Abstract
He practiced medicine for 50 years, and in the last 20 he worked from a storefront building he owned in a one-street town in rural America. The street ran parallel to the railroad, and little had changed since the Union Army had encamped there in 1863. Nearby was a council oak beneath which Indian chiefs considered the perils of the coming changes in the development of the region in the next 200 years. It is not that the old town is dying. It actually never was more alive than this sleepy place where history and humanity move in a slow and gentle flow rather than surging tides of brilliance and violence. His old office was graced by a waiting room with chrome chairs well worn and copies of Field and Stream and Reader's Digest. There was a little desk long abandoned by the receptionist, and the patients were entirely polite in remembering their order of entry into the waiting room and thus their turn to be seen. Doc had an office somewhere in back with a few old textbooks, a too large desk, and his modest trophies from practice and ardent fishing. Old family photographs were neatly interspersed with his diplomas and certificates. The microscope and lab bench he had used for whatever technology offered in his early years were dusty and had not done a complete blood count or microscopy in decades. The phone was most used to confirm the Thursday night poker game with other community leaders, a constant in his schedule. His information source was not a computer or any particular reading of journals but his enormous experience with people and their medical, social, and personal problems.
He knew everyone in town and the surrounding farms, mills, and shacks. He had known the parents and grandparents because this was not only his site of practice but his hometown as it had been for his ancestors. After being trained in general medicine he had returned to bring medical care to the people he knew so well. He belonged to the medical society, and it is pretty clear that he was never party to litigation or censured for any unprofessional behavior. He and his family were the mourners at every funeral and attended the local Baptist church faithfully, and he was not known for anything other than straight talk and total confidence. He was highly respected but too close to the general community to be revered. Rather, he was a part of the terrain like the sandstone bluffs that looked benignly down on the little village from the heavily wooded mountain above. He could be trusted.
Doc attended the required continuing medical education classes and had a perfectly clean medical license and narcotics number. Early in career he had identified the telltale signs of human frailty in alcohol and the various manifestations of hypochondria. His advice and prescribing habits took that knowledge into full practice in his patient's best interest. He was slow to recommend disability, days off from school, or excuses for absence of dalliance by local farmers when the tedium of the valley took them off to the nearby city for a little fun. He was aware of the social diseases of the community and firm in his advice. He did not prescribe much in the way of opiates and generally stuck to a minimalist approach to all chemical intervention. He followed the methamphetamine epidemic closely and knew the signs of abuse in weight loss and severe gum disease as well as social decay that attended the savage addiction. He knew the kinds of burns that resulted from fires in meth labs and added that medical knowledge to his deep understanding of domestic abuse, chronic illness, child neglect, and old age. He just would not agree to postpone a problem with a poultice of drugs to curb the immediate rather than face up to an issue. No enabler was he. Despite these rather severe restraints in prescribing, his practice never flagged. The waiting room was as full in his last week of practice as in the years of full practice when he did minor surgery, some testing, and house calls.
Over the years the county seat some 20 miles away had acquired a respectable general hospital; local surgeons and internists were well trained, specialists came from some distance for office hours once a week, and the medical system was tightly allied with the larger medical systems of the state. The larger town practice became more and more specialized and relied upon the credentials of the physicians proudly displayed on fancy office walls, and electronic records plied the ether of the medium of medicine around the country as very modern diagnostic testing proliferated. There was even a free-standing magnetic resonance imaging unit in the larger town, and a former gas station had been converted to a cancer center. The helicopter could get emergency cases to the larger towns, and the local population was conversant with such terms as bypass, stent, chemotherapy, hip replacement, and obesity surgery. Why did Doc's little practice have the confidence of the community, and what possible purpose could it serve in the information age? Why did the people think it indispensible?
In this rural place, like so many others in our sophisticated culture, the people had an old-fashioned suspicion of newness. They would seek the advice of relatives and neighbors long before resorting to professional help. Few used the Internet to explore their concerns about disease. But when they really wanted an honest opinion, there was Doc. He listened. He always listened. Then he would advise with remarkable accuracy a course of medical action that might involve a trip to the city to an appropriate specialist for testing and conclusive diagnostics. He just knew when the complaint sounded ominous. He also could explain to patients what they had been told in the city. He used few Latinate words and only elaborated after careful listening to the patient's concern. He had a remarkable ability to realize when a complaint had grown great in the fertile imagination of his patient and what was needed was a dose of common sense and restraint. He would advise following a situation and letting its natural course inform us better as to the direction the problem was headed.
Of course that was the most common advice he dispensed, and such an approach will work in most instances. However, the symptoms of diabetes, irregular menses, thyroid dysfunction, or pigmented skin lesions were never ignored. Some things you do not follow anywhere, except the straightest path to definitive care. He was the one who convinced Great-Grandmother that it really was time to go to an assisted living facility, to stop driving, and to cease her doctor shopping for sleep medications. He broke the news about herpes to the youth and told middle-aged patients that despite such an early onset this must be menopause. He was also generous in his lifestyle advice to correct abuses that contributed so significantly to the disease burden of chronic obstructive pulmonary disease, obesity, diabetes, and heart disease in his community. He may have dined daily in the country inn next door for lunch, but many noted that he mostly consumed the gossip and not the abundant fried goods that defined the cuisine.
In that tiny office he listened to and studied the life of his town. He just listened to the tales of human failing and fear spilled out in fitful sentences of shame and fear and filtered them through the prism of his great experience and concern. The spectral lines of truth shone through. The sorted and clear solutions were a great solace and immense value to his patients. He was a sage; he was a confidant; he was the Doc.
It is fairly clear to everyone's recollection that in later years he kept no records. He associated with no insurance carrier. He had no drug advertising in his clinic. For that matter he had no drugs. In his rumpled old suit and school tie askew he ambled from his office and saw his patients in two old exam rooms. Each had a writing table, old manual exam table, blood pressure cuff, and ophthalmoscope. A few sterile supplies were his stock for wound management. Splinters came out with an ouch; little boils were lanced; his arthritic old fingers probed the places of complaint and gently patted the shoulder of patients from childhood to senescence as he just told them the plainest of truths. Whenever he was finished and sure the patient understood, he took his fee of $5.00 cash and wrapped it around the large wad in his pocket. He thanked the patient and excused him or her, stepping to the waiting room door where he called “Next.” The polite crowd identified that patient, who proceeded to the office to explain today's concern.
Medicine has moved forward in so many wonderful ways. Information is richly abundant, and evidence for decision support is ubiquitous. Telemedicine means we can even be in this small town by the railroad when needed to provide current and authoritative medical management. We can go to every farmhouse for home care and speak with authority and professional insight. We can fit people into a continuum of care and a context of information integrity for their entire lives. Doc died a few years ago, and the town grieved. Recently at the country inn next door the older crowd talked about Doc. Despite the great advances of medicine it was clear they missed him, and he was slowly taking on some perhaps unearned mythic qualities. Still, he had a place in this community, and it is not clear the newer approaches have made such a physician irrelevant. We continue to seek ways to have machines win at chess, provide the bon mot for a story, and help us with our clumsy syntax and miserable spelling. Yet there is a place for the marvelous outcome when a sentient, caring, experienced human being interacting with another human in distress yields a very warm, comforting, and highly effective diagnosis and the grace of acceptance. Perhaps we should study Doc a little more and prepare new healthcare workers who will know what he knew and can bring the power of information into a cozy environment like this old office. A new generation could be expected, empowered by information and connectivity to interact with patients, bringing a generational confidence and love for patient care.