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Office Visits

John R. Wieder, M.D.

It is strange how over 26-years practicing general medicine in Spartanburg County, South Carolina, just a few office visits that were so meaningful for me from my patients will remain as very precious memories that I will carry to my grave. The names will remain confidential but if they ever read this essay, I trust that they will come to know how very dear to me those visits were to me and still are.

A physician in the United States is trained in anatomy, physiology, biochemistry, pathology and the etiology, diagnosis and treatment of disease processes. The modern physician learns to appropriately provide certain chemicals, medicines, to combat these diseases to cure the patient's illness. Thank God the outcomes are usually positive. There is very little, if any, importance given to learning to bond with, or more aptly learning to love one's patients. This has led many to see their doctors as aloof, uncaring and viewing the patient merely as a disease process to be probed, poked, prodded and cured. In reality the patient is a living, breathing, evolving creation of the Creator. They - all patients - bring to the examining room an entire lifetime of differing circumstances, beginning with genetic inheritance, or course, and overlaid with childhood memories, both good and bad, relationships with others involving love and hate, differing levels of education, differing levels of understanding of just how their bodies function, personalities that differ in temperament from complacent to pathological ambition, from grouchy to compliant and alertness to dementia. It is one of life's greatest experiences to be a physician and meet so many of my fellow men who differ so much, yet, are all human beings in the end. It makes me realize more than any scripture or sermon that surely a benevolent God does exist, and believe me, I have felt His presence in my examining rooms on many occasions. For many years I was agnostic in my views but science has brought me closer to that ultimate creative force - the Star- Maker - than any religious service I ever attended.

Fortunately, my training at the Medical University of South Carolina in the most beautiful of American cities, Charleston, did its very best to instill in all its' students to remember to treat the whole patient - not just his or her disease - but the whole patient as a unique and beautiful living being. In fact, all of us students heard that term "the whole patient" so much that it almost became a weather beaten phrase - almost I said, not quite. I am still truly amazed at medical meetings when I run into my old school mates at how caring they all seemed toward their patients. For example, and I believe he will not mind me telling you of the experience and name the names, Dr. Robert (Bob) Scarpato, a classmate of mine and a man whom I hold in the highest esteem, related a house call that he made to those of us sitting around a table. Bob is a vascular surgeon/cardiologist in Hyannis Port, Massachusetts. He was taking calls for another physician when his beeper went off and he answered it. He was stunned to learn that he was requested to come to the Kennedy compound in Hyannis Port, Massachusetts. Arriving at the compound, he was met by a guard and asked to identify himself. After the establishment of who he was and why he was there, entrance was allowed and he drove up to the mansion itself. Knocking on the door, he received no answer. The door was slightly ajar, so he pushed it open slowly. Upon entering the foyer he noticed a large array of photographs, some recent and some of the distant past of the Kennedy clan. One thing caught his eye - a framed letter from a young school-age child to his mother, Rose, and was signed in childlike letters, Jack.

Bob said that his skin became goose fleshed and a swelling of tears came to his eyes. He was literally awestruck, by the history surrounding him and it struck him how fortunate he was as a physician to experience such a house call. Composing himself, he wandered through the house and heard noises coming from the kitchen. There he startled several cooks going about their duties. After introducing himself, he was taken to a bedroom to examine the patient. At that point in telling me the story, Bob choked up again. In retrospect, to the best of my memory, he said, "Dick, you cannot believe the feeling that came over me when I entered the room and there, sitting on her bed, was this woman of such great beauty, intelligence and grace that I was totally overwhelmed." He was in the presence of Rose Kennedy.

He did not say, nor did I ask, of the nature of her problems that evening, for I know how much Bob respects patient confidentiality. I wish now that I had given him a hug, for I could see the feeling of awe on his face to have been privy to such an experience that he would never have had, had be not been a physician. Dr. Robert A. Scarpato is a man of great knowledge and humor, equaled only by his great love and compassion for humanity. He can best be described as a loving old country doctor in surgeon's garb. It is a privilege to be called his friend and colleague.

I, on the other hand, have never in my years had the privilege to treat such a famous and gracious human being as Mrs. Rose Kennedy, but I do have some marvelous memories of my own.

The first visit was quite embarrassing to me, my nurse and the patient herself. In Enoree, South Carolina, a small mill village in southern Spartanburg County, I had a solo general practice for eight and one-half years fro 1975 to 1983. My office was a small building owned by Inman Mills, who literally had built the town over the years. One examining room was about eighth feet long by four feet wide. Between the examining table and the medical cabinet, on an opposing wall, an area of about 18 to 20 inches was allowed for me to stand at a table and examine my patients. A very attractive young lady had come back for a recheck, for which I had treated her ten days earlier. My nurse, Mrs. Virginia Sakalaris, escorted her into the room, took her vital signs and prepared her for my recheck exam. Virginia informed me that the young lady seemed to be very upset. I entered the room, followed by my nurse and stepped in front of the patient - remember that this was a tiny room. The patient has her blouse pulled out and unbuttoned but held closed by the tail of her blouse. I asked how she was feeling. At that moment, her lower lip began to quiver and her eyes began to water. She reached high on her blouse, flung it open, thrust her bare breasts in my face and screamed "That antibiotic you put me on shrunk my tits!" Startled, I fell back against the metal cabinet rattling speculums and glass jars so much that it sounded like a tornado had hit the building. My nurse fell back against the light switch pitching the room into total darkness. In a brief second or two - that seemed like an hour - Virginia turned the light switch back on. I was read as a beet, the patient was crying and Virginia lost it completely. Then we all broke out laughing so hard that we were all tearing. "Honey," I said, "There is no antibiotic that will shrink your tits." I tried to convince her, but to this very day, I do not think that the young lady believed me.

In order to understand one of my most memorable office visits, one must be aware of what the practice of medicine has become. There was a time when a doctor left his training to go into private practice with the ability to decide how and with what to diagnose and treat his or her patient. I pity the newer physicians coming into his field, for they will never know the joy of making one's own decisions. The insurance companies and especially HOMs want the public to think that they are based on the idea that all doctors and all hospitals are out to bankrupt patients by greedily over-medicating, over-testing and performing needless surgeries. I merely ask you to trust me when I say that 98% of all doctors, nurses and hospitals have always done their best to give good, competent and reasonable care to the American public. Yes, so
me doctors seem aloof and at times uncaring, but hospitals and allied health professionals must give their very best, because, if they do not, some lawyer will sue their ass off. HMOs developed formularies; lists of drugs that they will pay for and ones they will not pay for. In other words, businessmen fresh from the business colleges, aided by salaried physicians on their payroll, decide what is best for the patient. I have known many of my patients for 26 years. Based on their particular needs, I may pick a given medicine to treat their needs. But those businessmen and women, in cahoots with certain physicians - Who have never met my patients and would not know them if they walked up and spit in their face - decide decide what is best for them. This really sticks in my crawl! All amoxicillins are not the same. All ACE inhibitors are not the same. The HMOs prefer generic drugs in all cases. The difference in medications largely lie in their release mechanisms. An antibiotic and ACE inhibitor may be touted as once a day medicines. But in a patients system, some, but not all, generic drugs may release all of their substances too quickly, or too slowly and thus not give the patient the degree of required. It does a patient no good at all to use substandard medication. The HMOs tout generics to save the patient from paying higher co-payments, to save the patient money, to keep costs down. Name brand drugs are more expensive, but the pharmaceutical companies spend millions of dollars over many years to develop any given name brand product. When medical patents are granted, the research facility is given a chance to make up their cost and make a profit. After all, our economy is a capitalistic one. But, in the long run, this process has brought the vast majority of our populous a better standard of living than any other nation on earth since the dawn of history. Almost every time I order a test, scan or an MRI, I need permission from businessmen and women, who live hundreds, maybe thousands of miles away. In nearly every case my decision is denied by these people. They want me to use a less accurate, cheaper test. There is no test for a specific purpose that can tell me more about my patient's condition in certain cases than a CT or an MRI. The HMOs do not care about diagnostic accuracy! They are trying to save money, at times,maybe at the expense of my patient's life. In fact, HMOs use as their basis: keep costs down. Quality medical care is not cheap. It never has been, and it never will be.

Most HMOs require that a doctor, desiring to admit his patient, must first call the home office to obtain permission to admit their policyholder. Remember, these people making the decisions are not in the emergency room, looking at and touching the patient. They are not reviewing the lab work. They are not reviewing x-rays. They are off in some other city or state counting their profits. They are not seeing the fearful look in the patient's eyes who does not know what is happening to them. They have no idea how maddening it is for the physician to tell his patient, "you need to be in the hospital, but some SOB in New York or some other home office does not think so; now, I can go ahead and admit you, but the insurance company will not pay anything on your bill." The patient is left to figure out if it is worth a huge hospital bill for them to go into the hospital, or go home and possibly die. The patient may also be thinking that, "my doctor must be a jackass and does not know what he is doing if my insurance company will not let him admit me." Whoosh, there goes all of the trust that a doctor has built with his patient.

Please understand that these restrictions are absolutely maddening to the doctors in America. It is frustrating, stress inducing and cripples the thinking of all American doctors.

Here is the hooker: Here is the kick in the butt! The CEOs of the HMOs in this country receive salaries and compensation ranging from $3,000,000 to $54,000,000 a year! This is a matter of record. It make me think that a white collar mafia is in charge of American medicine.

If the companies do decide that the doctor can admit a patient, each diagnosis that they approve for admission is granted "X" number of day to get them in, get them well and get them out!

Keeping all of this in mind, I go to work each day to try my damnedest to give my patients the best care I can and still stay in the mafioso's guidelines. One particular day I was in a terrible mood, overworked, p.o.'ed at several letters of denial recently received regarding procedures I needed on some of my patients and ready to bite the next person's head off that even spoke to me. I reached up to grab the chart from my examining room door. Glancing quickly at it, I could see that a five-year-old boy named Jonathan had a fever and sore throat. With furrowed brow, clenching jaw and heart racing, I entered the room. There on the examining table was an adorable boy, sandy blonde hair, blue eyes, and perched on the end of the table leaning forward, on his hands. Now, I had seen this boy several times before and he is a very sweet little kid. I quickly perused the progress note sheet to check his vital signs and review the nurse's notes. Then I glanced over at his face, He was grinning up at me. Then from his lips he said, "Dr. Wieder, I just love you." For a split second I froze, , then unable to control it, broke into uncontrollable sobbing and ears dripped down my face. I dropped the chart and put my arms around him and kissed him on top of his blonde, fluffy head. I turned to his mother and through my embarrassing sobs, told her of the absolutely horrible day that I was having - of wanting to kick butt, throw my office chair through the window, stomp out and never come back. Then from the heart of a five-year-old boy, God let me know that I was performing the dream that I had always dreamed- being a doctor. Through all of the crap governing medicine today, it is still the most rewarding profession a human being can enter. The reward is not money, status or a big fancy car. The reward is the thanks and love of a grateful child or an older patient who may say as he or she leaves the room, "thanks, Doc."

Two other visits that I will recall are very similar in their content and happened within days of each other.

A woman whom I had known for nearly 25 years as a patient came to my office because she was having problems adjusting to her father's death. He died of metastatic cancer at home with her at his bedside. She had been very close to her father throughout her life. When his cancer had been found, there was still a lot of hope that he would beat this thing and recover. Time proved otherwise. When it became clear that he was not to survive, she went through a period of denial; Thank God he was going to make it! Her father was not going to die! Then his physician referred him to Hospice. Now, if there are angels in human form, it is the nurses of the ancillary staff that make up Hospice. They are called in at the end of life, not only to care for the dying patient, but especially to assist the family of the patient. They are, in a word, wonderful! Now this woman's mother was in the early stages of alzheimer's so it befell Sandy, as I will call her, to be the strong one in dealing with her father's death.

Sandy said that her father had once told her never to put her mother in a nursing home and to look after her until she passed away. This was causing Sandy a great deal of grief as she knew, to well, what alzheimer's will lead to. Well, Sandy was told by Hospice that sometimes the death of a person can be hampered and even made harder for the dying patient by the family constantly reassuring the person that everything is going to be okay, you are going to be all right, when in fact I believe very strongly many dying patients are well aware of the impending end. They can be uncomfortable because they do not want to upset the family members that seem so confident that recovery is just around the corner. I also think that many dying patients would love to say "look, I am dying, help me with it, be there for me." It is far more beneficial to that patient to let them know that the family is aware, though saddened, and it is all right to let go. Sandy's father had an old dog that slept on his bed every night. Now that he was home from the hospital surrounded by all of this strange equipment, the dog stayed true to his master and remained in his spot every day and night at the foot of the bed, nestled against his master's leg.

One evening Sandy was sitting at the side of her father's bed, talking quietly with him even when his eyes were closed. He would pass in and out of a fretful and painful sleep, perhaps a sleep induced by his medication, but she kept talking in a quite voice relating memories. Suddenly, the dog arose and began furiously running around the room. Her father opened his eyes, staring past her toward the foot of the bed. Sandy was puzzled by the dog's behavior and when she looked back at her father, he had raised a diseased weakened arm and was pointing to the foot of the bed. "Do you need something, Dad," she asked? She Looked in the direction that he was staring and saw nothing. "Do you want mother," she queried? He shook his head no and pointed again. "Is it the dog?" Again, he whispered no. Suddenly, without thinking, she asked, "Dad, is there an angel in the room?" He answered with an affirmative nod of his head. His arm slipped back onto the bed. She took his hand and whispered, "Day, it is okay, you can go," and with that he peacefully breathed his last; he was gone. Sandy then slipped her face down into her hands and wept. I felt in a sense that her tears of sadness that he was gone, mingled with tears of grateful joy that she had been able to share this last precious moment with him.

It was truly a beautiful moment for me and I arose and crossed the room, knelt down beside her and put my arms around her shoulders and whispered to her. All I could say was to thank her for sharing with me, her doctor, this divine moment in her life. I knew at that second that this was an office visit I would never forget and I told her so.

Karen, as I will call her, came to me in March of 2001 stating that she was depressed. She was not eating well. She was not eating well. She was not sleeping well. She was losing interest in life and having crying spells. Her menstrual periods were becoming holy hell for her. After a brief discussion of depression and a cursory exam, I started her on Sarafem 10mg. a day. This is a remarkable new product marketed by the Eli Lily Company for PMDD. PMDD is an emotionally trying condition for some women related to estrogen changes in their cycle among other things. I instructed her to go to 20mg. a day after the first week.

She returned to my office in mid-June 2001, crying and telling me that nothing was working. She did not know what to do. She was at the end of her rope. I discussed other alternatives to Sarafem, trying to bolster her with the fact that it was not right for her. Her marriage was sound, her job was stressful, but then what job isn't? Then she really cut loose with huge sobs, so much so that she could barely speak. Then, she blurted out that her father had not eaten in two weeks. I asked what was the problem? She finally calmed down at least to the point that she could speak. Her father had been diagnosed some time ago with prostate cancer. He had been doing well. Just a few weeks ago his urologist had been hopeful that things would be better. The family was overjoyed. Then, only a few days before her visit to me, she was at work when she received a phone call that her father was bleeding out of his mouth and was being rushed to the hospital. She rushed to his side. Later that day, the family learned that his cancer had returned with a vengeance. It has metastasized to his liver, lung and brain. He did not even know who Karen was at times. She was devastated.

I suddenly realized how wrong I had been last March. Here was a woman trying to understand the great changes that were taking place in her life. Everything was happening so fast. She was not depressed, she was grieving horribly and I had not been astute enough to be there for her. Depression is one thing. Grief is another thing entirely. There is no medicine for grief, only time, and I had missed the boat. For several seconds I did not know what to say. The doctors and nurses had told her and her family that there was just no hope. He was in the final death throws of his life, and a brief one at that, being in his late 60's.

Thirty something years ago her father laid down in an intimate moment of bliss and made love to her mother and brought Karen into her own world and life. She carries half of his genetic pool in every cell of her being. She could feel down, even to the chromosome level that something in her too, was dying. I believe that some mechanism not yet known to medical science, something occurs to us at the cellular level when a parent, sibling, child or even any blood relative dies. And to a slightly different sense, if the death occurs in a spouse, in a special friend or even in a stranger, for all human beings are connected together by the human gene pool. We are all truly one. Anyway, maybe that is the difference between depression and grief.

And with Karen, as I do with nearly every one of my patients who has lost or is about to loose a relative or very close friend, I recommend a book entitled " Life After Life", by a psychiatrist named Dr. Moody, who did the first true investigations into the near death experience. It was a book, which I read 25 years ago, that led me out of my misty world of agnosticism towards the light of my creator. In telling Karen about this book and describing some of the cases related there, her entire mood changed. She began to smile, her tears stopped, then she related to me the story of her friend Dawn. She and Dawn were the closest of friends, sharing their innermost secrets with each other. In fact, they both had vowed that if anything should happen to either one of them and if either one of them would bear any children the survivor would promise to look after any of those children. Oddly enough, both Karen and Dawn shared a very similar dream on one occasion. Dawn had confessed to Karen that she had a horrible dream that someone had died tragically. She had gone to the hospital emergency room. As she approached the body she was unable to discern the face and so she could not identify the person.

Karen eventually gave birth to a daughter. One evening Dawn and her boyfriend were visiting at Karen's home and saw the baby for the first time. As the evening progressed, Dawn and her friend left in his car. Moments later, Karen heard what she thought was an automobile crash. As it turned out, two blocks from Karen's home, Dawn was killed.

Karen's daughter is now 6 years old. Not too long ago, Karen put out a framed picture of Dawn onto a table. Seeing it, her daughter rushed up and said, "Mama, Who is that?" Karen responded by saying that was a picture of Dawn, a very dear friend. Her daughter's eyes widened and she turned to Karen and said, "She is my friend too, she is always with me and says that she will always look out for me." Karen said that this just absolutely flabbergasted her. One evening later they were passing a cemetery while driving through town. Her daughter looked out the window and said, "That is where Dawn lives, but she is here with me now." Both of us just stared at each other.

It was obvious at this point that the office visit was drawing to an end. Both Karen and I had dried our tears and we were both...just kind of giddy, and we were giggling. It had been a catharsis for both of us. I wrote down the name of the book and author and Karen promised to buy it and read it. This visit was on Friday morning, June 22, 2001. I was off that Friday afternoon and weekend. I can honestly say, as God is my witness, that was the most joyful weekend off I have ever had. I was ecstatic. I was walking six inches off the ground. It was the very afternoon that I felt compelled to begin this essay. It is a day that I know that I will never forget.

I have just stopped and read what I have written so far, making a few corrections. I was adding in words I had forgotten when it struck me like a bolt of lightning! Why these three office visits in particular (there are so many beautiful moments that I have shared with patients) but these three...why?

I believe is is because that in these visits, I too had received a healing. A cure. I had never thought of my patients healing me! After all, I am the trained healer. And yet, I now understand the full import of something said a long time ago. It has a whole new meaning for me now...Physician, heal thyself. For in some metaphysical way, when we reach out to help another, we receive help ourselves. When we can uplift another, we uplift ourselves. Do unto others, as you would have them do unto you. Whatsoever a man soweth, so shall he reap. These patients had unknowingly reached out and touched me by their situations. When in a moment of extreme frustration, resentment and anger, an adorable five-year-old boy told men that he loved me. He made me realize how petty I was being. He made me realize again what a marvelous life I had in realizing my childhood dream of becoming a doctor. The two women trying to come to terms with the losing of their fathers had finally brought closure to me. My grandfather John "Cap" Wieder died in June of 1947. That was my first experience at losing a loved one. I remember it as if it were yesterday when my sister, Libby, came running outside to the sidewalk where I was watching cars go by at 1507 Spring St. in Parkersburg, West Virginia, "Grandpa Cap's dead," she kept screaming it over and over. I turned to run back into the house where we lived. The entire scene remains blurry in my memory because my eyes were full of tears. I did not understand at the time just what "dead" was, but somehow I knew that I would never see Grandpa "Cap" again.

My father, Maj. John M. Wieder, whose death hit me harder than any death I have ever experienced, died in the wee hours of January 27, 1997, at approximately 12:30 a.m.. My dear stepmother Dotty, called to tell me of his passing. At that moment I felt as if an eight-pound cannon ball had been fired through my chest, leaving a hole that would never be filled. My father served his entire adult life in the Military. He enlisted in the United States Army in 1939. He joined the U.S. Air Corps at the end of WWII and took his flight training at Randolph Field in San Antonio, Texas. I have quite a few memories of that time, 1946, because after that he never really lived with us again as a family. My growing up was largely without him. Memories that should have filled my heart where that cannon ball hole was now never to be filled. And until that Friday afternoon, June 22, 2001, when two of my patients who had lost or were losing their own fathers, that date I swore I heard my dad say, "See Dick, I told you that everything would work out well." He died a noble death, strong and unafraid. My brother, Steve, who was with dad at his death, told me later that he had never known anyone in his life that had faced death so nobly and so strongly as my father. Totally unafraid, dad had turned to Steve that night, saying that he had lived a full life, he had loved a lot of people and he hoped that a lot of people had loved him. He could not understand why God had yet to call him home. His only hope was that God would take him soon. Shortly after those words, my father died.

Libby, Steve and I are now the old guys of our family. At future reunions of our clan, we will be those old gray haired people who slip quarters to nieces, nephews and grandchildren. Hand out wet sloppy kisses. Have to be helped to our feet. And talk of folks passed on that none of the children there will ever know. It will be a wonderful feeling to be at that stage of life.

Those three patients have healed me of my fears, helped me to come to terms with the death of my father, and allowed me to re-attain my dream. I have but only one wish- only one dream- only one hope in my life and that is, like my father before me, as did the quarry slave in the poem "Thanatopsis" at my death be..."soothed and sustained by an unfaltering trust approach thy grave like one who wraps the drapery of his couch about him and lies down to pleasant dreams."