Needed: More Small-Town Doctors

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It was a rainy day on the island of Kauai. Sunbathing was not an option, and neither was swimming or snorkeling. The ocean water’s typical clear blue color had been replaced by an unappealing shade of brown. Stranded away from the water we resigned ourselves to wandering through the stores in the Kukuiula Village shopping center near Poipu Beach.

After meandering through stores selling beach themed home goods we wandered into an art gallery that featured photos of scenic locations from around the Hawaiian Islands. I did not recognize many of the images in the pictures and asked the proprietor, a woman who appeared to be in her seventies, where some of them were taken. She answered my questions and then asked some of her own, the standard tourist questions of “Where are you from?” and “Where are you staying?”

After hearing our answers, she volunteered that she had moved to Kauai over 20 years earlier and still felt like she was new. She told us of the small town nature of the island (there are 27,000 permanent residents, only about 2000 of whom live in the Poipu area), and how everyone knew everybody else. She mentioned that there was only one department store on the island and that everyone wore the same outfits because they all shopped at the same Macys.

As there was no one else in the store and she seemed to be in the mood for conversation, I decided to ask her what life was like living on the island. In particular I asked her about the quality of medical care. “It isn’t very good,” she replied.

She told us that the only up to date mammogram machine was on the southwest side of the island, nearly an hour’s drive away from the hospital and over 2 hours away from the village of Hanalei. The hospital on Kauai was not very advanced. It was equipped to handle common conditions and emergencies but was not staffed for more complicated cases. Her husband had been diagnosed with pancreatic cancer a year earlier and had needed to travel by plane to Honolulu for treatment. Their medical care was comparable to that one would find in rural America.

The best part of their health care was their family doctor who had provided their care since they arrived. He was kind and compassionate. She shared that she was concerned about the future of their medical care because he would soon be retiring. She then told us a story of her doctor that helped us understand her fears.

A few years earlier her brother and his best friend had gone out fishing on her brother’s boat. They were about 8 miles off the coast when they hooked a massive fish that weighed over 200 pounds. The friend worked to reel it in while her brother went to get something with which to hit it in the head so they could pull it into the boat. Metal stick in hand her brother called to his friend to pull the fish in a little closer so he could reach it.

“I don’t feel very good,” the friend said. Then he dropped dead on the deck. Her shocked brother radioed the Coast Guard and started CPR. It took a while for the Coast Guard to arrive, too late to do anything for his friend. The Coast Guard took his body away. Her brother returned to the harbor alone. Waiting for him on the dock was his family doctor. The doctor had heard of the tragedy, and concerned for her brother’s state of mind had driven to the harbor to meet his grief-stricken patient.

As the woman told the story it was clear that she had not been surprised by the kindness of their physician. His caring act was what they had come to expect from him, standard practice from their small-town doctor. While this behavior was normal for her physician she knew that it was a level of kindness that could disappear now that he was retiring. She did not know if she would ever find a physician who cared for her that much, a physician she could trust to be there when she needed him.

Her story has stayed with me. I repeatedly find myself reflecting on the power of this small-town physician, the healing and comforting power of relationship and friendship, the importance of simply being “there” when needed.

I think of the times I have been able to care like that, the patients I have known over the last 25 years who have allowed me to be a part of their lives. The house calls made, the phone calls answered, the stories told and the tears that were shared. So often what mattered most were the moments shared, not the medications prescribed.

Our society is moving away from these relationships. Medicine is now practiced according to a set schedule. Interactions with primary physicians are often limited to the hours of 9-12 and 2-5, Monday through Friday, if scheduled in advance.  After office hours and on weekends patients get the stranger in the Emergency Room or the Urgent Care Clinic. The feeling seems to be that people need a doctor, that seeing their doctor is not all that important.

The woman’s story, and my experience, suggest this is not true. There is more to good medical care than knowing medicine. Truly excellent care requires knowing the person who is receiving treatment, a truth small-town doctors know and the rest of us need to learn.

- Bart

 

In

The Night I Became a Doctor

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I didn’t know what to do. The location of the young woman’s pain was consistent with appendicitis, but the level of pain wasn’t. The classic exam findings of marked tenderness, worse when pressure rapidly removed, and a firm abdomen, were absent. Her blood work was normal, and she didn’t have a fever. I did not think I could justify taking her to the operating room, but I wasn’t comfortable sending her home either. I had only been a doctor for a few months, so I did not have much experience to draw on.

It was 1990 and the medical profession hadn’t yet figured out the value of CAT scans and ultrasounds for diagnosing appendicitis so all I had to go on was my head and my hands. I felt badly that the patient had me for her doctor and worried that I would make the wrong diagnosis. I remembered that the symptoms of appendicitis typically increased over time so I admitted her to the hospital with the plan of checking her every few hours. I figured that the pain would either get better or get worse, and that time would prove to be the best diagnostic tool. I was confident that the answer would come within a few hours. It didn’t.

Six hours later nothing had changed. She still had pain and tenderness over the appendix, and nothing else. I knew enough to worry but did not feel like I knew enough to make a decision. I nervously decided to call the surgeon on call and ask him for advice. He was the Chief of Staff for the hospital and had a reputation for being a no-nonsense jerk with a tendency to yell at stupid interns, but he was the man who would be doing the surgery if surgery was needed. I was afraid he would be bothered by my call, but it was 11 PM and I was pretty sure his mood would only get worse the longer I waited, so I called his answering service.

He returned my page within minutes. In typical intern fashion I launched into a detailed explanation of the patient’s history and physical examination. I had barely begun my story when he interrupted me. “Do you want to take her to the operating room or not?” he demanded. Taken aback, I attempted to explain to him my uncertainty. He wanted nothing to do with my lack of confidence.

“You’re the doctor, I’m the consultant. Be a doctor. Make the call. You say the word and I’ll do the surgery. If you don’t want to do the surgery then hang up the phone and let me go back to sleep. Make the call.”

His words were like a punch in the stomach. It was time for me to “grow up” and be a doctor. The fact that the evidence wasn’t clear was irrelevant. A decision had to be made and it was up to me to make it, right then and there.

I made up my mind as I spoke my reply, “If it was my wife, I would want her in the operating room.”

“I’ll call the OR,” he answered.

A little over 30 minutes later I was standing across from the surgeon as he made the incision in her abdomen. I watched as he reached in with his gloved handed and gently worked to bring the appendix into view. It was not in its most common position. It was swollen and infected but it was tucked behind the cecum in such a way that the cecum blunted the pressure of examining fingers. It would have ruptured before the diagnosis became clear. Waiting would have brought harm.

As he prepared to remove the appendix the surgeon looked up at me. From behind his mask he said, “You made a good call.”

I have never forgotten his words, for they have meaning beyond medicine. I learned a life lesson that night. Sometimes there is no one to turn to but yourself. We can’t always wait for things to be clear. Sometimes being a grown up is about making the best decision we can in the moment and learning accepting the consequences.

- Bart

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Your Doctor Isn't a Robot

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News flash- doctors are people. As such, we do people things. Please don’t punish us when we do.

I recently had a patient come in because he had been coughing for three weeks. This year’s cold and flu season was a particularly “coughy” one, so I was not surprised he had been coughing for so long. Although his cough did not worry me, it was obviously a concern to him, so I did my best to address his fears.

Although I did not think pneumonia was likely, it was a possibility. This, combined with his concern, was enough for me to order a chest x-ray. I sent him off to get the pictures taken, making sure to mark the order “STAT” so the radiologist would send a report the same day. A few hours later I sent the patient a message telling him that the results were normal and that he had nothing to worry about. I was confident I had done a good job and that the patient was satisfied.

He wasn’t.

Several weeks later I received a report on the results of the medical group’s most recent patient satisfaction survey. My scores had declined dramatically. I searched the report for an explanation and found it in the comments section. The coughing patient had left a scathing review, saying, “I went in for a cough that has lasted several weeks. Doctor Barrett ordered an x-ray but did not give me anything for the cough. He obviously does not care at all about his patient’s feelings.” Ouch!

In typical human fashion, I had focused on one thing, making sure he did not have a pneumonia. As I was waiting for the results to determine treatment, and as the x-ray was normal, I had notified him of the good news and forgotten to send in a cough medicine. Oops! What to some would be a harmless and understandable mistake was for him a capital crime. Off with my head! (And down with my patient satisfaction scores!)

Such disproportional wrath has become a regular part of medical practice. It is not uncommon for patients to tell me how “bad” another doctor was. A recent patient complained to her insurance about her oncologist because of a side effect from chemotherapy. The fact that the doctor had picked the best medication and prescribed it appropriately did not matter. Her cancer was better, but she had gotten dehydrated and he needed to be punished.

I have heard doctors criticized for saying too much and others for being too quiet. One patient will complain about too long of a wait, the next will complain about a doctor only spending 15 minutes with him (for a 15-minute visit.)

I sometimes think patients do not understand our humanity. We work hard to avoid big mistakes such as incorrect medications and missed diagnoses, but we sometimes make little mistakes such as failing to click the “send” button after entering a medication, forgetting we had a meeting at the hospital and running late in the office, or forgetting a patient’s name.

The best patients understand this and extend us grace and a helping hand. They ask questions when communication is not clear, instead of saying we do not care. They forgive us when we have to check the chart to see what their name is. They save their complaints for serious mistakes and don’t jump to negative conclusions.

The very best patients go even further. They say, “Thank You.”

- Bart

Thanks for reading and for sharing. For future posts, subscribe to the blog or follow me on twitter @bartbarrettmd. Comments and questions are always welcomed.

Ulcers, Easter, and Truth

Truth is at times unbelievable.

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By the early 1980’s medical experts were certain they understood the causes of gastric ulcers. As the stomach is an acid secreting organ, and because acid can damage tissues, everyone knew that acid was the reason people got ulcers. Because ulcers were more often found in urban businessmen, doctors concluded that stress had a role. This theory was “confirmed” by studies in rats that showed ulcers developed when rats were wrapped in straight jackets and dropped in ice water, and when research showed antacids prevented these ulcers.

Enter Barry Marshall, an internal medicine doctor in Perth, Australia. Along with a pathologist colleague, Robin Warren, he gathered evidence that ulcers were the result of a bacterial infection. Further, he found evidence that the bacteria was a root cause of stomach cancer. He started treating ulcer patients with antibiotics, with remarkable results.

The medical community refused to accept his findings. They thought they knew the cause of ulcers, and could not believe that a bacterial infection could be the cause. It did not make sense. Bacterial infections were the cause of acute infections, of pneumonias and ear infections and sinusitis and cellulitis. They did not cause chronic infections, and they definitely did not cause cancer. Marshall’s theory was simply unbelievable.

It was unbelievable, but it was true. Convinced of the truth of their claims, Marshall and his colleague fought for their findings. The medical community took longer than they should have to accept their research, but the eventually did. In 2005 Marshall and Warren, were awarded the Nobel Prize for medicine. They changed the world of medicine forever.

Their story came to mind today as I thought about Good Friday and the Easter Story. The Gospel accounts tell an unbelievable tale. The Bible declares that Jesus of Nazareth, a Jewish teacher of dubious parentage, was actually the Son of God. This Son of God, instead of asserting his right to rule and demanding that all honor and worship him, allowed himself to be put to death at the hands of the Romans who governed the conquered Jewish nation. He was publicly executed in brutal fashion, nailed to a wooden cross where he hung until in agony he died.

The story did not end with Jesus’ death,  the New Testament writers report that 2 days later he appeared alive to many of his followers. He had risen from the dead, in so doing proving to the world that he was indeed who he had claimed to be, the Son of God and the savior of the world.

What an unbelievable story.

So much of the story does not make sense. Why would God decide to live as a man? Why would he choose to die? Why couldn’t he just choose to forgive everybody without going through such suffering? How could someone come back to life after two days in a tomb. There are too many “whys” and “hows”.

The story flies in the face of so much that people know. The story is unbelievable.

That does not mean it isn't true.

- Bart

 

The Unrelieved Agony of a Dying Man

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I never planned on being a hospice doctor. I had almost no training in end of life care during my Family Practice Residency. I learned about ethics, about patient’s rights to refuse care and to die with dignity, but caring for patients during the dying process was not part of the program.

One of my first exposures to end of life care in practice was when my aunt died of cancer in 2002. I loved my aunt and had fond memories of her but we were not close. I had not even been told she was dying. It was not until the last few days of her life that I knew how grave her circumstances were. It was then that I received a call from my grandmother. She told me my aunt was in terrible pain and the hospice doctor did not seem to be doing anything about it.

I drove to her home in south Orange County to see first hand what was going on. She was moaning in pain, even though there was a nurse present. My aunt was not fully lucid, and I asked the nurse what medications were being prescribed for pain. I was stunned at the response. I did not consider myself an expert on the treatment of cancer pain but I knew she was on a very low dose of morphine. The IV was delivering only 1 mg an hour, a dose so low that pain relief was extremely unlikely. I did not know much about cancer pain but I knew I could do better, so I volunteered to assume the supervision of her hospice care. I instantly doubled the dose of morphine. When her pain continued, I doubled the dose again. I repeated the process every few hours until she was comfortable. She did not achieve a pain free sedated state until the next day when the dose reached 100 mg an hour.

When she died a few days later my grandparents thanked me for taking care of her. They had watched her suffer for days, and I had changed that. The experience also changed me. After caring for my aunt I made myself a promise. No patient would suffer under my watch. I would personally manage every hospice patient in my practice. I knew I couldn’t save every patient but I could darn sure make sure they did not die in pain.

For the last 16 years I have kept that promise, making house calls and responding to calls from hospice nurses anytime, any day. I have aggressively managed pain, increasing doses as needed, committed to the relief of suffering. I have been consistently able to make all my patients comfortable.

Until the last few weeks. I had a patient whose pain I could not relieve.

He had aggressive lung cancer in his left upper lobe. The cancer had grown upwards into the soft tissues of his chest and shoulder, compressing the nerves that supplied his left arm. Nerve pain is the worst type of pain, and his was resistant to everything I tried. Multiple medications, from narcotics to nerve medications, failed to reduce the agony. I consulted pain specialists, palliative care doctors and radiation therapists in search of a treatment that could relieve his pain. I tried everything, hoping that the next medication, the next change in dosage, would prove to be the one that worked. After each adjustment in medication or dose I called to ask him how his pain was. The answer was almost always the same, ten out of ten. One the rare occasions when the pain went down the relief was only temporary. The pain would peak again in a matter of days.

The last week of his life, as the end was clearly approaching, I encouraged the nurse to get more aggressive with his medications. His dose of morphine reached a remarkable 400 mg every few hours, yet his pain remained. I called the best end of life doctor I know, and he recommended a change to methadone. The pain persisted. We added sedatives, hoping he could find a way to rest. He ultimately passed in his sleep. I can only hope that he did so without pain.

I was a heartbroken when he passed. I mourned the loss of man I considered a friend, of my inability to be at his side in his final days (I was out of town), and most of all, the knowledge that he had suffered so much. I was, and am, grateful in the knowledge that his suffering has ended, but find myself wishing I could have done more.

He suffered. He remained positive and kind to the end, but he suffered every day.

His passing makes me acutely aware of the limits of my profession. No matter how hard I try, there will be conditions beyond my reach, diseases I can’t cure and suffering I cannot relieve. It is the reality of life.

Even more, his pain causes me to again wonder as to the purpose of suffering. It is hard to see the good in circumstances so bad, hard to see the hand of a loving God in the midst of such agony. For this patient and I, it was our shared faith that sustained us. We both clung to the hope that his faith assured an eternity free from suffering, and reminded each other of this hope in our times together.  We also prayerfully shared the hope that God would somehow, someway, use his last days to touch the lives of those he loved, that God had a purpose.

I do not know what these purposes are or might be. The answer may not come in this life. All I can do is focus on the purpose that I know God has for me right now, which is for me to do the best I can to love his family and encourage them. I can share the story of his faith with others, of the hope that we shared, that others may find similar assurance. And I can do all I can to comfort and care for the other dying patients God brings my way.

- Bart

Thanks for reading and sharing. If you are so moved, consider saying a prayer for the man's family. There loss is profound. Comments and questions are always welcomed. I can be reached via the contact button on this website, or followed on twitter @bartbarrettmd.