January 2012

Kerri Arsenault

Locus Pocus

The Family Doctor

In the past eleven years I’ve lived in five cites, three countries, and my cat turns fourteen this summer, which is noted in her EU passport alongside her vaccinations, flea treatments, and teeth cleanings. I wish my own healthcare could be as mobile and tidy. Each time I move, I select a new Primary Care Manager (PCM) at random from a giant database of approved practitioners. I begin a new doctor-patient relationship, with my medical history slightly altered between the remembering, the telling, what the doctor actually records, and the erroneous records of the past. The only continuity is that there is none.

My health care package is an acronym-laden behemoth program worthy of the federal government, my benefactor. The 73-page Tricare Overseas Prime (TOP) plan explains that when I am living overseas (as I am now) I am supposed to call “International SOS” (based in another country, where I am not) when I need a doctor, rather than call the doctors themselves. One day, I call SOS (acronym is self-explanatory). I spell my last name between the crackle of a weak Internet signal and the echoed delays of overseas VOIP. What followed were labyrinthine transactions and negotiations where this SOS intermediary relayed my case to my provider, who contacted me, and reported back to intermediary. Then, intermediary gave approval for treatment, and reported back to provider, until finally they made appointments for me at the nearest Medical Treatment Facility (MTF), which happens to be thousands of miles away. The process is complicated by my lack of a local PCM, and because my previous doctor recently sent me a form letter stating she moved on, but didn’t disclose where. SOS? I was in pain, in tears, and confused as hell.

It’s no secret that the state of health care in the US is grim, even if you have a plan, as I do. Health crisis shenanigans such as this make me pine for the days when my family doctor, a man who delivered my four siblings and me, could give me medical advice in the produce section at Hannaford’s. This doctor also knew my parents, their friends, most of my family’s medical history, and my batting average for the high school softball team. It was Maine, the way life should be, as the billboard on the Maine Turnpike declared as you cruised into Kittery via the Piscataqua Bridge.

There is comfort in a shared history derived from lifelong familiarity with a doctor who delivers you, then watches you come and go with chickenpox, strep throat, or eczema and later tends to your parents’ ulcers or heart disease. At it’s worst, it’s hokey small town Maine but at its best, it’s holistic health care based on emotional, social, familial, and psychological factors, administered by a real live “Doctor” rather than a “Primary Care Manager” and in a renovated schoolhouse rather than a “Medical Treatment Facility.”  

John McPhee wrote about these rural Maine family doctors in Heirs of General Practice. Originally published in the New Yorker in July 1984, this book is an accidental ode to those doctors who chose family medicine over more specialized fields. McPhee observes three rural Maine doctors, not unlike my childhood doctor, tending to their patients and describes their visits, and the doctors themselves, using case study techniques, the same methods these doctors use to assess their patients. McPhee’s observations reflect the acuity that family doctors need to use in order to treat a sometime reticent or stoic patient, often the kind found in rural Maine. Other related problems, he indicates, can be ferreted out by factors other than physical symptoms, often times just by listening.

Thirty-nine-year-old female presents with a sore throat -- possibly strep, possibly viral. Her doctor knows her, and knows that the sore throat is only the precipitating reason for her coming in… Three weeks ago, she woke up in an ambulance, riding away from a demolished automobile… what she wants is general talk and counsel… She has three children and runs a farm by herself. "The divorce becomes final on Friday," she remarks to the doctor… Her family could not accept her husband and made life so difficult for him he left. He is eighteen. Her first husband died of cirrhosis. Like the children, like the second husband, he was the doctor’s patient.

Her question to the doctor this day; is depression an after effect of an accident?

The patients come and go in rapid succession and McPhee concludes, “When someone comes in for a physical or a checkup, there is often a hidden agenda” and he sees the doctors act as de-facto counselors-cum-listeners who offer simple “watchful sympathy” to those who need just that.

Dr. David Thanhauser practiced in Belfast, Maine. One of his patients, a baby with spina bifida, had “essentially no muscles in the back of her legs, and will -- at best -- require braces to walk. Her eyesight has also been affected, too, but might respond to surgery.” Basically, there was nothing Dr. Thanhauser could do. But McPhee saw that “he can do something no less beneficial. Between major medical events, he can watch, examine, explain. He can select referrals and guide the parents. He can be there when no one else would be.” Dr. Thanhauser was a true and useful “SOS” intermediary, something my own failed to be.

A master of narrative structure himself, McPhee relays the note-taking methods of Dr. Sandy Burnstein from Mars Hill, Maine, who “appears to doodle as he listens, drawing circles and squares on a sheet of paper, connecting them in various patterns, placing an X here and there, or a number, and a word or two as well.” Males are portrayed as squares and females, circles. A dotted line encircles households, an X indicates a death, and so on. This shorthand is known as a genogram and McPhee writes, “In a few minutes of listening [Bernstein] can outline something like a Russian novel.” For Dr. Burnstein, the point of the graphic exercise is to see the connections and relationships of the whole family so he can deliver better health care to the individual.

Dr. Anne Dorney worked in Skowhegan, Maine, and one day treated a “Ten-year-old male with allergy problems… Dorney asked at length about the family’s history, and the father happened to remark that now and again he took his own blood pressure.” He admitted the last time he checked it was 170/110. Dorney took the man’s blood pressure knowing that his brother had recently died of a myocardial infarction. Her diagnosis and subsequent medication and treatment was swift: “Adult-onset diabetes and [he was] was developing angina.” McPhee observes, “It was a sequence of familial treatment that might not have happened in another kind of office.” And likely, the man would have died.

Edward Martin grew up in Mexico, Maine (my hometown), left for Colby College, then marched overseas to serve in World War II, as did most young patriotic boys. He returned to New England where he went to medical college and returned home to practice medicine, eventually my old elementary school. Doc, as most people called him, was a family doctor there for over 40 years, delivering about 2,500 babies, ministering to a community of 3,000 people (most of whom would rather not go to the doctor), was married for 32 years, and had nine children of his own. Because of his long-term and personal relationships with people in the community, like the doctors in McPhee’s book, he spotted generational trends in the health of his patients, more specifically, an elevated rate of cancer compared to the national average. Doc connected the dots between what his patients divulged, a holistic understanding of each person’s complaints, the statistics he gathered, and his personal research and fingered the local paper mill as the main source for cancer. His efforts to stop the mill from dumping dioxin and toxic waste into the land and air made some impact until, ironically, he died from cancer himself. He wasn’t an oncologist and wasn’t perfect by any means, but his continuity among town residents and shrewd observations of their habits, at work and home, compelled him to try and correct the erroneous records of the past.