Thallassemia, Vitamin D, and Testosterone


 Arriving at the office at 730 this morning I found a the usual bunch of lab results in the lab queue. I enjoy reviewing the numbers in the quiet of the office before the rush starts. Every result ties in with a face and a family, a story that by itself would be a novel. There will always be at least one surprise a day.

Worried about a child with unusual symptoms and an abnormal blood count, I asked the lab to send a slide of the blood to the pathologist for review. If I had been more diligent in med school I would have learned to read such slides on my own. On the other hand, I wouldn’t have read enough of them to be any good at it. The punch line was thallassemia minor, an hereditary blood problem involving abnormal hemoglobin. At least we have an explanation for the symptoms, the family will be relieved, treatment is not obnoxious. I haven’t seen a case since 1988.

I always enjoy getting back a low vitamin B12 level, especially if the patient is suffering from numbness, weakness, fatigue, or loss of memory. I get to save the patient’s life at the cost of about five bucks a year.

There was a low testosterone level, and I’ll be able to make the patient feel better, have better sex, and probably bring down his weight and cholesterol by replacing the deficiency.

Abnormal thyroids, though, are my favorite.

Every time I make a patient better it’s a rush of endorphins. Saving lives is good, and relieving pain before they walk out is wonderful. In Family Practice, we don’t get much immediate gratification. The vast majority of our work has to do with delaying actions on the consequences of unhealthy life style decisions. So when the opportunity comes along to get that fast feedback, I revel in the moment. I can’t count the number of vitamin D deficiencies I’ve seen in the last two days—I don’t have that many fingers.

I have fit in well with my partners. No one has gotten defensive when I make a diagnosis that got missed, and pretty much no one makes fun of me for going to look for the unusual diagnoses, the “zebras.” I didn’t always fit in well with my colleagues, this has been a good group to work with.

I visited the plastic surgeon this afternoon about the squamous cell skin cancer growing between my eyebrows and set up the surgery about two weeks from now. I didn’t squawk about having to miss work; having made the decision to leave makes it much easier for me to care for myself. My reputation for having sense of humor preceded me I and broke both the surgeon and her nurse up by observing that it was so cold the photos of Tiger Woods on the TV showed his zipper was up.

Mixed feelings roil inside with every patient. Come back in three months, I say, and while I will probably be there when they come back, I might have already Gone Walkabout. I am losing my continuity of care. On the other hand, freedom beckons. I received eleven job offers today, and I can see that I might spend my entire day off talking to recruiters. I’m not sure if they’ll believe me when I tell them I’m not in it for the money.

When I interviewed at University of Colorado Medical Center in 1974, they didn’t believe me. The doc I talked to had evidently had a hard time trying to deal with insurance companies just before he met me, and the interview centered around the question of “How much are you worth, Doctor?” He didn’t like my answers. I didn’t get offered a position, and I wasn’t encouraged to reapply. Just as well. Michigan State was very, very good to me.

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