Cat-Like Observation

photo by Nate Gibson
photo by Nate Gibson

Even doctors must become patients eventually, and often challenging patients at that.  We know enough to be dangerous but not enough to be in charge.  We want to question everything but try not to.  We can tend to be catastrophic thinkers because that is how we are trained to be, but fear being alarmists.  We want our care providers to actually like us, when we know they inwardly cringe knowing they are dealing with another physician.  We wouldn’t want to take care of us either.

Due to intermittent changes in vision in one eye, I have recently been getting some practice at trying to be a model patient.  Unfortunately, I have become an ‘interesting’ patient, something no patient really wants to be.  That means the symptoms are not classic, the diagnostic tests not straight forward, the exam findings not clear cut, the differential diagnosis list very long.   It also usually means a visit to a tertiary care center for a visit with a sub-subspecialist to try to pick the brain of one of the handful of living physicians who thoroughly understands one aspect of complex human physiology and anatomy.  As a primary care physician who always sees an entire forest when I approach a patient, it is a unique experience to watch a colleague at work who truly concentrates on understanding one leaf on one tree.

A public academic training institution’s subspecialty care outpatient clinic is a fascinating place to spend a few hours.  The waiting room was packed to capacity with people from all walks of life sharing our afternoon together because of a shared concern about one small but crucial part of our bodies — our retinas.  We were all told the average time spent in clinic could be three hours or more and we all knew it was worth the wait so didn’t mind a bit.   Despite the long wait, not one of us would have thought to object when a couple of sheriff deputies accompanying a shackled county jail inmate dressed in his orange jumpsuit were escorted right into an exam room, rather than taking the only empty seats in the waiting room next to several elderly ladies.   We figured he was more than welcome to jump to the head of the line.

Finally my turn came to be seen first by a technician, and then a resident physician, then more testing with more technicians, and finally by the subspecialist attending physician himself.  I appreciated his gracious greeting acknowledging me as a colleague, but also his unhesitating willingness to be my doctor so I could be his patient.  His assessment after his exam  and review of everything that had been done:  there was no clear cause for my symptoms,  so my diagnosis would carry an “undifferentiated” label rather than the currently less preferred “idiopathic” label.   In other words, he didn’t know for sure what was up with my retina and as an expert he didn’t like to admit that, but there it was.

He then smiled and said “so for now we’ll treat you with MICCO.”

MICCO?  I knew there are many new unique pharmaceutical names that I have not been able to keep up with, but this was a brand new one to me that I figured only a sub-subspecialist would know about and be able to prescribe.

So he explained: Masterful Inactivity Coupled with Cat-like Observation.

In other words, do nothing for the moment but keep a close eye on it and be ready to pounce the minute something changes. Watchful waiting.

I am relieved to only be under watchful surveillance for now even though my diagnosis, its etiology and prognosis is unclear.  I realize it is a treatment strategy I need to use more in my own clinical practice.    It helps solidify that doctor/patient partnership, especially when the patient is a doctor;  I am content to do nothing but watch for now,  knowing I’m being watched.

It was an afternoon well spent in the sub-subspecialty world, as I come away with a commonsense piece of advice very appropriate for some patients in my own primary care practice:

Right now it might appear I’m doing nothing, but doing nothing makes the most sense and is the least risky option.  I’m keeping my unblinking eye on you, ready to spring into action if warranted.

Treatment plan: MICCO prn

photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson

Listening to Owls

Last night was clear with full moonshine and the owls were busy hunting on our farm, calling back and forth to each other, comparing notes on where to find prey.

Thankfully they were not calling my name. At least I don’t think so, nevertheless their hoots haunted me.

A coastal tribal legend has it that if you hear an owl call your name, your death is imminent. I’ve had no recent brushes with death, thank goodness, but as a doctor turned patient over the last two weeks, I’ve had cause to consider the preciousness of life and preservation of health.

The first was dutifully going in for my annual screening mammogram which became a two hour marathon of the radiologist asking for various wedge and coned down views, finally resorting to an ultrasound to determine that a small simple cyst had developed under a nipple and did not, from its appearance, need further investigation. Whew. My worry meter, working overtime through all the imaging, slid back to zero.

Then a subtle vision change in one eye resulted in an appointment with my optometrist who confirmed new vitreous floaters and opacities, but also noted an abnormal retinal artery in that eye. The next stop was the retinal specialist who documented a small retinal “wrinkle” and tear, but was more concerned about the artery which appeared to show some previous injury, whether from a clot or atherosclerosis was not clear. Initial screening lab work for diabetes, lipids, sed rate and metabolic functioning looked okay so more specific testing was ordered (D-dimer, C reactive protein) with elevated levels suggesting I am at risk for clotting, cardiovascular disease, and stroke, not to mention possible hidden malignancies causing a hypercoagulable state. As a 57 year old with hypertension whose family history contains plenty of cancers, wayward clots, unfortunate strokes and one sudden death heart attack, this certainly got my attention. The worry meter has gone into overdrive. Now I’m going through testing of my legs (no clots but lousy incompetent deep veins), carotids (no plaque) and next week my heart (to look for valve issues and emboli). Whether more testing is warranted beyond that has yet to be determined, so I’m sitting in the uncomfortable position of feeling just fine, thank you very much, but that is my denial kicking in.

There are no good reasons for retinal artery problems. They are all bad reasons. As someone on blood pressure medications for a decade and having gained weight I don’t need over the years (just in case of an unexpected serious food shortage, right?), I consider myself sufficiently warned. Besides aspirin, fish oil capsules and lipid lowering agents, I must change how I take care of myself or things will change for me without asking permission first. The doctor turned patient has been given a chance to make a difference in at least one patient’s future, or I’ll be no use to any patient.

The owls may not be calling my name but their hoots haunt for good reason. I’m listening.