Humane Medicine — House calls, Homebodies

In my student days, I trained at an urban health clinic. Although we saw the gamut of general medical ailments, my most invaluable lessons came when the doctor and I ventured out into the local community to make house calls.

Interested readers can now access my latest Humane Medicine column, House calls, homebodies: Remembering that you came, recently published in the Journal of the American Academy of Physician Assistants.

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The Hands of a Surgeon

A young Vietnamese immigrant wandered into the inner city clinic where I trained as a student and subsequently worked for several years. Although he spoke little English, his chief complaint was obvious:  an unsightly mass protruded from the right side of his face along the jaw line.  He had been to a number of medical facilities for treatment, but no one wanted to excise the cluster of bumps just beneath the skin.  In retrospect, the reason was obvious—he had no medical insurance.

I asked my supervising physician to have a look. He agreed with my assessment: a cluster of subcutaneous cysts. “You could do it,” he said. “Incise directly over the blebs. It should be fairly straightforward. You won’t be able to get them out without breaking them, but no matter. It should pull together nicely.”

In those days we performed minor surgery in the clinic. I scrubbed and prepped the area, positioned the drape, infiltrated the region with anesthetic and with a scalpel made the incision. Our nurse stood by, ready to assist, as I began the dissection.

When I was an adolescent over the course of three summers I worked on the staff of a local camp. One year I taught camp craft and pioneering. Under my supervision my young charges felled a number of tall tulip trees, lopped off the branches and laid them out according to plan. We spent several weeks that summer constructing a signal tower, using only braided rope for the lashings that bound the spars together.

As we labored one afternoon in the hot sun, the camp director wandered into the meadow to observe the progress. He stood with his hands on his hips, watching me demonstrate a standard lashing to the boys. Afterwards, he paid me a compliment: “You’ve got the hands of a surgeon,” he said. Carefully chosen or not, his words stuck in my head.

Several years later I learned how to close simple lacerations when I worked as a hospital corpsman aboard a high-endurance cutter. One night during a layover in Lisbon I was called to attend a sailor who had been stabbed during a fight that broke out in a bar. The man was drunk. They hauled him into sickbay and stretched him out on the table. I explored the shoulder wound (not as deep as it first appeared), irrigated and surgically closed it. The next day we put out to sea. Ten days later I extracted the sutures. The wound never suppurated; I counted both him and myself lucky.

Several of my classmates in PA school elected to pursue careers in general surgery. I opted for a track in general medicine instead. Even so, I found myself standing over this young Vietnamese man that afternoon, excising a mass that other clinicians more experienced than I had refused to touch.

I dissected the mass in toto and closed the wound, using vertical mattress sutures. The following week the young man returned to have the sutures removed. Only a hairline scar remained. I showed him the result in a hand mirror. I remember his smile—the only thing he had to offer in payment.

I still close minor lacerations on occasion in the office. These days I use Dermabond for the most part. It’s quick, easy and painless. They say that the results are every bit as good as surgical closure.

That may be the case. But I take some satisfaction in knowing that somewhere out there today, an older Vietnamese man remains grateful for the gift I was given in my youth: the hands of a surgeon.

Living on the edge of being

In an article that appeared in the New York Times Magazine on Aug. 26, 1990—Doctor, Talk to Me—Anatole Broyard envisioned the ideal physician who would treat a patient’s body—and his soul:

”In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and much to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror and exaltation of being on the edge of being, between the natural and the supernatural.”

Each one of us lives every moment of our lives on this edge of being, even though most of the time we pass our days totally unaware of it.  In part we are too busy, too caught up in the mundane affairs of everyday living, to glimpse it.  And I suspect that most of us would find living in a constant state of such awareness too intense to bear.  Wonder, terror and exaltation can fill our lives with awe—or burn us out.

As clinicians we are called to minister to our patients in many ways.  Sometimes we are called to talk, sometimes to listen.  In Broyard’s words, we have much to gain by letting our sick patients into our hearts.  The wise clinician learns that compassion helps to heal in ways that medication cannot—and that such healing can be reciprocal as well.

Anthony Martinez, a retired Navy eye surgeon, spends his days doing house calls on the homeless in Washington, D.C.  Each morning he slings a bag of medical supplies over his shoulder and tramps off on foot to visit those who live under bridges or in the street.  Martinez says that his work has given him a newfound purpose in life.  “It helps me deal with my own demons,” he observes.

In her poem “What I Learned from My Mother,” Julia Kasdorf writes:

Like a doctor, I learned to create
From another’s suffering my own usefulness, and once
You know how to do this, you can never refuse.
To every house you enter, you must offer
Healing: a chocolate cake you baked yourself,
The blessing of your voice, your chaste touch.

“Ruminating on GERD” published in YJHM

Something happened to change the approach to treatment of infant spittyness over the past decade:  H2 blockers and PPIs were introduced into the pharmacological armamentarium of pediatric primary care.

I was chagrined to learn recently that 5% of infants are prescribed medication for GERD—gastroesophageal reflux disease, the latest diagnosis du jour in primary care pediatrics. >>more

Readers can now access my latest essay, Ruminating on GERD, newly published in the Yale Journal for Humanities in Medicine.

A kind, big-hearted, gentle person

Daniel Mongiardo, a physician in Perry County, Kentucky, and also Lieutenant Governor of that state, recently described his colleague Dr. Dennis Sandlin as “a kind, big-hearted, gentle person.”  Dr. Sandlin had been in practice for over thirty years at the Leatherwood-Blackey Medical Clinic in southeastern Kentucky when a disgruntled patient showed up with a gun and shot him dead.  The dispute was reportedly over a prescription for narcotic drugs.

I was amazed at the vehement responses submitted as online comments to a recent editorial in the Journal of the American Academy of Physician Assistants which advocated that healthcare professionals counsel their patients on firearm safety.  Here are a few choice reader remarks:

Cars, swimming pools and tobacco can certainly be blamed for far more deaths than firearms. Quit being a nanny and do your job.

Since you seem to know nothing about firearms or their owners, I suggest you stick to practicing medicine.

You’re trotting out all the tired old anti-gun arguments in your text and you advocate disarmament.

Doctors should really advise us not to exhale, as the EPA has listed carbon dioxide as a dangerous pollutant. It certainly would cut down on all the hot bags of wind that try telling us in crappy little articles that they know better than I do when it comes to my safety.

The most amazing thing about every one of these emotionally charged comments is that their authors seem to have missed the entire point of the editorial, which advocated counseling patients on gun safety in the interests of keeping a safe environment in the home.  (Note:  All of these comments have been deleted by JAAPA editors because they did not adhere to comment guidelines and were deemed to be outside the scope of professional discourse expected on the journal’s website.  As of this writing, comment posting on this editorial has been closed to discourage members of the public from pursuing private agendas at this site.)

When I was a boy growing up in Pennsylvania, adolescents were required to complete a rigorous hunter safety course as a prerequisite to obtaining a hunting license.  The state was not advocating gun control or restricting the use of firearms—it merely wanted to insure that those who used firearms would do so in a safe and responsible manner.

Outside of the first year of life, the number one cause of mortality in the pediatric age group is accidents—deaths related to automobile accidents, drowning in backyard swimming pools, accidental poisoning by mouth, falls, choking hazards, burns from hot liquids and house fires (including smoke inhalation), and accidental deaths from firearms.  A good part of primary care pediatrics is centered on prevention of morbidity and mortality.  Included in this armamentarium of preventive medicine are the timely administration of childhood vaccines, monitoring the growth and development of young children, and counseling parents on how to keep their children safe.

Although I am not an advocate of carte blanche gun control, as a practicing pediatric clinician I do spend time counseling parents about how to keep their children safe.  Firearm safety is one piece in the accident prevention paradigm, and counseling patients on how to stay safe—regardless whether the issue is sexual practice, drinking and driving, substance abuse or proper handling of firearms—should remain an integral part of preventive medical practice in primary care.  The American Academy of Pediatrics has issued a policy statement on office based counseling for unintentional injury prevention which includes firearm safety.

Could gun control have prevented the death of Dr. Dennis Sandlin, a kind, big-hearted, gentle clinician, revered by his patients and the members of his community?  Perhaps; perhaps not.  But regardless of how an act of violence is eventually carried out, it is first formulated in the psyche of the perpetrator.

While we can all agree that when it comes to divisive issues, spirited debate is healthy and perhaps even desirable; those who resort to the use of threatening, abusive and demeaning language should be granted no voice in professional forums.

“Medicine in the time of the EMR” posted in YJHM

The EMR, we are told, will help cut healthcare costs.  When medical records are converted into digital format, data will be instantaneously available to all providers caring for the patient.  Clinicians will have carte blanche access to previous laboratory and radiological studies, thus insuring that such investigations are not performed repeatedly or needlessly.  Data will be collated and scrutinized to insure that standards of care are met and that medical errors are eliminated.  Electronic billing will become the norm.  One day patients might even be able to schedule their own appointments online.  Somehow all this will serve to lower costs and improve the efficiency and quality of healthcare delivery.

Indeed it might.  But in my mind healthcare delivery is something different than the practice of medicine….>>more

My latest essay, Medicine in the time of the EMR, is now posted at the Yale Journal for Humanities in Medicine blog, a companion blog for the Yale Journal for Humanities in Medicine.

Casting pearls

“Should I have my daughter get the swine flu vaccine?” this mother asks.  She stands next to her toddler who sits on the exam table.  The little girl has had difficulty gaining weight.  Now two years of age, she barely tips the scale at 23 pounds.  Otherwise, she’s been a healthy child.

“The vaccine is available and indicated for her age group,” I say, attempting to disseminate the information in a non-biased way.

“I know, but should I do it?  What are the risks?  It’s so new.  You hear so much about problems with vaccines these days.”

“It will protect her against the swine flu.  The vaccine is manufactured by the same companies that have been formulating flu vaccines for years.  It’s been field tested and found to be safe.  Apart from some minor side effects, it’s a good vaccine.”

The look on this mother’s face tells me she’s not convinced.  “What will happen if she doesn’t get the vaccine and comes down with swine flu?  Will she die from it?”

I take a deep breath and recite my litany:  “She’ll get sick with fever and feel lousy for a few days, but she’ll most likely recover.  Of course, there are no guarantees; but chances are good that she’ll make it through fine.”

“So I’m not a bad mother if I don’t have her get the vaccine?”

“No, you’re not a bad mother if you decide not to have her immunized.”

The mother averts her eyes and reaches for her little girl’s shoes.  “I guess I’ll hold off for now,” she says.  “If I change my mind, can I have her get it later?”

“Of course—assuming the vaccine supply lasts.”

I step out of the room, toss the child’s medical record on my desk, reach for the next chart in the bin and step into the adjacent room to greet an adolescent boy.  His mother has brought him in with complaints of a sore throat.

I glance at the vital signs:  no fever.  I ask a few questions and proceed with the examination.  As I expected, he exhibits signs of a mild scratchy throat.  There are no significant swollen glands in his neck.  I prescribe a course of saline gargles, acetaminophen, throat lozenges and warm fluids.  Afterwards, I ask if there are any questions.  “Can he get the swine flu shot today?” his mother asks.

“Right now he isn’t eligible for the vaccine.  He doesn’t fall into one of the high-risk priority groups.”

I can see the look of disappointment on her face.  “Can he get the regular flu shot?  I heard that that might give some protection.  Is that true?”

“The regular flu shot will protect him against seasonal flu, but it won’t be effective against the swine flu,” I tell her.  “And at this juncture we’ve exhausted our current supply.  We should have some additional vaccine next month.  If you call the office, we can have him come back for the shot.”

“I can’t believe that there’s not enough vaccine to go around.  Everyone says to get the flu shot this year.  What are we supposed to do?”

I shrug my shoulders.  “I share your frustration.  We’re at the mercy of the vaccine suppliers.  Unfortunately, there’s been a shortage this year.  We can only work with what we’ve got.”

I step out of the room and walk to the front office.  All of the telephone lines are busy.  Each time one of the receptionists hangs up a phone, it rings again.  Everyone is exasperated.  “We don’t know what to tell the patients any more,” one medical assistant says.  “Everyone asks if we’re recommending the swine flu vaccine.  When we tell them that there’s not enough to go around, they go off on us.  One lady used such foul language, I told her that I was going to hang up!  I’ve never done that before in fifteen years.”

My third patient of the morning is a 12-year-old girl who has come in for her annual physical examination with her mother.  At this age the child is due for a number of inoculations:  booster shots for tetanus and chickenpox, as well as the meningitis vaccine.  I review the chart and note that the girl has a history of asthma.  “She should also get a flu shot today.  With her asthma, she’s high risk.”

“She’s never had a flu shot in her life,” her mother tells me.  “I haven’t either.  We don’t get the flu in our family.  Besides, three shots are enough.  Aren’t they going to tax her immune system too much?”

Once again I explain the reasoning for my recommendation.  The child has a history of asthma.  If she contracts swine flu, she would be more likely to develop a secondary pneumonia, further compromising her respiratory status.  The vaccine is available; it makes sense to give it to her today.  And in answer to her last question, no—one more vaccine won’t compromise her immune system.

“Can’t she have the vaccine that you squirt up the nose?  At least that would save her a shot.”

“The nasal vaccine is formulated with live virus.  It shouldn’t be given to someone with asthma.  And right now we’re only authorized to administer the nasal preparation to children below six years of age.”

The mother looks at her daughter, who pleads silently with her mouth:  No, not another shot!

“Well, if you think it’s a good idea, I guess we’ll do it,” the mother says, avoiding her daughter’s misty eyes.

I scribble a note in the chart and think:  How will I ever get through this day, let alone the next five months?  At times like these I wonder whatever possessed me to opt for a career in primary care medicine.

My last patient of the day is a 6-year-old boy.  I’ve known his mother for years.  The boy has brittle asthma.  She knows how to treat it when he gets sick.  Today he has a fever, cough and runny nose; he looks ill.  “I have an appointment to have him get his flu shot day after tomorrow,” she tells me, with a concerned look in her eyes.

Thankfully, the boy’s lungs are clear.  I take a nasal swab specimen and test it for swine flu.  Ten minutes later the tell-tale red line appears on the test strip.  There won’t be any need to vaccinate him now.

I write a prescription for Tamiflu, a drug that will blunt the viral infection surging through his small body.  His mother remains calm while I explain the treatment.  At the end of the visit she thanks me with an easy smile.  “I’m glad you were able to see him today,” she says.  “It’s a comfort knowing you’re here when we need you.”

And suddenly once again I remember why I elected to practice primary care pediatrics.