Rural Doctoring

A Doctor's Guide to Being Human

When I was a senior at Stanford, my ambitions for my final year of college were terminally derailed by a geological event called the Loma Prieta earthquake.  The temblor caused so much damage in my residence that everyone had to be relocated to other dorms. I was the resident assistant (RA) for my house, meaning I was the problem-solver and support person for the rest of the students who lived there. This was a paid position and was something of an honor, and I took it seriously. Within minutes of the earthquake I was back at the house to account for the whereabouts of all the residents. I lost my wallet during the chaos and had to walk around for two weeks with nothing but some loose change in a paper bag. As the days went by and the damage to the building was being evaluated, all of us suffered from various symptoms of post-traumatic stress. I remember diving under the nearest table whenever an aftershock struck. I didn't sleep well. I had no appetite. It was hard for me to concentrate. I looked like something out of an Edward Gorey illustration.

Suddenly, Things Are Different

I haven't been posting very actively on this blog or on Twitter, and this is because I am processing some news I got last week. 

My life partner had a nodule on her back. At first, it looked like a shiny papule and I thought it was a basal cell carcinoma so I didn't call the dermatologist right away.  Within six weeks, it had doubled in size, and then it took another five weeks to get an appointment. Our dermatologist took one look at the nodule, which was now quite large and melanotic, and did an excisional biopsy. He thought it was probably a squamous cell carcinoma, but the pathology told a different story:  melanoma.

Pathology from the biopsy revealed a 10mm tumor with evidence of microscopic ulceration, two poor prognostic signs. Right now, we're in the process of arranging for a sentinel lymph node mapping and a wide excision. After that, there will have to be an oncology consultation to see if there is any role for adjuvant therapy with interferon-alfa or radiotherapy.

We've been through some health issues in the past, but nothing life-threatening. Now suddenly we are facing a vast, malignant uncertainty. In an effort to ground my understanding of what is happening to us, I've been researching melanoma and its prognosis. This tumor is at least IIC and perhaps IIIB, depending on the outcome of the sentinel node mapping. Apparently there is a five-year survival rate of 45-67% for IIC, and 29-65% for IIIB. It is hard to grasp wide ranges like that, but what I take away from these data is that there is a 1-in-2 or 1-in-3 chance that her life may end in the next five years.

All the other information--about cell morphologies, lymphatic spread, most common metastatic sites--tends to blur around the edges, even to my medically-trained mind. Because in this situation, I am not a doctor, I am family, I am an individual person who is as terrified about the development of a terrible disease in someone I love as any person in the same situation. And terror is not an exaggeration. I haven't been afraid of anything in many years, and now I am.

So I have been doing what I do when I am afraid and anxious: a little retail therapy, a little reality TV, and some fearsome rearranging of furniture. Eventually this stage will evaporate and I'll need to find some long-term coping strategy. Recently I have reaffirmed my identity as a writer, so--with my partner's permission--I have decided to write about our journey on this blog, or--to be specific--about my journey as a family member of a person with a serious disease, a family member who just happens to be a doctor. I anticipate a lot of growth and challenge during this journey, and I believe this is the kind of experience doctors--people--need to share. So look for a new category called The Melanoma Chronicles on this blog. And don't worry--I don't plan to let it take this blog over completely.

Image in the public domain.

Case: Forest vs. Trees

I was a fourth-year medical student by the time I finally rotated through anesthesiology.  Students who suspected they might be interested in entering this specialty scheduled their rotations early in the third year, but crunchy family practice types like me let it slide until fourth year, when you have a bit of medicine under your belt and can kick back and have some fun on a procedure-rich rotation.  Yet there are primary-care teaching moments on every rotation, even ones which take place largely in the operating room rather than the clinic.  Here's one example:

"This Rough Magic, I Here Abjure"

My favorite Shakespeare play might be The Tempest.  Thought to be Shakespeare's final play, the play revolves around themes of revenge, redemption, and the longing for human connection (click here for a synopsis).  I have the complete works on my iPhone and, whenever I'm stuck waiting somewhere, I like to scroll around and memorize a few lines.

Here's what I committed to memory while I was walking my mother's Pekinese yesterday.  It is from Act Five, Scene One and occurs when Prospero, a magician, decides to abandon his powers and return to a common humanity.

Birth Story #128: Hurricane Hardt and the Case of the Purloined Robe

All facets of medicine are difficult to teach, including childbirth care.  I know some people will argue that childbirth is inherently different than all the pathology-based medicine we practice in the other areas of medicine, and I'm not going to argue the point, but learning about birth in all its complexity is very much like learning about, say, diabetes management in that you need to see a lot of cases and learn more than one approach to the topic in order to feel confident when the next patient walks into your exam room.  

Road Trip Playlist #1

I don't know about everyone else, but I spend very little time alone these days.  Between clinic, hospital, and home I usually have any number of human and non-human spirits co-existing in the same space as me (colleagues, patients, staff, significant other, parents, dog, cats, and occasional field mice dropped off by cats in my living room).  The only time I have any time alone, it seems, is when I'm in my car.  The only downside to the Rural commute is that it lasts only ten minutes and I don't really get to explore an audio program and barely have enough time to start singing in the car before I've arrived at my destination.  This is why I've been enjoying the occasional trip to San Francisco or Ashland, each of which takes 4-5 hours and is enough time to do some serious listening.  Here's what I listened to on the way down to San Francisco yesterday:

The Weekly Wrap: November 7th-13th, 2008

I read a lot online, not only blogs but several regional and national newspapers.  My favorite items from the past weeks are listed below, and reveal some of my odder interests.

Back to Work

As of tonight I am rural doctoring once again. I've been off work for six weeks, taking a mini-retirement to catch up on rest and uncommitted time. Of course I had a million plans for my time off, including:

Why I Live Here

A commenter recently asked why I live in California, if the cost of living is so high.  I don't really have a firm answer to this question, but here's one reason:

This is the view from Highway 1 just 20 minutes north of where I live. I love the hectic, noisy, untrammeled coastline up here, and I love the way the ocean crashes against forested mountains. You should see it in person, you really should.

The Labor Files: My Favorite VBAC

As I mentioned in an earlier post, I've kept pretty good records of all the births I've attended as a primary caregiver.  I'm using the same Bellefontaine notebook as I started with and I believe I'm up to 476 or so births logged in that book.  However, I've been around four times that many labors, newborns, and births as an assistant, and my perspective on birth comes as much from these experiences as the births that have occurred into my waiting hands.  I'm going to be sharing some of those stories on this blog under the column title "Labor Files," and because a commentator recently asked if I have any VBAC experience I thought I'd start with my favorite VBAC story.

Why I Left Primary Care, Part 4

In the earlier posts in this series I discussed my reasons for choosing a primary care specialty, the problems I encountered while practicing primary care, and considered some factors which might draw me back into the field.  In the final post in this series, I've pulled together a few tips for young doctors considering a primary care career.

The Weekly Wrap: October 31st-November 6th, 2008

I know I'm not alone in being profoundly relieved at the end of the presidential campaign.  While grappling with the enormity of the democratic process, I have also been attending to other critically important tasks such as considering a format change for the Weekly Wrap.  A lot of my preoccupations involve reading beyond medical blogs, so I'm going to try adding in non-medical links just so you know what I've been reading in general.

Dr. Santell's Rounds: Do the Right Thing

One of Dr. Santell's pet peeves was how residents wrote orders for intravenous (IV) fluids.  I used to spend an inordinate amount of time trying to figure out how to order fluids on a new admission without doing something stupid--giving dextrose-containing fluids to a poorly controlled diabetic, for example.  

I'll admit a lot of this dithering was no more than an attempt to read the old man's mind, because he was always very specific about his fluid orders.  For example, he hated it when one of us ordered the default 1/2NS + KCL 20meq at 125cc/hr on a CHF patient receiving Lasix, for example.  One of the standard rites of passage at our residency was to have Dr. Santell say to each of us:  "You may have heard me say this before, but I don't like giving fluids and Lasix in the same patient."    Those of us who'd heard this speech before snorted quietly in the background, but the hapless new intern who was presenting the case turned beet red, although he wasn't really in trouble.  You were only in trouble with Santell if you made the same mistake twice.

Childbirth Philosophy 6: The Role of the Family Doctor

As I've been keeping up with this blog and establishing productive dialogues with natural childbirth and alternative birth practice advocates, I've been struck by the recurring statement women often make of me and the birth center where I work:  "I wish we had doctors who practice like you/hospitalist like yours where I live."  This is both flattering and alarming, because it reminds me most women don't live in areas where providers and hospitals support minimally interventions during labor and birth.  

One reason why my hospital continues to provide opportunities for natural/alternative childbirth practices is because the majority of the births are attended by midwives (two CNMs and one licensed midwife) and family doctors.  Other blogs already provide excellent advocacy for midwifery-directed childbirth care, so I'm choosing to focus on those aspects of my family practice training which have influenced my own childbirth philosophy.

Why I Left Primary Care, Part 3

I've been writing this post series in an effort to unpack my mixed feelings about leaving primary care to become a full-time hospitalist.  Part One described the original Dream of Family Practice which inspired me to enter primary care in the first place.  Part Two described how reality fell short of the dream.  In this post I want to examine how I feel about my decision and revise the dream to propose specific changes that might lead me--and other doctors in similar situations--to return to primary care.