Old Doc Leathers

AUTHOR:
Bruce Martin, MD
Boca Delray Cardiology Center, Delray Beach, Florida

CITATION:
Martin B. Old doc Leathers. Published online August 12, 2020. Consultant360.

This Doctor's Story is a fictional short story. The characters do not exist, and the events have not occurred. 

At 80 years young, Dr Lawrence Leathers had certainly developed a formidable reputation. Having devoted his entire career to a family medicine practice in a small town, the doctor had an enormous following of loyal patients, many of whom had grown older with him. Towering in height and lean as a flagpole, with a booming voice and commanding manner, his patients loved him but were also terrified of him. They obeyed his orders without question. No patient had ever even entertained the thought that Dr Leathers could be wrong at anything.

After his Army days, Leathers graduated medical school and then pursued his internal medicine training at a well-known mid-Western hospital. He was attracted to the Western lifestyle and adorned his medical office with accoutrements of the frontier. He was known to wear a cowboy hat and had the head of a longhorn mounted on the wall behind his desk. He loved to tell patients about the time he rode a bison, about the outing during which he chopped the head off a rattlesnake, and about the week he spent at a ranch in Wyoming driving cattle. Because of these affinities, his patients called him “Tex.”

Despite his long, successful career and thousands of adoring patients, his advancing age finally convinced him to hang up the spurs. In order to maintain continuity of care, Tex sold his practice to a young doctor just finishing his residency training. A letter was sent to his entire patient base introducing Dr Jeremy Milstein to all, assuring them of his confidence in this new doctor’s intellect and diligence. As per Dr Leathers, “I have the greatest confidence that Dr Milstein will provide all of you with the same high-quality medical care that I have given you all these years.”

Meeting Dr Milstein

It was a brilliant Monday morning when Dr Milstein arrived at the office to begin the process of meeting his new patients, one by one. Trained at a top medical school and residency, the young doctor was exceptionally well-educated, astute, and already highly experienced.

He rose to greet his first patient of the day, eager to apply his knowledge and diagnostic ability. To his surprise, the patient did not walk in but was brought in sprawled across a cushioned wheelchair—a shriveled, cachectic man appearing approximately 90 years old. Dr Milstein immediately observed the patient’s sunken, jaundiced eyes that displayed no spark of life.

The patient appeared to have muscle wasting and malnutrition, along with swollen joints and parched mucus membranes. There was a severe, reddened, butterfly-shaped rash across his face and a green coat on the tongue. The noisome odor of yellow and black fungus wafted upward. His mental status was lethargic and depressed. Dr Milstein noted edematous ankles and audible wheezing. The patient looked to be end-stage.

As kindly as possible, Dr Milstein asked the patient, “Mr Henderson, when did you start to feel sick?”

The patient answered slowly in a voice frail and strained: “About two years ago, I came to see Dr Leathers because I was getting chest pain. I had a twinge on the right side of my chest.”

Dr Milstein said, “OK, keep going. Then what happened?”

Mr Henderson continued, “Well, Dr Leathers told me I had an ulcer and started me on an antacid. I did feel a little better for a while, but the pain then came back.”

As the patient was speaking, Dr Milstein quietly perused the sloppy handwritten chart notes from previous visits with Dr Leathers. He read the office note from two years ago, and sure enough, it confirmed what the patient had related. But as the doctor scanned the page, he came to a horrible realization. The elderly appearing, atrophied, morbidly ill patient before him was only 38 years old. He was also taking 49 different medications.

“Mr Henderson, how old are you?” asked Dr Milstein.

“I’m 38. I can’t believe what’s happened to me these past two years. I feel so weak. I used to be so healthy. My weight is down 40 pounds. I have no appetite.”

Dr Milstein flipped through the chart, following the sad timeline. After the patient’s initial office visit with Dr Leathers, a few weeks later the patient once again presented with chest discomfort. Dr Leathers therefore prescribed an anti-inflammatory medication, naproxen. One of the most common adverse effects of naproxen is hypertension caused by fluid retention.

A few weeks after that, the patient’s blood pressure was elevated, so Dr Leathers prescribed amlodipine. The most common adverse effect of amlodipine is swollen ankles.

A few weeks after that, the patient came to see Dr Leathers for swollen ankles. Dr Leathers started the patient on a water pill, furosemide. A known adverse effect of water pills is gout.

Soon after that visit, the patient developed a gout attack. Dr Leathers started the patient on allopurinol. Allopurinol can cause elevated liver enzymes.

A few weeks later, the patient was noted to have mildly elevated liver enzymes. At that point, Dr Leathers started the patient on prednisone. A common adverse effect of prednisone is elevated sugar levels.

Two weeks after that visit, the patient was found to have elevated sugar levels. Dr Leathers told the patient that he now had diabetes and started him on canagliflozin. This particular medication increases the risk of urinary infections.

Three weeks later, the patient presented with urinary discomfort and frequency. Dr Leathers diagnosed a urinary infection and immediately started the patient on an antibiotic. A major risk of antibiotic therapy is an overgrowth of dangerous bacteria in the colon, causing infectious diarrhea.

Soon after that, the patient developed abdominal pain and explosive gushes of diarrhea. Dr Leathers was on it, immediately prescribing a tincture of opium to stanch the bowels.

On and on it went, the list of medications growing and growing, until finally the patient was started on procainamide, which can and did cause lupus. When the patient saw Dr Leathers for symptoms of lupus, Dr Leathers suggested starting a chemotherapy agent and preparing for radiation.

A computed tomography scan was ordered, along with ultrasound studies of the liver, gall bladder, and pancreas. He also recommended placing a feeding tube in the stomach to treat the weight loss, to perform an immediate rigid sigmoidoscopy to examine the rectum using a tool he referred to as “the green monster,” and a biopsy of all lymph nodes and the spleen.

Dr Milstein sat for a while, pondering the astounding situation before him. As gently as he could, the doctor began to explain to the patient what amounted to an almost incomprehensible example of malpractice.

“Mr Henderson, I know you just met me for the first time, and because of that, you may not feel comfortable with what I’m about to tell you. I understand how much you loved Dr Leathers. But …” Dr Milstein hesitated for a moment.

“Go ahead, doc. Tell me. I can take it. It’s curtains for me, isn’t it?” Mr Henderson asked sadly. I guess I need to get my affairs in order. How long do I have?”

“No, it’s not like that at all. Look, Mr Henderson, you may find this hard to believe, but you don’t need any of these 49 medications. The chest pain you experienced two years ago was just a simple condition called costochondritis. It’s like a little arthritis in the chest wall. It’s really not a serious illness. If you had just used a heating pad and had taken some Tylenol, it would have cleared up within a few days. You didn’t need any of this. I’d like you to stop everything. Stop all 49 medications. Everything, today. Just stop it all.”

Bewildered but exhilarated, Mr Henderson stopped all 49 medications that day. And within two weeks, his appetite had returned with a vengeance, he had gained back more than 10 pounds, his joint swelling resolved, his muscle strength returned, the rash disappeared, his mental lethargy was quickly clearing, and he felt better than he had in a long time.

At the same time, he heard through the grapevine that Dr Leathers had purchased a magnificent ranch in Wyoming. He was also in the process of setting up a small medical walk-in clinic in town. Incoming patients were impressed not only by the massive longhorn head on the wall but also by a prominently displayed honorary plaque, awarded to Dr Leathers for “a lifetime of superlative medical care.”