Winter 1998


By Alison Stuebe
Once upon a time, it seems, physicians were wise and good, and medicine was an art. That's the feeling I get reading from the Chahar Maqala, tales from a time when doctors diagnosed lovesick princes from a urine sample, a pulse, and a review of local geography.

American medicine in the late 20th century seems considerably less romantic. Protocols and seven-minute patient visits are supposed to leave physicians tracking blood pressure readings and calibrating Prozac prescriptions. There's no time for wisdom in an HMO, or so the wiser and more ancient of current physicians lament. So it was with certain trepidation that I spent a day last December in an internist's office.

The morning started slowly, with a 63 year old woman with a history of hypertension, back in the office four months after her pills ran out. Her blood pressure, not surprisingly, was high. The doctor reminded her, wearily, to call the office for refills. She nodded. "Compliance," he told me, as we left the exam room, "is our biggest problem."

As the day wore on, a steady procession of patients made their way into exam rooms, worried about menopause, stuffy sinuses, colds caught from grandchildren, and all that ails retirees in late December.

Just before lunch, an 86-year-old man edged his way into an exam room, dividing his weight between his cane and his wife. "Yesterday, I felt like I couldn't breath," he said. "I can't leave the house. I get too tired."

I'd been warned that I would help take the history on this patient, and I was planning out my questions. A pulmonary complaint - "I can't breath" -- elicit a standard list, designed to distinguish heart failure from pneumonia from various other ailments - when did the shortness of breath start? Had he noticed he was more tired recently when he walked or exercised? Did he sleep with lots of pillows to prop him up when he slept? Did he feel pain in his chest when he inhaled? Exhaled? My mind was racing.

The doctor, meanwhile, was interested in golf. "Do you get out on the greens at all?," he asked.

The patient sighed. "No, I'll fall down, can't walk that far. I'm too tired. I can't breath."

After asking the patient's wife to leave the room, the doctor told him to undress. As I turned to leave, he stopped me. We stood and watched. When the patient tossed his jacket onto a nearby chair, the doctor asked him to get down from the examining table, and hang it up.

For the physical exam, he asked the patient to stand in the middle of the room and hold his cane vertically, swinging it from side to side.

As the patient dressed, we talked in the hallway. The diagnosis: "He's full of it, and that's what I'm going to tell him."

The strategy became clear: asking the patient to get off the exam table, arrange his clothes, climb back up, swing the cane, keep his balance. He'd been found fit for a day on the greens, despite a past medical history of a double bypass and back surgery.

"He may fall down and die on the golf course," he told me, "but what's the alternative? Fall down and die at home?"

He sat down with the couple, admonished the patient to get out more, and sent them on their way. Leaning less heavily on wife and cane, the patient left with a prescription: 9 holes, as needed for shortness of breath.

As Nizami-I-Arudi would say, "All wise men will perceive that one cannot heal by such methods of treatment save by virtue of extreme excellence, perfect science, and unerring accumen."

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