Mrs. Allard had a mastectomy five years ago, Mrs. Perlman had an episode of clostridium difficile colitis last year after taking antibiotics for a dental infection, and Mrs. Jones had just finished rehab after a knee replacement. All three women had been labeled as suffering from chronic kidney disease during their hospitalization.

Mrs. Allard was in on Monday. She never fails to ask what her Glomerular Filtration Rate is when she comes in for her visits. Every time I have to reassure her that her numbers are stable. She struggles to believe me when I tell her that her frequent urination is not a warning sign of impending kidney failure.

“GFR is chemistry, bladder spasms are a plumbing problem”, I tell her every time. “They are not related.”

“I don’t want to end up on dialysis and I have read that people with kidney disease are more likely to have heart attacks. My nephrologist tells me that, too. Mrs. Perlman said last Tuesday. Between her quarterly visits with Harold Wesson, the Chief of nephrology at Cityside Hospital, she worries enough to always mention her kidneys when she sees me for other things.

“But, Doctor, I have Stage III kidney disease!” Mrs. Jones said with obvious fear in her voice. It was Thursday afternoon and we really should have been talking about the dark mole on her right thigh.

“That doesn’t mean you’re in any real danger…” I began. She looked suspicious. “In fact, your kidney function two years ago was exactly the same.”

“Are you telling me I had kidney disease already then?” Her eyes widened.

“To the same degree, yes. Do you remember how I asked you to stop taking ibuprofen for your sore knee because it could harm your kidneys?”

“Yes, that’s when you gave me those prescription pain pills.”

“Precisely. I was concerned then that we needed to be kind to your kidneys – that’s pretty much all we do when people have what we call Stage III chronic kidney disease.”

“But you never told me I have kidney disease.”

“I didn’t use the word because I feel it alarms people more than it helps them. We talked about what helps the kidneys and what hurts them; we got you off the ibuprofen, we tightened up your blood pressure control with a new medication and we lowered your cholesterol. All those things help your kidneys work better and last longer.

“But Stage III – I mean, how many stages are there? How close to dialysis am I with Stage III disease?”

I was ready for her question. With all the patients like her I have seen, especially lately, I have put together some articles and teaching materials.

“I have been a doctor since 1979 and I can count on one hand the patients I have cared for that ended up on dialysis or dying from kidney failure. Look at this graph”, I said and pointed to the latest addition to my bulletin board. “You’re 74, and your GFR is 54. This graph shows that at your age, your GFR would have to be somewhere around 15 to make you more likely to die from kidney failure than something else.

She stared at the graph.

“So 54 is actually not a bad GFR?”

“Well, it’s not normal in terms of perfection, but it is very common. Even people who aren’t perfect can live a long and happy life.”

“So you’re saying I shouldn’t worry?”

“Not about your GFR specifically. Remember to be kind to your kidneys, like we have talked about.”

She nodded.

“Now, here’s the bad news”, I explained. “People with even mild kidney disease statistically are more likely to have heart attacks, strokes and other cardiovascular problems.”

She started to raise her eyebrows, and I hurried to continue:

“But, and this is important: I’m not smart enough to know what’s the chicken and what’s the egg. Do they have kidney disease because they have hardening of the arteries everywhere, or does the kidney disease itself cause it to happen?”

I continued:

“So we do the usual things – good diet, cholesterol, blood pressure. And we don’t just focus on the GFR.”

“I can’t help worrying about the numbers”, Mrs. Jones said.

“There’s a name for that”, I told her. “We call it albuminurophobia.”

“Really?”

“Really. There is a medical term for just about everything these days.”

She shook her head.

“Now, about this mole”, I continued…

As I was reading along I registered the sound of the dogs snoring rhythmically nearby. My eyes glanced over my magazine’s headlines with words like guidelines, accountable care, pay-for-performance, evidence-based and quality.

I had just made the quiet observation that there are innumerable forces that create and use buzzwords like that when trying to tell front-line doctors like me how we should do our jobs without really thinking for ourselves when Emma broke the silence in our living room.

“This is really interesting”, she said. “The way clicker training works may be by stimulating the amygdala of animals, so they feel instant joy before they consciously become aware that the trainer approves of what they just did.”

I knew a fair amount about clicker training; Emma has been using it on our canine family members and I have seen it work wonders with our adolescent female German Shepherd.

“Isn’t it just a conditioned response like Pavlov’s bell?” I asked as I looked up from my journal.

“Well, some people seem to think the actual sound of the clicker may be a more direct way to stimulate the amygdala than other sounds or words people use in training.”

My eyes moved from my wife’s face, framed by her beautiful long brown hair, to her eyeglasses reflecting the light from her computer screen, to the stack of books next to her. Suddenly my mind jolted at the title of the book on top. For a split second I thought it said:

How to Clicker Train Your Doc 

Emma was back to reading her webpage. The dogs snored peacefully. My mind was spinning.

Physicians are not quite subjected to clicker training, but we are certainly recipients of signals that are aimed at our preconscious minds, if not our amygdalas. All those people and institutions that try to influence physicians’ behavior are trying to get into our minds below the radar of our critical thinking, just like advertisers work on all of us. They use feel-good messages that try to do what clicker training does to our pets – create new behaviors we would otherwise not pick up on our own.

But doesn’t it go deeper than that for most doctors? It seems to me we often make ourselves do things that run counter to our nature. We do what others say we are good at, even when there’s no one around to cheer us on – even when doing it is to our own ultimate detriment. We end up using our burnout skills because we have created our own conditioned responses.

I opened my own laptop and started reading about clicker training and the amygdala. Wikipedia gave me the following quote:

“Clicker–trained animals become great problem–solvers, develop confidence, and perform their work enthusiastically.”

Just like doctors…

From Latin morbus (disease), Ancient Greek iatros (doctor, healer), -genēs  (born) – similar to Latin genus (kin): Disease caused by the physician.

*

“There are some patients that we cannot help; there are none whom we cannot harm.”

Attributed to Arthur L Bloomfield

John Fernald in room 4 was clearly not right. He seemed drowsy, weak and disoriented and he had a low-grade temperature. His wife and I had to help him up on the exam table. His chief complaint was chills.

John was a tall man, generally very healthy. He had an enlarged prostate and took pills for his urinary frequency. Over the past eighteen months he had gone for a couple of PSA tests and they were steadily rising, but just barely over the upper limit for a man his age with a good size prostate gland.

Three days before, he had undergone a prostate biopsy by his very competent urologist at Cityside Hospital. John had received the usual antibiotics after the procedure, but he sure looked septic to me.

John said very little, but his wife, Zena, was in complete agreement with sending him over to the hospital for admission.

Across the hall in room 1, John’s contemporary and neighbor, Bill Boland, sat awkwardly in the exam room chair with an expression somewhere between pain and motion sickness.

He had a habit of always sassing me for knocking on the exam room door before entering. “Don’t knock, for Pete’s sake, it’s your room!” he usually yelled as I entered the room. Then, he would always stand up from his chair to greet me with a firm handshake.

“Pardon me if I don’t get up”, he moaned.

He was in my schedule for back pain.

“What happened to your back?” I asked.

“I have no idea. It’s been aching for a week now, and it’s just getting worse.”

“Any injury? Did you fall or lift anything heavy?”

“No, nothing.”

“Any pain or tingling down your legs?”

“Negative.”

“Do you feel better when you lie down?”

He shook his head. “No it aches the same…”

By that time I was worried. When a man in his age bracket has back pain, it is more likely to be something ominous than it is in a young or middle-aged person. The fact that his pain didn’t get better at rest was particularly disturbing.

I flipped through his chart. When was his last blood count, chemistry panel? Any risk factors for cancer? Had he had his screening tests for colon and prostate cancer? Nothing seemed unusual or less than up-to-date. In fact, he had just had a colonoscopy a month earlier by our top gastroenterologist to follow up on precancerous polyps removed three years before, and this time his scope had yielded two more polyps but no cancer.

On his physical exam I noted there was no pain when I tapped over his kidneys. Tapping on the lower spine caused him severe discomfort, but there was no muscle spasm or tenderness. He had drops of sweat on his forehead, but no fever.

I ordered bloodwork and an MRI. Autumn was able to get his MRI for the following afternoon. Bill and I agreed to touch base the next morning about his results.

John Fernald with his fever got settled into the hospital and Bill Boland with his back pain went to the pharmacy for some pain medication. I kept thinking about the two neighbors as my day continued.

Two days later, John was still in the hospital and on intravenous antibiotics. His blood cultures were positive and in all likelihood his blood poisoning was a direct complication to his prostate biopsy, which turned out to be negative for cancer.

Bill, my back pain patient, sounded uncomfortable when he answered the telephone. His bloodwork showed signs of inflammation and his MRI showed osteomyelitis of his lumbar spine. We arranged for admission to the hospital for blood cultures and intravenous antibiotics for him, too. I had never seen a bone infection develop as a complication from a colonoscopy before, but I had read about the possibility. Could this be what was going on with Bill?

That was almost three years ago. John Fernald’s PSA is a little higher than it was, but neither his urologist nor John are eager to go ahead with another biopsy. Bill Boland still has back pain, but it is mild and seems to get worse when he stands at the workbench in his shop too long. He has noticed some blood in his stool a few times lately and, technically, he is due for another colonoscopy.

“I’m not having one of those again, Doc, I’ll tell you that. You can’t tell me I got that spinal infection from anything else but that scope test!

John is now of the age when he is less likely to die from a newly diagnosed prostate cancer than something else like a heart attack or stroke. Bill faces a 2% ten-year-risk that any new precancerous colon polyp will turn into a cancer. And in ten years he’ll be 80 years old.

First, do no harm.

                      William Bodri

”So, you need a referral to a pulmonologist?”

“Yes, I’ve been to the University Health Center almost every month since August and they’re getting tired of seeing me there.”

“Did you have much trouble with your asthma when you were younger?”

Kaitlynn and her mother exchanged a quick glance and a mutual head shake. The young woman continued:

“No, they called it exercise-induced asthma then, and I just used an inhaler before sports.”

“And now you’re on Pro-Air, Claritin, Advair and Singulair?” She nodded yes to my rhetorical question as I finished my thought: “And you’re still miserable.”

I knew all she seemed to want from me was a pulmonology referral for when she got back to the University after break, but I was intrigued and I wanted to do a good job facilitating the consult.

“What’s your best and worst peak flow?”

“400 on a good day, 200 when I’m sick.”

“Did you ever have a chest x-ray?”

“Yes, the clinic sent me for one.”

“Do you know what it showed?”

“My lungs were too inflated, I think.”

“Are you exposed to cigarette smoke?”

“The guy I live with smokes, but not inside.”

“You have an apartment?”

“Yes.”

“Any pets?”

“Two cats.”

“Did you grow up with cats?”

“No.”

“Do you have wall to wall carpeting?”

“Yes.”

“Any mold problems?”

“I don’t think so.”

“Is there anything you think might be bothering your asthma?”

“Well, my best friend has a dog and I think I’m worse around the dog.”

I started my physical exam while continuing to ask Kaitlynn questions. I noticed the ‘allergic shiners’ under her eyes. Her nose was congested and she had coarse, sonorous rhonchi and higher-pitched wheezes in both lungs.

“Do you ever have heartburn?”

“Actually yes. I was diagnosed with a hiatal hernia when I was very little and there was some problem with my swallowing.”

I finished my exam and sat down across from Kaitlynn and her mother.

“I think definitely you need some testing”, I began. “You could have some other, rare, lung disease, but this is probably asthma. The question is what caused it to get worse. You could be allergic to your cats, because no amount of medication can stop you from reacting to your own cats who live in your apartment if you have a severe allergy to them.”

She looked down. I continued:

“You may have stomach acid going into your lungs while you sleep, or you could be aspirating small amounts of food or fluids and your lungs could be reacting to that. Or, maybe your childhood asthma just got worse – it sometimes does that in your age group.”

Mother and daughter were both nodding. I felt I had achieved a fair amount in just a few minutes. As my eyes met Kaitlynn’s, she looked amused. She turned toward her mother, who was almost grinning. I thought I must have really somehow impressed them with my quick analysis. I cleared my throat.

“Here’s my suggestion: Let’s get a blood test today to screen you for some common allergies like cat and dog, and let’s pick a pulmonologist near the University…”

Kaitlynn and her mother exchanged looks again.

“I already had a blood test. Doctor Freese did that the first time I saw him, but I haven’t heard the results yet.”

“Who is Doctor Freese? The Student Health doctor?”

“No, the lung specialist.”

I raised one eyebrow and squinted with the other eye.

“Have you already seen a lung specialist?”

“Yes, and he said the same thing you did”, Kaitlynn giggled.

I sighed.

“So you didn’t need me to refer you to a lung doctor – you needed an insurance referral, so his fee will be covered by your insurance…”

“That’s right. We thought you knew that.”

“I didn’t, but we’ll take care of it.”

The two of them got up from their chairs simultaneously, gave each other another bemused look and said good-bye as they left the room.

There I stood, watching them leave and thinking I had just spent some jing I could have used better somewhere else.

My first version of the previous post on this blog didn’t meet with her approval. She pointed out that my narrative sounded jaded and encouraged me to come back to it on a day when I was less tired. I gave the post a few days rest before revising it and felt better about the second version.

The other night, as I was describing a difficult day in the office with a schedule that didn’t make my job easy to do, she reflected:

“You treat your patients better than you treat your staff, or your family sometimes, for that matter”.

I looked up from my dinner plate. She wasn’t joking.

“You can be such a healing presence for your patients”, she said, “but you have a tendency to turn that off in dealing with the rest of us. You could be more healing in all your relationships”.

I thought of what she said. She was right, of course. I can be hard on myself and on those around me. I tend to think of us as working only for the patients or some abstract ideal of perfection rather than also with each other.

How many times have I simply told my wife or my children that their symptoms – sprains, migraines or bellyaches – will go away without offering a fraction of the support my regular patients get in the same situations? And how many times have I been less attentive to their worries and heartaches than I should have been?

I realize my loved ones get less care than they deserve, because “I already gave at the office”.

Do I really think I have a right to switch off my healing presence? I don’t mean that I or any other physician should try to work longer hours or take on more patients than we are able to take care of. What my wife made me think about is my whole way of being:

I always wanted to be a doctor. Now that I am one, I am a doctor every moment of my life. I am not a husband or a father or a pet owner just certain days or hours of my life. Neither one of those roles is “just a job”. Neither is being a doctor, particularly in specialties that profess to treat the whole person.

Obviously, I am still working at it. I’s my New Year’s resolution.

This time he was in my schedule with a concern about heel pain. “Plantar fasciitis”, I figured before I knocked on the exam room door.

“Hi there. I haven’t seen you in a while. How’s the heartburn?” I asked.

“Doing good, as long as I take my pills, but I can’t go without them very long.”

“Any trouble swallowing, cough, hoarseness or belly pain?”

“No, not at all.”

“Then, in your age bracket, as long as the pills work, we’d just tell you to keep taking them. Then, maybe at 50, we’d send you for a scope test. Now, today you’re here for some heel pain?”

Sure enough, he had the typical heel pain when he first started walking in the morning and he was worse those days at work when he had to do a lot of walking on concrete floors. His physical exam was consistent with the diagnosis, so I started explaining the mechanism behind his condition and the various things we can do for it – anti-inflammatory medication, ice, stretches, heel cups inside his work boots, ultrasound treatments and, the last resort, steroid injections.

I went to pick up my handout for plantar fasciitis and heel spurs and he agreed to a physical therapy referral. I entered the request into the electronic medical record.

“Why do my hands go numb at night?” he asked when I had finished typing.

“Both hands, all fingers?” I asked.

“Uh-um”, he nodded.

“Ever happen during the day?”

“Once in a while.”

“Any neck pain?”

“No.”

“Show me how far you can turn your neck each way.”

His range of motion was normal, as was the strength in his arms and hands. He had normal feeling in all fingers. Tinel’s and Phalen’s signs were negative – no sign of carpal tunnel syndrome – and Adson’s maneuver was negative – no sign of cervical ribs or any other impingement of the circulation to his arms. He did wince slightly as I pulled his right arm back, though.

“My shoulder’s been sore for years”, he explained.

“That wouldn’t explain both hands tingling, though”, I said. “I don’t think you have carpal tunnel syndrome, and it doesn’t look like a clear cut neck problem, although sometimes too thick a pillow can trigger this sort of thing. I think you have what we call acroparesthesias…”

“What do you think of this rash?” he interrupted, and exposed his neck and upper torso.

“That’s called Tinea Versicolor. It’s an infection that changes how the pigment in your skin behaves, We treat it with athlete’s foot creams, but then you have to tan a little to even out the color sometimes.”

“Oh, I can buy one of those creams over the counter, right?”

“Sure, any one of them. Leave it on for a good ten minutes, then wash it off. Do that once a day for a week.”

“Great.”

“So, for your heels, you’ve got the exercises, you can get the heel inserts, buy some naproxen. They’ll call you from physical therapy for an appointment. And – if all else fails – we can give you a shot.”

He winced.

“So, you and Beth have a good Christmas”, I said as I got up from my stool and reached my hand out towards him.

“You too, but what about my shoulder?”

I paused and glanced at the time; 22 minutes into his scheduled 15 minute visit.

“Well, that’s a whole other project. We’ve covered a lot of ground today already, and my next patient is waiting. We could order an x-ray and have you come back for a full evaluation of your shoulder if you’d like.”

“Never mind”, he said.

‘What are we to do with all this old rubbish by a man named Osler? He must have had very little to do to spoil so much paper. Where did he live anyway?’

‘Oh, I don’t know. Baltimore, I think. Any how they have a Hall there that bears his name.’

William Osler, 1909

Sir William Osler underestimated the influence he would have more than a hundred years after penning those words for the inauguration of Osler Hall. His oration was published in JAMA under the title “Old and New”.

His scientific discoveries and his method of teaching medicine at the bedside have lived on, and his words about being a physician still speak to doctors all over the world.

Thumbing through old books and reading online, I have found letters and speeches that could have been written specifically for doctors in my specialty, Primary Care, in 2011.

The other day my WordPress dashboard listed as one of the search terms that brought a visitor to A Country Doctor Writes “Holiday reflection by Sir William Osler”. That got me thinking: What would Sir William say to doctors like me today?

(Curiously, William Osler’s first published article, at age 20,  is said to have been one with a Christmas theme, “Christmas and the Microscope”, in Hardwicke’s Science-Gossip.)

Perhaps Sir William Osler would write something like this today (every phrase in black is quoted from his writings):

Christmas greetings to you all.

I hope everything is going well with you, the silent workers of the ranks, in villages and country districts, in the slums of our large cities, in the mining camps and factory towns, in the homes of the rich and in the hovels of the poor. To you is given the hard task of illustrating with your lives the Hippocratic standards of Learning, of Sagacity, of Humanity, and of Probity:

Of learning, that you may apply in your practice the best that is known in our art, and that with the increase in your knowledge there may be an increase in that priceless endowment of sagacity, so that to all, everywhere, skilled succour may come in the hour of need. Of a humanity, that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering, and broad charity to all. Of a probity, that will make you under all circumstances true to yourselves, true to your high calling, and true to your fellow man.

Each generation has its own problems to face, looks at truth from a special focus and does not see quite the same as any other.

In 1908 at Oxford William James made a remark that clung. ‘We live forward, we understand backwards. The philosophers tell us that there is no present, no now – the fleeting moment was as we try to catch it.’

The past is always with us, never to be escaped; it alone is enduring; but, amidst the changes and chances which succeed one another so rapidly in this life, we are apt to live too much for the present and too much in the future. It is good to hark back to the olden days and gratefully to recall the men whose labours in the past have made the present possible.

Hippocrates had a splendid paragraph in ‘Ancient Medicine’ on the attitude of mind towards men of the past: “We ought not to reject the ancient Art, as if it were not, and had not been properly founded, because it did not attain accuracy in all things, but rather, since it is capable of reaching to the greatest exactitude by reasoning, to receive it and admire its discoveries, made from a state of great ignorance, and as having been well made, and not from chance.’

Like a living organism, truth grows. Much of history is a record of the mishaps of truths which have struggled to the birth, only to die or else to wither in premature decay. Or the germ may be dormant for centuries, awaiting the fullness of time.

Read the classics of medicine, and also The Old and New Testament, Shakespeare, Don Quixote, Emerson, Oliver Wendell Holmes. The average, non-reading doctor might play a good game of golf or of bridge, but professionally he is a lost soul.

The love, hope, fear and faith that make humanity, and the elemental passions of the human heart, remain unchanged, and the secret of inspiration in any literature is the capacity to touch the cord that vibrates in a sympathy that knows nor time nor place.

For the general practitioner a well-used library is one of the few correctives of the premature senility which is so apt to overtake him. It is astonishing with how little reading a doctor can practise medicine, but it is not astonishing how badly he may do it.

With half an hour’s reading in bed every night as a steady practice, the busiest man can get a fair education before the plasma sets in the periganglionic spaces of his grey cortex.

Be patient. It has been said that “in patience ye shall win your souls,” and what is this patience but an equanimity which enables you to rise superior to the trials of life?

Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaint.

Respect the Psychical methods of cure. After all, faith is the great lever of life. Without it, man can do nothing. Faith is the aurum potabile, the touchstone of success in medicine. As Galen says, confidence and hope do more good than physic – “he cures most in whom most are confident.” While we doctors often overlook or are ignorant of our own faith-cures, we are just a wee bit too sensitive about those performed outside our ranks. In all ages the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. We physicians use this every day; without faith, we should be very badly off.

The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of influence.

In the words of Sir Thomas Browne, whose Religio Medici was the second book I ever bought:

“There is surely a piece of divinity in us, something that was before the elements, and owes no homage unto the sun.”

*

I hope this will reach you in time for Christmas. I think especially of you country doctors, members of the class ‘Hippocraticus Rusticus’.

Never has the outlook for the profession been brighter. Everywhere the physician is better trained and better equipped than he was fifty years ago. Disease is understood more thoroughly, studied more carefully and treated more skillfully. Diseases familiar to your fathers and grandfathers have disappeared, the death rate of others is falling to the vanishing point, and public health measures have lessened the sorrows and brightened the lives of millions.

The vagaries and whims, lay and medical, may neither have diminished in number nor lessened in their capacity to distress the faint-hearted who do not appreciate that to the end of time people must imagine vain things, but they are dwarfed by comparison with the colossal advances of the past century.

So vast and composite has the profession become that the real dangers and evils that threaten harmony among you are internal, not external. Yet, no other profession can boast of the same unbroken continuity of methods and ideals. We may indeed be justly proud of our apostolic succession.

Your profession in truth is a sort of guild or brotherhood, any member of which in any part of the world can find brethren whose language and methods and whose aims and ways are identical to his own.

I wish all of you the best for this Holiday.

Affectionately yours,

W. O.

Sources:

1.) Aequanimitas, Sir William Osler, P. Blakiston’s Son & Co., 1904

2.) The Evolution of Modern Medicine, by Dr. William Osler, (Originally published 1913), Kaplan Classics of Medicine, 2009

3.) Sir William Osler By Harvey Cushing, Oxford University Press, 1925

She had been hospitalized twice, once for a “breakdown” in her forties, and again about ten years ago for what sounded like a manic episode. Since then she had been on several mood stabilizers and a few antidepressants. When her old psychiatrist, Dr. Andrews, left the area, she stopped her medications.

Several months ago, she came to see me about her nerves. She was anxious and depressed, and on top of it was exhibiting symptoms of mild dementia.

My usual armamentarium of medications for someone like her proved useless, and I had finally convinced her she needed a psychiatric reevaluation. After the first month of waiting to hear back from RPA’s appointment staff I decided to put in for a Prior Authorization from Wellcare, her Medicare D prescription insurer, for a more expensive agent for refractory and bipolar depression.

My heart sank when I saw her name in my schedule this morning. There had been no word from Rural Psychiatric Associates and there, right in front inside her paper chart, was the fax we sent off to Wellcare more than a month ago. There was no indication of any reply in her chart. I searched our new electronic medical record. She had no clinical notes in it yet, nothing about any response from Wellcare, and there was nothing in the referral module about a psychiatric appointment.

I checked the time – five minutes into her allotted fifteen minute visit. I called Wellcare with some trepidation. This was likely to take time, but I felt I owed Mrs. Carignan this, since the system – actually three different systems – had failed her.

After only a minute or two on hold I told Wellcare’s customer service representative my errand:

“I am a physician. I faxed you a coverage request more than a month ago and have not had any response yet.”

She politely promised to put me in touch with someone who would be able to help me.

Two minutes later, a young man with a heavy accent offered to help me. I had to spell Mrs. Carignan’s name twice, and he double-checked her birthdate and policy number. He put me on hold and I listened to the same music I had already become familiar with.

“I apologize, Doctor, could you give me your patient’s birthdate and policy number again”, the young man said. I obliged, and he excused himself again. I glanced at the clock above my desk. Five minutes left of her visit, I noted with more than a little concern that I might not be able to do much for her today.

“I am sorry, Doctor, we have a client with the same name, different spelling and not quite the same birth date”, the young man announced when he finally came back on the line.

“This is her Social Security number…”, I offered.

“Let me look her up that way, then, Doctor. Would you mind holding for just one minute?”

I looked at the clock again. Two minutes left.

“Thanks for holding, Sir. I am sorry but we have no client with that Social Security number.”

“I see”, I said. “Well, I have already spent her entire appointment speaking with you on the phone. Thank you very much for looking into this. Good-bye.”

I grabbed her paper chart and my laptop and entered Room 1.

“I’m sorry to keep you waiting, Mrs. Carignan. I have just spent the last fifteen minutes talking to Wellcare, your prescription insurance, about that medication I wanted to prescribe for you. They claim they never heard of you.

“But I’ve been with them for years.”

“Let me call your pharmacy”, I said as I pulled out my cell phone.

A minute later Sandy, the new pharmacist at Williams’ Rexall answered my question:

“Wellcare is paying us just fine for her medications, but the policy number we have is different. It’s 596 0059.”

I wrote down the number, wondering when I would ever get the time to call them back.

Opening my laptop, I said:

“So we have no word from the psychiatry office and your insurance company don’t know who you are.”

She looked puzzled.

“Should I go on taking this”, she asked, reaching into her zippered toiletry bag with all her pill bottles. She produced a small bottle with an antidepressant I had not prescribed for her.

The name of the doctor on the bottle was Mary Meyerer, the new chief at Rural Psychiatric Associates. The fill-date of the prescription was almost three weeks ago.

“Oh, you did get an appointment with the psychiatrist!”

“Yes, and I’m going back next week again…”

“Great. I’m glad you finally got an appointment. You see, some specialists, particularly psychiatrists, don’t tell us when they make an appointment for someone we refer to them.”

“That seems silly…”

“Well, yes.” I paused. “At least you got in.” Looking quickly through her chart I added:

“I see it’s been a while since you had your bloodwork done for your cholesterol. Let me put an order in the computer for that…”

The task bar on my laptop informed me that I was 30 minutes behind, with two patients waiting in exam rooms and a third in the waiting room.

Looking back through her record, I came across a mildly elevated ammonia level a few months ago. I remember speaking with her psychiatrist back then about Elsa and a couple of other patients we share, whose routine ammonia levels were mildly elevated. Elsa had a standing order from the psychiatrist for ammonia levels every three months because of her valproic acid (Depakote) prescription for her mood disorder.

All my research has led me to the conclusion that ammonia levels are of little or no value in predicting whether patients on valproic acid are headed for trouble due to the drug’s unpredictable tendency to cause ammonia to build up within the central nervous system. I have come to understand that ammonia levels are only slightly helpful even in assessing a patient with coma or near coma; the correlation between brain levels and peripheral blood levels of the toxic ammonia relate poorly to each other because of how the blood-brain barrier works to keep the chemistries inside and outside the central nervous system separate. Many experts recommend against routine measurements of ammonia levels for this reason.

Watching Elsa fumble her way down the hall, I decided to order an ammonia level “just in case”. It came back elevated – twice as high as it had been ten weeks ago. Her liver function tests were normal.

I ordered her valproic acid stopped and made sure her psychiatrist got a copy of the lab report and my notes.

This week, Elsa is finally walking straight. She is attending her day program, says “good morning”, makes good eye contact and smiles. She also shows more of a temper, but nothing inappropriate.

Maybe this time I finally got it right.

“Sounds reasonable”, I answered. Let me look at her chart.” Elsa is on valproic acid as a mood stabilizer and sees her psychiatrist every three months. Her drug level was just about due to be checked, so I ordered a fresh set of labwork and decreased the dose of her long-acting insulin.

We continued our stand-up rounds, going through dozens of reports and issues on the many residents who were not scheduled to be seen that day. I then did two admissions and saw a couple of patients for their scheduled visits.

The next time I went to the boarding home, I checked on the results of Elsa’s blood tests and reviewed her blood sugar log. Everything was well within range.

“How is she doing?” I asked.

“The girls still find her a little off balance now and then, especially in the morning.”

“Tell me again how long this has been going on…”

“Probably a month or a month and a half.”

“Any urinary symptoms? Anything else going on?” I flipped through the chart again. My eyes fell on some insurance paperwork. There, two months ago was a rejection letter for a Prior Authorization request for a brand-name drug Elsa had been taking for urinary frequency.

“Well, she’s incontinent sometimes, but that’s not new, and she has no dysuria. But we did have to switch her to that generic drug for her urine two months ago”, the charge nurse answered.

“Well, if she’s still incontinent, let’s stop the pill, because that could cause her to be dizzy”, I said, “so let me write the order for that.”

Yesterday I stopped in at the boarding home again to speak with the family of one of my patients. While standing at the nurses’ station I happened to see Elsa coming down the hall with her walker.

With every step Elsa took, she and the walker veered more and more to the right until she came to a stop with the right front wheel against the wall. She then lifted the walker toward the middle of the corridor and started walking again. Eight or ten steps later, she was back against the wall. She stopped and lifted the aluminum walker toward the middle of the corridor again and repeated the same procedure.

“Look”, I whispered to the nurse.

We watched as Elsa repeated her zigzag veer and correction half a dozen times until she came to the TV room half way down the hall. After she settled into her chair, I asked to borrow her walker. She seemed bemused.

I picked it up and spun the wheels, which rolled without any apparent resistance. I checked the length of its four legs and the tightness of all its bolts.

“Let me just take it for a spin”, I said. Elsa grinned as I started walking.

The moment I put even the slightest pressure over the front wheels, the walker started turning towards my right. I hit the wall just as fast as Elsa had. She giggled. The nurse sighed with her hands on her hips.

“Let’s get you a new walker!” I said as I returned the defective unit to Elsa. She smiled and nodded.

I didn’t know whether to feel good or bad about my diagnosis. It had taken more than two weeks, but really only took a minute to arrive at once I got on the right course.