Not on a Silver Platter

The clues are usually there, even in the hardest of cases. They just aren’t presented to you on a silver platter.

Gwen Stephenson had an ill-defined polyarthritis and had been on methotrexate for some time. Her rheumatologist, Norm Fahler, had tapered her off the medication while keeping an eye on her inflammatory markers and they had leveled off at just above the normal range.

Seven or eight years ago, Gwen had suffered a bad bout of sciatica, and a few weeks ago, she had told me her sciatica was bothering her a little again. “Not enough to have those injections yet, mind you”, she had said with a grimace and a gesture indicating the length of the needle her pain specialist had used to deposit the steroid in her lumbar epidural space.

The visit when she mentioned her sciatica was a diabetes visit, full of bookkeeping tasks – keeping track of her eye exam, foot exam, microalbumen, blood pressure readings, blood sugar log, lipid management and cardiovascular review of systems.

I accepted her assessment that her sciatica was not of the magnitude that it required any immediate intervention.

After Gwen left, Autumn came into my office to pick up some forms I had signed, and she said:

“Did you notice that Gwen’s temperature was 99 for the second time in a row? I wasn’t sure if I should have pointed that out to you.”

I had not noticed it. Looking back, I saw that a week earlier, when she had come in just for her B-12 shot, it had also been 99.

“I’m not sure if that means anything”, I remember saying.

Two days later, Gwen came in with a nasty cough and I thought I could hear some very faint rales in her lower left lung. Her temp was 99.4 and I put her on antibiotics for pneumonia. We didn’t have X-ray available that day, but it was obvious at that time she needed an antibiotic.

The following evening I was on call. Gwen phoned the answering service around 9 pm and asked if an axillary temperature of 103 was high enough to be alarming. She hadn’t been able to take an oral temperature because her teeth were chattering with the terrible chills she was having.

She was admitted to the hospital, where intravenous antibiotics were started for her apparent pneumonia. Her fever didn’t come down, and the radiologist disagreed with the initial emergency room reading of her chest X-ray. So she became a “fever of unknown origin”. The blood cultures that were drawn in the emergency room grew staphylococci, and, because her back pain kept getting worse as she lay in bed day after day, she had an MRI of her lumbar spine. This showed a possible discitis at L5-S1 and a psoas abscess.

They teach you in medical school that early imaging isn’t indicted with back pain or sciatica, unless there are “red flag symptoms”. Fever is one of them. But Gwen’s back pain was recurrent, and had been there for a while, and her fever was borderline when I saw her, and it developed after the back pain. Still, I was quite humbled. I wasn’t actively connecting all the dots, and I was too focused on the housekeeping tasks of her diabetes care to see the subtle manifestations of her smoldering infection.

Art and Archetypes in Medicine

The cognitive part of the practice of medicine spans between two extremes, from registering and recognizing the most minute nuances of human and biological expression to seeing the overarching big picture of complex constellations of details.

Like the arts of painting and photography, it requires us to see both the unique and the universal in the most ordinary manifestations of everyday human life. But instead of capturing with imaging tools what we see and perceive, we turn those impressions and observations into the understanding and interventions we call diagnosis and treatment.

The art of medicine involves both technical mastery of treatment and the carefully honed ability to register, analyze and evaluate a vast array of what we might call data. While there is still respect for masterful treatment, perhaps especially when it is of a technical or procedural nature, there is growing disdain and disrespect for what we used to call clinical judgement. In picking stocks, web design, marketing and many other human endeavors, experience seems to have retained or even expanded its value, but in medicine it is often downplayed or even ridiculed.

Non-physician healthcare thinkers have evangelically big hopes for “data”, entered into medical office computers by fallible, disillusioned (think “Meaningful Use”) and distracted humans and new generations of “connected” medical instruments, and analyzed by centralized computers at Medicare, research institutions or big insurance companies. The vision is that more data will unlock the hidden potential for economies of scale and unseen patterns of disease, and generate vastly improved accuracy and efficiency of diagnosis and treatment.

But more data doesn’t always lead to better insights. Borrowing from other arts, a well-written poem can sometimes convey to the reader as much as a novel. And the weight of each piece of “data” isn’t the same to an experienced physician as it is to a computer. Humans in the healing arts can do the work of a recording device, a lie detector, a microprocessor, a translator, a judge, a pastor and a teacher.

In real therapeutic encounters, the agenda is not always the stated one, the given history isn’t always accurate and the clinical exam isn’t always typical or even relevant; sometimes the physician gives more weight to the unspoken clues in a case, something a computer isn’t likely to do.

Even our definition of disease lends itself poorly to interpretation and intervention guided by a computer. Examples are obesity, diabetes and chronic back pain. The measurable parameters of these conditions, biometrics, average laboratory values or pain rating scales, tell little about what role the disease plays in the patient’s life. And, unlike routine cases of pneumonia or step throat, sometimes the disease defines the person across a whole lifetime, and takes on archetypal meaning. Just talking numbers isn’t likely to change the manifestations of such conditions. Only going to the depths of the subconscious can alter the trajectory in most such cases. It would be naive to think that computers can do anything for such patients. Only a human with considerable skill and wisdom can penetrate the layers surrounding the core of these conditions.

The art of medicine is making the connections on a personal, case-by-case level with the archetypes that most of us relate to on some level, but which almost never exist in the physical realm. But they exist in the inner lives of all of us, as heroes and villains, as our inner children, older selves, and better or worse incarnations of our own spirits.

Classic disease presentations are like archetypes; we look for them all the time, and we think we see glimpses of them, but we seldom see the true personification of them.

And, the most important archetypes of all in the realm of medicine, the Patient and the Healer, hover in the air above us in every clinic room, hospital ward and nursing home. Patients enter the therapeutic encounter with ancient perceptions of what healers can or should do for them, and providers have visions of how patients should behave; we fill these roles for each other in the slowly evolving ritual we call healthcare.

It is probably terribly inefficient, but modern life generally is; we are not machines, but an ancient species with stone age reflexes in a postmodern society.

Husbands and Wives

When a wife suddenly comes in for her husband’s appointment, I usually worry a little; when a husband shows up for his wife’s visit, I sometimes worry a lot.

I have come to expect that when I enter an exam room and a male patient has his wife with him in the room, she is there to make sure I hear some part of his symptom history that he has never told me before.

It may be vague chest pains after splitting wood, snoring and interrupted nighttime breathing, excruciating headaches or profound and worrisome memory lapses. Men can be minimizers when it comes to bodily symptoms, and women end up being the designated worriers in many families.

Sometimes, the wives talk about their husbands during their own appointments, and I can listen, but I can’t usually say much. Even if spouses have given me permission to share their medical information, the foundation of medical diagnosis and treatment is the exchange and relationship between doctor and patient.

Not infrequently, wives ask me to speak to their husbands about something without letting them know who put me up to it. That can be a difficult request to honor, but sometimes I know I am in a unique position to turn a bad situation around.

Concerns about things like problem drinking are easy to handle, as we are expected to screen for those sorts of things anyway. Less straightforward is the angry and irritable husband who himself denies any psychological symptoms when I screen him for depression in the office. Not long ago, such a husband admitted to insomnia and feeling some stress but denied that it affected his mood or behavior. I treated his insomnia with an antidepressant that is commonly used for insomnia, rather than a straight sleeping pill. He was pleased with how the medicine worked, and his wife was very grateful when she told me he wasn’t just sleeping better, but he also wasn’t tense or edgy anymore.

One request I get periodically is from wives of recently retired husbands to help get the men to stop following them around, questioning and offering helpful advice about everything the wife used to do without the husband’s interference all the years he was working. “Please tell him to get a hobby or something“, is a plea I have heard more than once. In that kind of situation I offer what sounds like generic advice I might give to anybody in that particular stage of life.

Two things about wives’ visits worry me.

The first thing is the wives who come in numerous times with multitudes of concerns. Usually the underlying problem is somatization and anxiety, which can often be very difficult conditions to make better, but sometimes the source of the psychosomatic symptoms or anxiety is a bad or abusive marriage that the patient may or may not be admitting, even to herself.

Sometimes the frequent return visits of wives, or in some cases mothers with children, are acts of self-protection in situations of domestic abuse. By going to the doctor’s office often, abused wives sometimes create a measure of relative safety by indirectly letting her husband know that there is someone who will notice if she is distraught from emotional abuse or if she has a bruise or any other visible sign of physical abuse.

The second worrisome type of wife visit is when the husband starts coming in. Unlike the wives who add to their husbands’ medical history, a lot of men who come in for their wives visits sit quietly and just listen. That raises the possibility that instead of being there out of concern for her health, he could be there to discourage her from revealing anything about a bad or abusive relationship.

Nobody wants to be paranoid, but as members of a healing profession, our mission is not only to prevent and treat disease, but also to prevent and relieve suffering when we have the opportunity to do so.

One in four women in this country will experience domestic abuse in her lifetime, which makes this a true epidemic, almost as prevalent as obesity. Are we physicians considering it in our differential diagnosis often enough?

The Reinvented Wheel, Now Square

Twenty years ago, I changed the name and focus of the “annual physical” I offered my patients. I designed a new form on my laptop with Geoworks, my favorite DOS-based (pre-Windows) desktop publishing program, and rolled out my “Annual Health Review”.

I explained to patients that many of the things we used to do in routine physicals every year had proven to be of little value, but there were more and more screening and preventive services we simply needed to talk about. It was also a time to do a thorough review of systems, and to update the family history.

When patients started talking about sore knees, allergies or frequent urination, I would try to gently steer the conversation by saying something like “those are things we can look into some time, but today I’d like to focus on the big health issues that could kill you”.

This approach was generally well accepted, and my homemade form made documentation quick and efficient. As the years went by, and as guidelines changed, some things disappeared from my routine. For example, screening or baseline EKGs were proven to be of little value, and I also stopped doing visual screenings on adults, because I wanted them to go to an eye doctor to get their intraocular pressure checked. My own Schiotz tonometer had become a veritable museum piece as it is so much more awkward for patients than modern tonometers.

I never did have a set of routine blood tests for a routine physical. Even when PSA testing for prostate cancer screening was de rigueur, I reasoned “this is America, and nobody has to do anything; who am I to boss people around by requiring that they have certain tests?” Ordering blood test was something I always did with the patient’s informed consent. Even with cholesterol, I always had plenty of patients who felt they had a healthy lifestyle and simply didn’t want to know what their cholesterol was.

I talked with patients about diet, alcohol, seat belts and all kinds of lifestyle issues. But I didn’t screen for things we essentially cannot treat, like early dementia. In our annual conversations, I usually got a good sense of who was high-tech in terms of wanting “everything done” in case of a cardiorespiratory arrest, but I admit I wasn’t quite systematic in collecting Advance Directives.

Of course, my Annual Health Review was not covered by Medicare, since it was perhaps technically a physical. But Medicare did pay for long visits where three or four chronic health conditions, even stable ones, were reviewed, so sometimes it was possible to add the Annual at no charge to a chronic care visit.

The other doctors in my practice used the same form, but I know each one carried a slightly different conversation with their patients. This visit was in the hands of my colleagues a reflection of each one’s style and of their patients’ preference. Dr. A ordered a few more blood tests, Dr. B recommended vitamins and supplements, and Dr. C promoted exercise with more passion than I did, and so on. These differences caused patients to gravitate to the one doctor among us that resonated most with their own ideas. This was personalized health care before patient-centeredness became formalized and formulaic.

All of us were pretty comfortable with our combined physical and health review visits.

Fast forward twenty years.

Today, under the new world order, doctors are mandated to perform Annual Wellness Visits on their Medicare patients, but not according to their own best efforts or their patients stated preference – one item missed or omitted out of deference to conflicting guidelines or common sense, like the kindergarten-style visual exam for new Medicare beneficiaries in their first six months of coverage, and no payment is collected. And similarly, check a few basic things like lung or heart sounds, the presence of leg edema or skin cancer, and the free insurance benefit is forfeited.

What was a naturally evolved focused physical combined with an individualized health risk assessment has been replaced by a tightly scripted no-touch session that leaves many doctors and most patients confused and bemused.

This new “Annual” feels like an administratively reinvented wheel, downright square and not rolling very well at all, at least on the roads where I travel.

A Sore Thumb

It started with a sore thumb and ended with a lifetime of medication. In between there was an emergency room visit at one small hospital, an ambulance transfer to a big hospital, a Medevac flight to Massachusetts General Hospital, multiple invasive procedures and a diagnosis of an often lethal condition. And I was not the one who made that diagnosis.

Paul Allard had developed severe heartburn and indigestion earlier this fall, and had just recovered from a bout of wrist pain when I saw him a month ago. The pain and swelling had been there for a week or so, did not seem to be caused by any trauma or overexertion. It had cleared up after just three days of prednisone, and his rheumatology blood profile was completely negative.

This time, Paul had a pain along half of his left thumb and in the web space between his thumb and his index finger. It was sharp, burning and persistent.

As I asked all kinds of questions and checked his hand strength, skin temperature, monofilament and temperature sensation, arm strength, neck movements, axillary and supraclavicular lymph nodes, Paul clearly seemed uncomfortable. His partner, who usually seemed a little disinterested in Paul’s medical concerns, was leaning forward in his chair watching our exchange and my exam intently.

“I’m not sure what’s going on”, I said to the two men. “It could be something arthritic, like that episode of wrist pain, or maybe some type of vascular inflammation in a very small vein or even one of the four arteries that supply the thumb, but it could also be a pinched nerve, especially because it involves the space between the thumb and index finger.”

I suggested that Paul finish the course of prednisone he had been able to stop early when his wrist pain resolved. Paul and John agreed and we set up a five day followup.

That was Friday. Monday morning, my inbox had the next several installments of the story:

Late Friday night Paul suddenly developed nausea, severe abdominal and left flank pain, and went to our small hospital emergency room. They did a CT scan of his abdomen, which showed an infarction of his left kidney. When that happens, the cause is usually a blood clot, so they transferred him to Cityside Hospital for evaluation by the vascular surgeons.

A CT angiogram showed a large clot in Paul’s thoracic aorta. He was started on a heparin drip and airlifted to Boston. There, they didn’t see a clot in the thoracic aborts, but it had apparently just moved down to his abdomen. The clot was removed surgically, and while his kidney showed signs of recovery, and several specialists were working out his diagnosis, his left lung suddenly filled with blood. He had three quarts of blood drained through two chest tubes and was finally allowed to return to Maine with a diagnosis that explained what had happened and committed him to a lifetime of warfarin to prevent future blood clots.

“So, you have Lupus Antigen”, I said, rhetorically. “But they didn’t think that you have lupus?”

“Right”, Paul and John answered in unison.

“Sure, the wrist pain could have been something else. What did they think of the thumb pain, a small embolus in one of the four little arteries that supply the thumb?”

“They weren’t sure”, Paul answered.

“Who would have known…”, was all I could say.

“He could have died, they told us”, John said.

“Most people with this kind of clot do”, Paul filled in.

I half shook, half nodded my head as I punched in Paul’s warfarin dosing order in the computer. I thought, not for the first time, about how you see things on the front lines of medicine that turn out to be the first sign of a condition that other colleagues diagnose hours, days or even weeks later, as symptoms evolve and the clinical picture comes into clearer focus. It is a humbling experience.

It has been said about the Lupus Antibody Syndrome’s sister condition, “If you know lupus, you know medicine”.

It’s Time We Stop Comparing Health Care to Manufacturing

From ancient times, doctors have appreciated that, for all their similarities, no two patients are exactly alike. This understanding is what made physicians act like, and earn society’s respect as, professionals.

The commercialization of health care has brought in managers from other industries and other branches of academia, and their rise to power has been predicated on their ability to treat patients and doctors not as individuals, but as small cogs in the new health care industry.

There is no doubt that healthcare today is an industry, but I disagree with the notion that it can be closely compared with manufacturing.

In manufacturing, every aspect of production is built around standardized processes and standardized raw materials. But in health care, the “raw materials”, people with illnesses and risk factors we doctors seek to mitigate, are all different. And the processes often involve judgement calls and compromises between different objectives when patients have more than one disease.

Compare this to two types of carpentry:

Some carpenters build houses on empty plots of land, according to detailed architectural drawings, using standard sized lumber, creating homes that are identical, square and uniform. Novice carpenters learn relatively quickly how to build such homes, because the manufacturing process is consistent and predictable from one brand new home to the next.

Healthcare is more like old-house restoration than manufacturing. Put another way, real patients are more like old houses than new tract homes.

I have recently had reason to watch a master carpenter and a master painter turn a 1790 house and barn from a neglected near-dilapidated state into an inviting and comfortable home. Almost everything these two craftsmen did was improvised. Every flaw or asymmetry they tackled inevitably lead to another one that could not have been anticipated, let alone described with enough detail in architectural drawings or engineering diagrams for someone without decades of experience to tackle. Every decision these men made almost automatically and with little fanfare was a judgement call or an impromptu recreation of some antique detail; the carpenter chose lines to work from so that the house seemed straighter to the eye than if he had followed his level, and the painter filled gaps in the antique moldings with joint compound in a way that made the house seem tidy and whole but still showing its age.

When restoring a 200 year old house, there are no perfect squares or true plumb lines. The walls are never even and the floors are never level. But that doesn’t make such a house less livable, or less beautiful. It adds to its value. Manufacturing principles don’t apply when you set out to restore an old house, and the same holds true in holistic primary health care. Putting new drywall over a wavy plaster and lath wall is quicker than preparing the original surface for fresh paint, but the result breathes life and history into spaces that are now ready to live on with renewed purpose and dignity.

In medicine, whether it is doing plastic surgery, treating aging patients with three or four chronic medical conditions or counseling a patient facing life-changing circumstances, the manufacturing model can only cover the most rudimentary basics. It is the skill and experience of the practitioner in balancing all the variable manifestations of disease in real people that makes their treatment a source of healing.

Even the most predictable patient care processes, like taking out somebody’s appendix, don’t quite lend themselves to the manufacturing analogy. In medicine, the first step is not how to begin to remove the appendix; it is making the decision whether to do it in the first place. That isn’t always a straightforward, scientific decision, even with today’s imaging tests. It sometimes comes down to a judgement call here, too.


“The last thing Edward did was bring in the groceries from the car. I saw the perspiration rolling off his forehead and I heard him moan, but he didn’t stop to rest. I should have told him to come inside and sit down for a while. The next morning, he was gone”, an eighty-two year old widow said to me the other day in a voice filled with the pain of a secret guilt she had harbored for almost a year.

I stretched my hands out toward her and she put her thin, arthritic hands in mine. I held them gently, careful not to squeeze so hard that I might cause her pain.

“Oh, Mary”, I said, “Edward had hardening of the arteries everywhere in his body. He could have had a heart attack many, many years ago if you hadn’t gotten him to quit smoking when you did twenty years ago.”

Her hands returned my gentle squeeze and she smiled faintly as the tears streamed down her furrowed cheeks.

Today, as I familiarized myself with the medical history of a delightful little preschooler, her forty-something mother blamed herself for the little girl’s speech delays. “With my husband’s first losing his job when the mill closed, and then having a stroke less than a year after that, I just wasn’t there for Hayley to nurture her the way I should have”, she said as her eyes turned red and her voice grew faint.

“Look at this wonderful little girl”, I said. “See how she waits for her turn to speak and see how engaging she is with Autumn and me, even though she’s never been to our office before. She exudes a sort of gentle confidence that comes from being loved and cared for. It seems to me you have done a wonderful job with her, in spite of all the challenges you’ve had to deal with.”

“Thank you”, she whispered as she bit her lip, turned her head toward the ceiling and closed her eyes.

I am often reminded of the power of a physician’s words and the role our patients put us in of advisers in matters that go beyond diagnosing and treating illness.

A doctor, as the word “docere” was originally used, is a scholar and teacher, and the office we hold in the conscious or subconscious minds of many patients is like that of a priest or a judge.

We need to be aware of how a single, careless word or even our body language can hurt or undermine a patient’s hope or confidence. And we need to use our words and the authority some of our patients grant us as a kind of surgical instrument that can cut away festering doubts, fears or guilt. We have the power to ease suffering by wisely accepting and judiciously exercising that power. It is our responsibility to use it when that is what our patients need.

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© A Country Doctor Writes 2008-2015. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.

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