The Doctor’s Doctor

Doctors have a reputation of making bad patients. Many of us even hesitate getting a personal physician. Years ago it was common for doctors to treat themselves and their families. The Latin vocabulary used on prescriptions includes the phrase “Ad Usum Proprium”, which means “For Personal Use”. This is now considered inappropriate, except in emergency situations or for occasional minor illnesses.

When I turned fifty, after years of neglecting my health, I decided to get my own Family Doctor. I thought about it for a long time. I decided not to see one of my partners, but someone in the city 20 miles from here. It should be a physician with more years of experience than I had, not someone who was young and “aggressive”.  In medicine we use that term for doctors who order lots of tests and prescribe multiple medications. My choice of Family Doctor for myself was Wilford Brown, III, MD, a tall, gray haired man with a solid reputation as a thoughtful, conservative clinician.

Our first meeting went well. I told him which things I was interested in looking into and which ones I didn’t worry about. He obliged, did a brief but appropriate physical exam and treated me with utmost respect. If he disagreed with me, he didn’t say so. I really liked him. We had another visit a year later, and I thought things were going well until he told me he was retiring. My heart sank. I asked him if there was another doctor in his office he would recommend for me. He didn’t hesitate before suggesting Dr. John Royson.

My first and only meeting with Dr. Royson did not go well. I sat in a bare exam room, fortunately not bare myself, for an hour. The exam room door was open and I overheard the medical assistant call Dr. Royson on the phone. Her end of the conversation went:

“Hello, Dr. Royson? Did you forget you had office patients today?”

“Yes, for over an hour.”

“So when will you be here?”

I had taken a half-day off, so I declined the assistant’s offer to reschedule the appointment. After another twenty minutes or so Dr. Royson appeared. He was in his early thirties, sported a flat top and didn’t apologize or even mention anything about me waiting almost an hour and a half.

D. Royson seemed a bit flustered about having an older physician for a patient. He mumbled to himself about perhaps checking my prostate etc. The whole visit lasted ten minutes.

I didn’t have to fire Dr. Royson; he left the practice to become a full time Hospitalist, doing what he was doing when he forgot that he had me and other patients to see at the office.

Dr. Royson’s replacement at Cityside Family Practice was another interesting experience. Dr. Joe Washburn looked like he’d rather be surfing, started me on a new blood pressure pill with a prescription good for a whole year and didn’t say a word about how to follow up. I got the impression he was so uncomfortable treating a colleague that he wished I’d go away and do my own follow-up.

Not long ago our clinic had a new patient register. We have a preliminary registration sheet come to the doctors for approval, because we are at near full capacity. This patient  registration sheet caught my eye:

Name: Wilford Brown, III, MD. 

Reason for choosing our practice: Payback.

Clara’s Sinus Headaches

When people come to my office with “sinus headaches”, they often ask for an antibiotic and perhaps something for congestion. Pain in the forehead, behind the eyes or in the cheekbone area doesn’t always mean infection, though.

Clara was a widow in her seventies, who had experienced frequent and severe sinus headaches for years. She even had postnasal drip and a recurrent sore throat. I ordered a CT scan, which was negative; there was no sign of cancer or polyps, but also no sign of sinusitis. On this, one of many office visits, she asked for antibiotics. I agreed to prescribe something while we waited to get the scan.

When we had a follow-up visit to review the scan, I told her the films were completely normal. She told me the antibiotics had cleared all her symptoms, just like every time her previous doctor had prescribed them. How could she not have had a sinus infection when the antibiotics always made her feel better? It wasn’t long before she came back with another request for antibiotics.

The antibiotics always had to be brand name – she insisted generics made her feel badly and they never cleared her sinuses. The pharmacists would call and point out that the generic version of her favorite antibiotic was actually made by the same manufacturer as the brand name. Clara was unconvinced. She had good insurance, and all she needed me to do was check the box on the prescription and write “Brand Medically Necessary”. This is what she insisted on for her antibiotics as well as for her maintenance heart medications.

I didn’t feel comfortable with Clara’s repeated requests for antibiotics, so I sent her for a couple more CT scans over the years, and she reluctantly agreed to see an allergist and an ear, nose and throat specialist. She didn’t like either of them, and they didn’t help her. She seemed to enjoy her visits with me, and she often said that she wouldn’t know what to do without me; on the way out she would hug me good-bye.

Clara often seemed a little sad and lost. Her husband had always taken good care of her, although I wasn’t sure how happy their marriage had been. She had never involved herself with practical or financial matters. Now she was struggling with what to do with their mobile home in Florida, and she fretted about whether to sell their house, which was too large and too expensive to heat. I would try to help her find the confidence to tackle things one at a time.

We finally had a heart-to-heart talk about her headaches. I suggested we stop treating her with antibiotics, and she asked me if I thought she was just imagining them. I reassured her that I didn’t think so, but explained that you can have temporary congestion without infection.

Clara sold her home and moved into a senior citizen complex. I was busy, and didn’t notice how much time had passed. One day recently my office nurse, Autumn, grinned and said “Guess who just made an appointment to switch all her prescriptions to generics!”

Clara entered the office with an air of confidence and dressed to the nines. “You look well”, I pointed out. “I’m happy,” she beamed, and pointed out a new diamond ring. 

Clara had not been in for well over six months. She never had headaches anymore, and she thought it was time she tried the generics. I knew her problem had never been her sinuses. And I knew it wasn’t all in her head; all along it had been in her heart.

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…)