In the spring of 1938, Dr. Drayton Doherty admitted a sixty-year-old African –American man to the hospital. The small hospital was located at the edge of town in an old house that had been converted into a fifteen-bed hospital. Six of the beds were located upstairs at the rear of the house in what previously served as a sleeping porch. The patient was admitted to that porch.
Dr. Doherty went on to tell me that the patient, Vance Vanders, had been ill for many weeks and had lost over fifty pounds. He looked extremely wasted and near death. His eyes were sunken and resigned to death. The clinical suspicions in those days for anyone with a wasting disease were either tuberculosis or widespread cancer. Repeated tests and chest x-rays for both of these diseases were negative, as was the physical examination. Despite a nasogastric feeding tube, Vanders continued on a downhill course, refusing to eat and vomiting whatever was put down the tube. He said repeatedly he was going to die, and he soon reached a stage of near stupor. Coming in and out of consciousness, he was barely strong enough to talk.
R had been my patient for over a year. She was referred to me by a colleague. She had 38 symptoms. All tests and imaging studies failed to find any demonstrable medical disease; I considered her to have “symptoms of unknown origin”.
I had little information on R’s personal and family history. I did know she was 43 years old and was 7 years into her second marriage. Her first marriage ended in divorce from a severe alcoholic husband. She had no children. She dwelled on her many symptoms and avoided all my attempts to gather more personal or social information.
Before I can share my full experience with R, I need to provide some back ground on my clinical thinking.
In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. (1) I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.
An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.
Nothing has changed so much in the health-care system over the past 25 years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.
Q: “What is a well person?”
A: “A well person is a patient who has not been completely worked up.”
As I enter the exam room, a smiling 10-year-old boy greets me. Pete, my last patient of a long day, is here for his annual well visit. I chat with him about his life — home, school, nutrition, exercise, sleep, etc. — and I’m struck by something. Pete is really well. He’s well-fed (but not too much), active and well-rested, and, most importantly, he’s happy. He has not been to see me in an entire year, and only comes in for preventive health counseling. I think back on my entire day… and on my whole week. Pete is different from every other child I have seen this week. He is, in fact, the only truly “well” child I have seen in a long, long time. And I wonder — is he the last?
I’ve begun this post with a short riff on Dr. Clifton Meador’s satirical masterpiece, “The Last Well Person,” published in the New England Journal of Medicine in 1994. Meador profiles a 53-year-old man he imagines to be the last known truly “well” person in the U.S. in 1998. The patient is subjected to every known evaluation and found to be basically undiagnosable. I reflect on this story each day as I enter one examination room after another, visiting with patients (and their families) in my pediatric practice.
Sadly, the story of “Pete” is real. I no longer see many well kids even though I am a primary care pediatrician, dedicated to keeping kids healthy. Yes, I devote much of my time to counseling parents about lifestyle choices (e.g., nutrition, exercise, play, rest, sleep) to promote wellness and prevent disease. Still, each and every encounter must be “coded” with a numerical set of instructions based on diagnoses (associated with disease states) so that I can get reimbursed for the care I deliver. My ability to keep my office open (so that I can continue to try and help families keep their children healthy) is predicated on my skill in playing this diagnostic code game.
A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.
He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.
There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”
I began to wonder. I called my longtime friend and colleague, also a cardiologist. I knew him to be one of the best heart listeners. I asked him if he still listens to hearts. He answered, “Of course I do. I could not practice medicine if I didn’t. But you know every week, several patients tell me when I listen to their hearts that I am the first doctor ever to do that. Can you imagine that?”
Playing the devil’s advocate, I challenged my friend to tell me what he learned from listening to hearts.
He answered, “How could anyone not want to hear those murmurs, sometimes ever so soft, like whispers? Murmurs from the heart, even very faint ones, are trying to tell us significant things. Some sounds are very localized, even hidden or obscured by layers of air. And then there is the rhythm and the beat and the cadence that you cannot hear on the paper strip of the EKG. Also, careful listening is the only way to appreciate the rubs of friction if there are any. The devices are important, but the heart has its own spoken and unspoken language if you know how to listen.
A young doctor and his wife had just moved to the mountains of eastern Kentucky, near the border of West Virginia. The small town was nestled among the coal mines of the region. Nearly all of his patients would be coal miners or family members of a miner. Bill would practice family medicine. His wife, a veterinarian, hoped to build a small-animal practice.
Liz McWherther, the forty-seven-year-old wife of a miner, came to see the young doctor. Over several weeks, she had developed a curious set of complaints. Each morning she woke with a dry mouth and slurred speech. She also noted blurred vision and difficulty urinating. Within a couple of hours of waking, she was completely free of any symptoms. These symptoms had been occurring each morning and going away by afternoon.
Liz had had a series of tests done by the previous physician, but none of these tests were abnormal. The physical examination by Dr. Hueston was entirely normal. She denied drinking alcoholic beverages or using illicit drugs. Hueston had briefly considered some unusual response to marijuana or other drugs that were prevalent in the area. Liz had not been down in the mines, nor did her husband bring back anything unusual into the house.