto the stage by two women in long, white lab coats. A middle aged man with a bow tie welcomed us, the incoming class of the spring semester, to Uppsala University and the Biomedicine Center, where we would spend the next two years in “pre-clinicals”, until we knew enough to start our three and a half clinical years at the Academy Hospital.

The Biomedicine Center was almost brand new, a glass and concrete labyrinth with a large sculpture depicting Watson and Crick’s DNA molecule by the front entrance. The vast complex lay near S-1, the Uppsala military regiment. The brick buildings diagonally across the street were very familiar to me as the place where I had met the biggest failure in all my twenty years only months before.

As I sat in the large lecture hall with the corpse on the stage, I glanced over at L., my buddy from the Swedish military’s elite division, the Interpreter School, where we had also sat next to each other on the first day, when the Captain in charge told us:

“Soldiers, you may all have been the smartest kids in your school, but it’s different here. Most of you won’t make it, and will be culled over the next two months. The Interpreter School accepts eighty recruits and graduates twenty to twenty-five. If you don’t have what it takes, don’t waste our time or yours!”

L. and I had both thought that learning Russian would be a neat way to spend our compulsory year and a half in the military, but just barely more than a month after that harsh introduction, we were both on our way back to our respective home towns to figure out what to do until we would be able to start medical school. Our military service was put on hold until we could return as medics.

The man with the bow tie went on to introduce our guest professor, on loan from the University of Bavaria. As we all knew, the Germans had been the greatest anatomists since the last century, and all of us had already been to the University book store to purchase Hafferl’s “Topografishe Anatomie”, which would be our constant companion for the next five months.

“Hopefully, most of you took several years of German in High School,” the man continued, “but those of you who chose French instead and only took one year of German are encouraged to take advantage of our German night classes, every weekday from 8 to 9 pm in Hall B next door.”

With that, he gestured to the Bavarian guest professor, who bowed and began speaking as the first slide was projected behind him. He had the most peculiar accent, and spoke in a slow drawl. I strained to get a handle on what he was saying. L. cocked his head and as I turned toward him, I saw many heads shaking.

With every new slide, the German speaker seemed to increase the tempo of his speech and as the slides behind him changed faster and faster, more and more heads were shaking in the lecture hall. Soon, all of us had given up trying to understand as the staccato voice from the stage pounded the syllables faster than a sports commentator and the rapidly changing slides became more and more filled with details. Heads were shaking, many people were talking, some stirred and rose from their seats and turned toward the exit doors.

Then, suddenly, everything turned dark, the speaker stopped talking and all the chatter in the lecture hall ceased. We sat in darkness and silence for maybe a minute. Then, a faint tune from a small flute rose from the dark stage and dim lights began to illuminate the two women in white lab coats. One was playing the flute, the other picked up a clarinet and began to play.

As the lights continued to brighten, the sheet suddenly flew off the corpse, who sat up, pulled a trumpet to his mouth and belted out a tune like something from a Mardi Gras parade.

The stage filled with upperclassmen and the “German” professor took a bow as they all applauded in his direction.

Then, from a side door, a tall man with a very straight back, white riding pants, tall black riding boots and a whip appeared. Everyone fell silent as he began to address the students in the lecture hall.

“I’d like to introduce myself. I am professor A. of the Department of Anatomy. I just came back from riding in the fields beyond here. I want to welcome you all.”

L. and I looked at each other and shrugged – was this part of the joke?

Professor A. continued:

“So, you made it to medical school. And if you really want to, all of you will make it out of here with a diploma. Just work hard, enjoy Uppsala, and don’t worry about the German classes – all lectures will be in Swedish!”

He was right, all of us who wanted to made it all the way through. My friend L. chose to leave medical school for a life as a writer, but he often writes with great insight about doctors.

I remember that first day as if it were last week, but it was forty years ago. It was the beginning of a journey of learning I can’t imagine ever reaching a final destination. In 1974 there was no HIV; we had only Hepatitis A, B and non A-non B; Sweden didn’t have a single CT scanner; mammography screening was just beginning; Tagamet, Prozac, “statin” cholesterol drugs and clot-busters weren’t invented; low-dose aspirin wasn’t known to reduce heart attack risk, and so on.

In spite of all that has changed in medicine since I started, the way I learned at Uppsala how to evaluate scientific information, to elicit a disease history, to examine patients, and to approach them as individuals, not “cases” – that has not had to change in forty years of doing the only work I could ever imagine doing.

(Originally published on The Healthcare Blog, where my friend L. read it and thought I made it sound as if we were “culled” from the elite military school. We chose to drop out. Everything else happened just the way I wrote it…)

P.S. This is my 300th post on “A Country Doctor Writes”.


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