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Life – and medical care – in a northern town

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One of the first things I read this morning when I started work was an opinion piece in the New York Times by Abraham Verghese, MD, titled, "Treat the Patient, not the CT Scan." His piece struck a chord with me because I'd just returned from my not-exactly-annual annual physical where I pondered anew the challenges and benefits of living in a small, closely-knit community of fewer than 4,000 people in northern Montana.

Verghese writes of the widening involvement of technology in medicine and how it may increase efficiency at the cost of the doctor-patient connection. He cites the example of one patient who was diagnosed with advanced breast cancer that would have been easily detectable much earlier with a basic, hands-on physical exam.

In contrast, my own experience (the not-exactly-annual annual physical) was intensely personal. I've known my physician since I was in grade school. I socialize with her son (who also works with my mother in the school my children attend) and gasped through a series of horribly early exercise classes with her daughter-in-law. I've blown kisses at her granddaughter and congratulated all of them on their next baby on the way.

My doctor is also my mother's doctor, making questions about my family history almost moot. Our conversation instead traced the familiar path of where my siblings are living, how my mother has been doing since her last appointment, and the various internal and external forces in my life that could affect my health.

She spent more than 45 minutes conducting a thorough physical exam and discussing my concerns. (It turns out that when you haven't been to the doctor for five years, there's a lot to talk about!) There was not a computer to be seen. At no point did I feel rushed or dismissed, and I left the exam room feeling comforted and cared for.

But:

The hypochondriac in me sometimes wonders whether the more technologically intensive approach Verghese writes of would be "better." Am I missing out on something by having my medical records confined to handwritten pieces of paper rather than entered into the types of sophisticated computer databases he describes? What if I have a life-threatening medical problem that could only be detected by the most advanced imaging (coupled, of course, with my awesome power of worrying between 3 and 4 a.m.)?

After this morning, I think not. While I can easily see that medical progress saves and extends lives, I have to remind myself that these advances occur on a population-wide scale. On an individual basis, there's little or no evidence that a healthy, relatively youngish woman like myself would benefit much from a pantheon of medical tests and a stable of personal physicians.

For example, one of the issues I discussed with my doctor was when I should have my first mammogram (hey, I said "youngish"). Clearly, recent research has done little other than to highlight the lack of a consensus between medical professionals as to when a baseline scan should be done. Some say 40 years old; some say 50.

True to the spirit of mutual partnership, my doctor suggested a compromise: "I'll fill out the referral and you can decide whether you want to do it now or later," she suggested. There was no lecturing - just a thoughtful discussion of an issue with no right answer.

Maybe I can tell her my decision next time I see her at the grocery store. Or perhaps I should have asked the opinion of the lab technician who took my blood sample - we sing in the same church choir together. Small towns. A tangled, beautifully messy web.

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