Centuries ago, when I needed to evaluate male patients for groin hernias I would insert my gloved finger into their inguinal canal and ask them to cough. This inevitably resulted in them coughing all over me. Nowadays I say, “Please cover your mouth and cough.” My patients often look a little baffled when I make this request. Maybe they’re thinking, “You mean I don’t get to cough on you anymore? Bummer!”
Sooner or later all good things must come to an end. Once the examination is over we discuss my findings as well as any recommended investigations and treatments. When we’re finished most people say thanks, walk out and shut the door behind them. I’m never quite sure why they close the door. Perhaps they think I plan to teleport out of the room. Fortunately, I’m not claustrophobic. I finish my charting, reopen the door and mosey on down the hall to see what new challenges await me.
Survey Says…
My desk is littered with surveys. We rural physicians are a hot research topic these days – everyone wants to know what makes us tick. I imagine the brainiacs in their think tanks across the nation scratching their heads, vexed and perplexed.
“What makes them venture beyond city limits?” they ask one another. “And more importantly, what keeps them out there?” More fruitless head-scratching. Suddenly one of them leaps to his feet. He looks excited. Head Boffin arches a bushy eyebrow in the direction of his impulsive young colleague.
“Yes?”
“Sir, I’ve got it! Let’s send them all surveys!”
“Surveys?”
“Yes! We’ll ask them each a few hundred questions and then have our quantum computers analyze their responses!”
Head Boffin nods; slowly at first, then with increasing enthusiasm. Finally he breaks into a wide grin.
“Splendid idea, Dilton! First class! We’ll start immediately.”
And so it begins.
My receptionist unceremoniously dumps the morning mail onto my already overflowing desk. Junk, bills, test results, insurance forms, more bills… and two objects that look suspiciously like surveys. Shoulders sagging, I open the first one.
“Dear doctor, we truly appreciate you dedicating your life to rural medicine yada yada yada and we hope you won’t mind filling out the enclosed survey. Please review the following 200 items and rate their importance in terms of the impact they have on your desire to continue practicing rurally. We estimate this survey should take you no longer than 45 minutes to complete.” What?! 45 minutes? Are they nuts? I’ll be lucky if I get 10 minutes for lunch today! I wad the oversized monstrosity into a ball and three-point it into the recycling bin across the room. The crowd goes wild… .
Item two is a follow-up letter from a group whose survey I completed a few weeks ago. As I recall, this particular survey had asked more personal questions than most, but its authors had gone to great lengths to assure that all responses would be held in the strictest confidence. They also promised names would not be linked to the forms, so it would be impossible for them to trace answers back to the individual respondents.
“Dear Dr. 655, thank you very much for taking the time to fill out our survey. We notice, however, that you neglected to answer questions 19 and 99. Please complete them and return the form to us in the enclosed self-addressed envelope.”
Okay, this I can handle. I quickly finish off the questionnaire and drop it in the outgoing mail tray. Several hours later the penny drops – if they claim to be incapable of tracking the doctors filling out their surveys, how did they know the incomplete one was mine? Egads! I’ve been duped! With my luck the study will turn out to be the product of some nebulous federal intelligence-gathering agency. Good thing I didn’t mention my fluffy pink slipper fetish in the “deviant tendencies” section… or did I?
Although surveys can be a real nuisance, I’ll probably continue to fill out the shorter ones for years to come. Why? I figure those poor research eggheads need all the help they can get in their noble quest to decode the enigma of the rural physician. If they eventually succeed, perhaps one day we’ll be featured on a segment of Hinterland’s Who’s Who. First will come the familiar, haunting flute melody, followed by that unnaturally calm voiceover: “The Canadian rural physician is a peculiar beast that appears to thrive on challenge and adversity. Only recently have scientists come to understand why this curious creature voluntarily makes its home in the underpopulated nether regions of our great land… .”
Prescription for Parenting Skills
A few months ago one of my patients brought her three-year-old son in to see me. Although little Genghis had only recently begun attending daycare, the workers there were so alarmed by his pervasive aggression and impulsiveness they insisted he be assessed by a physician ASAP.
I walked in to find the rambunctious little fellow gleefully dismantling my examination room. His mother seemed oblivious to the crime scene unfolding around her. After reining him in a bit I obtained a history and wrestled my way through a physical. By the time I was finished, ADHD and suboptimal parenting were highest on my list of potential diagnoses. I spent several minutes reviewing my findings with his mother, gave her some reading material and made arrangements for a follow-up visit.
As I was about to leave I remembered Genghis had a five-year-old brother who had always struck me as being excessively busy. The last time I saw him I had suggested we schedule an appointment to explore the matter further, but his parents hadn’t taken me up on the offer.
“Did Anakin start school this year?”
“Yes, he did.”
“How’s he making out?”
“Super!”
“I’m glad to hear that.” I began leaking towards the door.
“At first we were getting a lot of notes from his teachers about his behaviour, but a few weeks ago I figured out a way to stop that.”
“How?”
“I just give him some Gravol right before he leaves for school every morning. It works great – he hasn’t brought home a single note since!”
Introspect/ Apologia
Lately I’ve been reviewing my medical narratives. Some are autobiographical, others reflect patient encounters, and most of the remainder relate to parenting. One thing I’ve noticed is that a few of the narratives depicting my interactions with patients are slightly cynical. Usually it’s just my warped sense of humour at play, but once in a while there's a bit of an edge to it. Some of this can probably be attributed to representational bias. I'm no neurobiologist, but I suspect difficult experiences engender higher rates of memory protein synthesis than neutral events. In addition to that, stories involving conflict are intrinsically more interesting to write about and analyze than their more peaceful counterparts. Who wants to read a book about unicorns frolicking in the sunset? For the purposes of discussion, though, if we suppose that I do in fact have an embryonic case of misanthropy gestating, is it being nourished by my patients, my job, or me? I think it’s probably a combination of all three.
For starters, I am definitely not the touchy-feely type. I tend to favour a linear, problem-solving approach to medicine. Within the first few minutes of most interviews I’ve usually assigned my patient’s presenting complaint to one of four categories:
1) I can fix this.
2) I can’t fix this myself, but I know someone who can.
3) I’m not exactly sure what’s going on here, but I get the impression it’s something fixable.
4) Jesus and Gandalf combined couldn’t fix this.
The instant I realize I’m probably not going to be able to help the person I’m seeing in any meaningful way, I start getting fidgety. The way I see it, every morning I arrive at work with a finite amount of expendable energy. Once it’s used up, I’m pretty much done for the day, psychologically speaking. This means I have to ration my resources wisely in order to try to do the greatest good for the greatest number of people. There’s nothing esoteric about this - it’s basic Utilitarianism 101. Unfortunately, a small percentage of patients are like black holes – they’ll pull you over their event horizon and suck all the energy out of you in a single sitting if you allow it. Trying to help them is akin to watering the Sahara with a garden hose. Over the years I’ve treated a number of these unusually needy people. It’s been my experience that no matter what I do for them, no matter how much time I spend, they never seem to get significantly better. Working with this challenging subgroup requires a lot of patience. Unfortunately, patience is not one of my strong suits. In fact, some days it seems I have none at all. This regrettable character flaw of mine undoubtedly contributes to the frustration felt on both sides of the desk from time to time.