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.

The Legend of the Avoidable Hospital Readmission

A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well.

Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a Very Big Business.

In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper or perhaps merely a gleam in your father’s eyes, Medicare and Big Insurance started collecting premiums from workers and dole it out to hospitals when the workers or retirees needed hospital care.

At that point, hospital fees became confusing. The people who received care didn’t see what the charges were, and the payers didn’t really know how much care was medically necessary or even actually delivered by the increasingly profit-driven hospitals, let alone how much it cost to provide those services.

Insurers demanded deep discounts, and hospitals raised charges. Billing became more and more convoluted and required more hospital documentation and more business staff at both the hospitals and the insurers.

When an aspirin became as expensive as a four course meal and an overnight hospital stay became more expensive than the monthly lease payment for a Bentley, Medicare thought they had figured out a way to outsmart the hospitals: They started paying a flat rate for each hospital stay, based on the diagnosis. Suddenly, the hospitals were penalized if patients stayed longer or required more procedures or more aspirins than the average case.

That’s when patients no longer got to stay until they were well. People were discharged home at five o’clock on Friday afternoons, only partway cleared of their symptoms, with promises of a visiting nurse the following week and instructions to call their family doctor first thing Monday morning for an appointment.

A few years went by, and Medicare realized patients often ended up back in the hospital shortly after their discharge. Hospitals, of course, got to bill twice for each such episode and Medicare was obligated to pay the hospitals twice – not what they had expected would happen.

Medicare’s next move came swiftly: They didn’t retreat and say “we were wrong, keep patients in the hospital until they are well enough to go home”. Instead, they announced they would penalize hospitals if patients with certain hot button diagnoses got readmitted within thirty days of discharge.

This was an ingenious move on Medicare’s part. They are now imposing this penalty not just for patients who were sent home before they were stable, but also for patients who have severe chronic or near-terminal illnesses. For these patients, even the best possible prognosis is multiple admissions or a lengthy stay until they die. Medicare is now forcing the hospitals to spend more money than they receive during each such hospitalization, and, through the penalties, Medicare is giving itself a rebate every time one of these chronically ill patients gets readmitted appropriately, weeks after any shortcomings in the initial care would have been compensated for by the follow-up care or the passage of time.

Today, Medicare is looking outside the hospital wards for a happy ending to this situation. They are starting to spend money (presumably the money they are taking away from the hospitals) paying primary care practices for reaching out to patients immediately after they come home from the hospital in order to identify gaps in care and plan for follow-up visits. We are now becoming more and more involved with the social and economic barriers to health.

So the legend continues to evolve. But, like all legends, it is only partly true: Hospital care doesn’t cure everyone or everything. Primary care practices and their new partners – Community Care Teams and all the other agencies they network with – can only do so much to help patients overcome the obstacles that our society as a whole cannot remedy. And as primary care practices shoulder more and more chronic disease management responsibilities, even with some extra money thrown in, will we be able to also provide the timely urgent medical care our patients need in order to stay out of the Emergency Department and the hospital?

A Black Hole

Theresa arrived in a cloud of noise and commotion.

She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic.

Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart and a couple of other stores, slinging her big handbag over her shoulder, opening it to pull out her wallet, stuff receipts and her reading glasses away and fumble for her asthma inhaler.

In my exam room she repeated her story and demonstrated how she had held the bag open, pulled things out of it and then put them back in, and then realizing that her two pill bottles were missing. She proceeded to also show me how she rummaged around for the pill bottles and even emptied the large, brown bag with its purple lining.

In a loud voice and with oversized gestures, she replayed every conversation she had had about her missing pill bottles with store clerks, her girlfriend and her pharmacist in the last thirty six hours.

I sighed. Theresa had a small amount of pain pills on hand, which she could safely go without, but she was one of those patients who had seemed stable and truly helped by her long-term alprazolam. This was endorsed for selected patients at the psychopharmacology courses I had attended in Boston many years ago, but it has now fallen out of fashion.

“Well, Theresa, you know these controlled substance agreements you’ve had to sign always say that lost or stolen medications will not be replaced”, I said.

“But this has never happened to me before.” Her voice was as shaky as her large, bony hands. “I’ve been on alprazolam for years, what happens if I stop it suddenly? I took my last pill last night, one I had saved in my nightstand.”

“You’re right. Stopping alprazolam suddenly can actually be risky”, I agreed. “Here’s what I can do: I can give you half your usual dose, in weekly refills that you will have to pay for yourself, and I’ll see you back every Wednesday until your next regular prescription is due. Then we can assess how you’re doing.”


I entered the new dose in the computer and clicked with my trackball on the “print” button. I doubted that Theresa was trying to scam me with diversion or addiction, but rules were rules. Obviously, I didn’t want risk withdrawal seizures.

Later that night I thought about Theresa again. I couldn’t completely ignore a slight shade of doubt. Was she becoming addicted or irresponsible with her medication? A mental black hole lay open but I resisted falling into it.

The next day, I heard Theresa’s resonant voice again, talking with Autumn somewhere down the hall. A short while later, Autumn appeared at my door. In her hand she held three pill bottles.

“Remember Theresa’s missing pill bottles?”

Without waiting for my answer, she continued:

“Well she was just here with that big handbag of hers. She lost her cell phone last night, so she emptied out her whole bag again and found a five inch hole in the lining. There, between the lining and the outer shell, was her cell phone, her two pill bottles and one of her spare pairs of reading glasses!”

The black hole was real, I thought, not in my mind, but in that big handbag of hers.

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