chapter thirteen
WET BEHIND THE EARS
A few days later Dr. Mitchell and I were discussing several of the patients I had seen in the office the day before—as well as looking at some of the plans for the new office building. I was growing to appreciate Mitch’s wisdom, experience, and common sense. Suddenly Helen came in to tell me, “Walt, your first patient is ready and in the procedure room.”
“Whatcha doing, Walt?” inquired Mitch.
“I don’t know,” I answered. I looked up to the nurse. “Helen, what am I doing?”
“Well, I’m no doctor . . . ,” she began, with her usual and somewhat sarcastic disclaimer, “but it looks like a small nonin-fected sebaceous cyst.” She paused for a second and then inquired, “You gonna use the iodine?”
At first I thought she was discussing the substance I would use to clean the skin prior to making an incision to remove the cyst. I thought, Doctors haven’t used iodine for operative prep for years. Most doctors use Betadine. My mind quickly reviewed our protocols at the hospital. Dr. Mitchell uses Betadine in the OR. Wouldn’t he use the same thing here in the office? So I decided to question her question—not necessarily a wise decision.
“Helen, I usually use Betadine. Don’t you have that?”
Initially she looked confused. And then she began to laugh, covering her mouth to try to hide her laughter. She looked at Mitch and then at me.
“Dr. Larimore . . . ,” she giggled.
I looked at Mitch. What was so funny? I wondered.
“Walt, didn’t they teach you about removing sebaceous cysts with iodine crystals at that fancy medical center?” Mitch chided.
Now it was my turn to look confused. “What in the world are you two talking about?”
Mitch stood there chuckling. “Helen, let’s teach this wet-behind-the-ears youngin’ an old dog’s trick, whatcha say?”
“Sounds good to me, Doctor,” she replied. She looked down her nose at me and turned to leave, while Mitch got ready to give me another lesson on how medicine had been practiced in these parts for the past fifty years. Mitch sat on the front edge of his desk, arms crossed across his chest. It was lecture time. “Actually, Walt, I didn’t learn this technique in school or in the service. Dr. Bacon taught me this, and he picked it up from the guys that were here before him.”
He thought for a moment, then continued, “Gosh, I guess I’ve been using this technique for over thirty years, but I don’t think I’ve ever seen it in a medical article or a textbook.”
“Mitch, you’ve got my curiosity up. Tell me about it.”
“Well, Walt, you can only use this technique to remove an uninfected sebaceous cyst. And you can only use the technique in areas where the skin is fairly thin. Just won’t work if the skin’s real thick or if there’s any infection or inflammation. In those cases it’s best to just cut it out by using the standard surgical technique. But in the right cases it works like a dream and is great for most of the local folks because they don’t have to come back to the doctor for follow-up or to have stitches removed. All you do is numb up the skin over the cyst with a little bleb of lidocaine. Then make a two- or three-millimeter stab wound, using a #11blade scalpel, down into the cyst. Take one or two iodine crystals— we get them from Doc John at the drugstore—and place ’em deep into the center of the cyst after you’ve made the incision. Put on a Band-Aid, and that’s all there is to it.”
I was dumbfounded. “How does that get rid of the cyst?”
“Well, son, it doesn’t.” Mitch was quiet, but his eyes were laughing. Was he pulling my leg? Was this a joke? He continued, “Apparently the iodine desiccates the cheesy sebum in the cyst. Causes it to shrink, blacken, and harden into a rock-hard little stone. This takes several days. While that painless chemical reaction takes place, there is just enough drainage to keep your stab wound open. After, say, five to seven days, the patient or a family member can just squeeze on the cyst, and out it will pop—like a pea out of a pod.”
“I’ve gotta see this,” I exclaimed.
“Won’t take but a minute for me to show you. Come on.”
I followed him down the hall to the procedure room where Helen already had the patient settled onto the operating table.
“How you doing, Jimmy?” asked Dr. Mitchell as he washed his hands and put on a pair of gloves. “Let’s take a look at that thing.”
There was a half-inch lump on the young man’s scalp, just behind the ear. “How long’s this thing been there?” Mitch asked.
“Don’t rightly know, Doc. Don’t rightly know. But it’s sure getting bigger. And it bugs the dickens out of me when I try to brush my hair. Sure would like it out.”
“No problem, Jimmy. Let me numb it up a bit. I want to show our new doc how we do this around here. Jimmy, this here’s Dr. Walt Larimore.” Mitch nodded in my direction. “He’s just joined us. Did his training down at Duke. But they didn’t teach him everything down there, did they, Walt?”
“Nope, guess not. Good to meet you, Jimmy.”
“Good to meet you, Doc. You’re learning from the best here. He’s took care of all our folks. My daddy and my daddy’s daddy. Won’t find better. Nope, you won’t.”
“I’m sure you’re right, Jimmy.”
“Jimmy, you hold tight. I’m gonna numb this a bit.” In only a second or two, Mitch applied a bleb of lidocaine and then Helen took the syringe and handed him a scalpel. He quickly and deftly made the stab and squeezed out just a bit of the malodorous and cheesy-looking sebum from the cyst.
“Walt, that confirms the diagnosis. Nothing but nothing looks or smells like the contents of a sebaceous cyst. The body has millions and millions of microscopic sebaceous glands. There’s one or two in each pore of the skin. The sebaceous oil from these glands is one of the body’s natural oils. But if the gland gets plugged up, it just keeps making the oil and it builds and builds until a pronounced cyst forms. I sure like seeing them when they’re not infected. One whole heck of a lot easier to treat.”
By now Helen had fetched a small black bottle and a pair of forceps. “Walt, you just take one or two small iodine crystals . . .” He reached into the bottle with the forceps, withdrawing a small black crystal, “ . . . and jam it into the middle of the cyst.” Which he did. Jimmy didn’t flinch.
“That’s it, Jimmy. This thing will be ready to squeeze out in about a week. I’ll have Helen here explain to you how to do that and how to care for it until then. If you have any trouble, you let us know, ya hear?”
“Yes, sir. I hear ya. Thank you, Dr. Mitchell.”
Then I heard, for the first time, a statement for which Mitch was famous. It made the patient feel good about coming in for the visit and magnified the doctor’s reputation throughout the region. “Jimmy, you got to me just in time with this thing. If you had waited much longer, it probably would have gotten infected, and I tell you, that’s a mess, son. But I believe we got it just in time.”
“Thanks, Dr. Mitchell. Sure appreciate you.”
“You bet, Jimmy. No problem at all.” Mitch paused just a moment, and I could see an idea dawn in his head. “Tell you what. Instead of me having Helen tell you how to pop this cyst out in a week, how about you drop by the office and let me show young Dr. Larimore how this works? That sound OK? I know you work just down the road. We could see you on your lunch break, and there’ll be no charge for that visit. Sound OK?”
“You bet, Doc. No problem at all. Always enjoy those free visits. After all, you don’t do that very often.”
Mitch smiled. “Gotta pay those bills, Jimmy. Gotta pay those bills.” He looked at Helen and me. “Jimmy, you wouldn’t believe what it costs to hire good help these days.” We smiled.
“Jimmy, you be sure to tell your dad and mom hi for me, you hear?”
“Be glad to.”
Mitch signaled me with his eyes and a nod of his head. We stepped out of the room.
“What do you think of this old mountain technique?” Mitch
asked me.
“I’ll have to admit it’s pretty neat. Does it really work?”
“Nearly every time. Piece of cake, son, piece of cake.”
He paused for a moment as though reminiscing, then continued, “Nothing like the practice of medicine, son. Nothing like this profession. I’ve got to have the best job on earth.” He turned to head into the next examining room. As he closed the door I heard him saying, “Good thing you got here to see me, Sammy. Let me look at that thing.”
I smiled.
The next week, I saw Jimmy’s name on my schedule and greeted him as Helen and I entered the room.
“How you doing, Jimmy?”
“Just fine, Doc, just fine. I’ll be glad to get this thing out. The black drainage has messed up the collar of a shirt or two—at least until I figured out how to stick a cotton ball over it.”
“Sounds like a good idea. Let me have a look at that thing.”
The cyst had indeed shrunk to at least fifty percent of its previous size and looked like a dark black stone just under the skin.
“Want me to show you how Dr. Mitchell does it?” asked Helen.
“You bet.” I took a couple of steps back.
Helen washed her hands and put on a pair of gloves. She placed a pointer finger on each side of the lump.
“Jimmy, hold on now. Shouldn’t hurt much.”
Then she pressed her fingertips toward each other and the iodizing remnant of the cyst popped out with the help of the compression on each side of the wound.
I smiled. “Wow, that looked easy. Jimmy, did that hurt?”
“Not a bit, Doc. Not even a little bit.”
Helen smiled as she placed a dab of Neosporin and a BandAid over the wound. “Piece of cake, Jimmy. Just put a dab of antibiotic ointment on this four times a day. It should be healed in just a few days.”
As Jimmy was leaving, Helen commented, “Usually I just teach a family member to do this at home. Saves the patient some time, some money, and, for many of them, a trip to town.”
I figured this was only one of many old tricks this new dog was going to need to learn in rural private practice.
At the end of each day in the office, Mitch, Ray, and I would usually sit for a few minutes and chat about the day. A topic of recurring concern to me was Drs. Mathieson and Nordling. Both seemed constantly irritated by my presence. Whenever I’d enter a nurses’ station, they would leave. Mitch and Ray tried to reassure me, and they encouraged me to just give them some time. We also talked about problem patients and practice management issues. Having had training in practice management while in residency, I assumed I had some expertise, albeit no experience.
Because my schedule as a new doctor in town was less crowded than Mitch’s or Ray’s, I offered to help them develop and improve some of their office procedures and policies. One of the most noticeable deficiencies was the billing and collection system. Mitch had some unpaid bills that were decades old. He would send out a bill four times a year—and would keep doing it, sometimes for many years.
We had been taught in our practice management classes that this way of billing was fairly useless. If within the span of about four months the average person had either not paid their bill or made arrangements to pay it off, our teachers said, there was virtually no chance that it would ever be paid. So we were taught that if the patient didn’t respond to the fourth or fifth monthly bill, then he or she should be sent a stern letter—return receipt requested—telling them to either pay the bill within thirty days or call the office to arrange to make payments on the bill within thirty days. If they didn’t do so, they would be dismissed from the practice within thirty days and their bill would be sent to a collection agency.
When I suggested this mode of operation to Mitch and Ray one evening, Mitch’s response was swift and stern. “You stupid, son? That won’t work here. First of all, folks pay when they can—and not before. Very few folks ’round these parts leave a bill unpaid unless they’re in tight straits. Second of all, if I throw them out of the practice, they’ll tell everyone they know. That’s no good for them, for me, or for you boys. Might work in the big city. But not here, not with our folks.”
I looked at Ray. He shrugged. I felt I shouldn’t push.
Mitch left to do evening rounds at the hospital. Ray looked at me. “You were wise not to press the issue. I’ve only been here two years, but I’m still learning a lot. Mitch knows his medicine and he knows this community. I’m learning to trust his gut. Let’s just see what happens.”
“Sounds good to me, Ray.”
“But, Walt, don’t stop making suggestions. You’ve made some great ones. Glad you’re here.”
Later that week, I was doing a well-baby exam when there was a knock on the door. Without waiting for my response, Mitch entered. He greeted the patient, “Howdy, Tammy. My oh my, little Libby sure is growing. Mind if I borrow your doctor for just a moment?”
We stepped into the hall. “Got a second?” Mitch asked. “Want you to meet someone.”
He headed down the hall to his office. I followed. Reva was chatting with a young couple. Sitting on the woman’s lap was a three- or four-year-old child. The way they were dressed indicated that they were not well-off. The man’s calloused hands and his tanned and wrinkled skin—making him look older than his age—indicated that he probably worked outdoors.
“Bobby and Jennie Sue, this here is our new doctor—Dr. Walt Larimore. He’s just joined us. I wanted him to hear what you had to say.”
The couple looked embarrassed.
“Go ahead,” Mitch encouraged, “he’ll be as proud of you as I am.”
Bobby began to speak—hesitantly and in low tones. “Well, me and Jennie Sue had Faye Marie here nearly three years ago over in Sylva. We come home from the hospital, and when she was six weeks old, I tripped while carryin’ Faye Marie out to the car. We was heading out to church. Anyway, we took a tumble and little Faye Marie banged the tip-top of her head on the car door. It wasn’t a real big cut, but she bled like a stuck pig. ’Bout scared me to death, and Jennie Sue here was near hysterical. I stopped the bleeding with my kerchief and we ran up here to the hospital. Louise called Dr. Mitchell, and he come and sewed her up.”
He paused and looked at the floor. “Frankly, we didn’t have the $60 to pay the bill, what with the baby doctor bills and all. My lumberin’s been a bit on the downside—prices not that good—and gas and oil’s been up. So I just couldn’t pay the bill. I called up Dr. Mitchell’s office, and Reva here just said pay when I could. Dr. Mitchell hasn’t even sent me a bill since then.”
He took a deep breath, then continued. “Well, we begun savin’ a bit, whenever we could. Cut back a bit on some things. And today we come in to pay our bill. To make it right.”
He looked up at Dr. Mitchell, admiringly. “Want to see your work?” He smiled and turned toward his daughter. Separating the hair on her forehead, he said, “Looky here. Can’t hardly see the scar.”
Mitch and I leaned forward. Indeed there was a barely discernable line, just a bit lighter in color than her skin color. I wasn’t even sure I would have been able to see it if her father’s calloused finger hadn’t pointed it out.
“She’s healed mighty fine, Bobby.”
“I think she had a good doctor and that’s why she healed so good.”
“Well,” replied Mitch, “you brought her to the right place, and just in time too! That made all the difference.” I smiled at hearing this classic Mitchism again.
“We’re much obliged to you, Dr. Mitchell.” Bobby held out his hand, offering three crisp $20 bills.
“Thank you,” Mitch said.
“No, thank you, Doctor. We best be off now.”
“Bobby, you be sure to tell your daddy and momma hello for me, you hear?”
“Yes, sir, I will,” he replied as he left. Jennie Sue politely smiled and turned to follow her husband down the hall, little Faye Marie in tow.
I sat in silence.
/> Mitch turned to Reva. “Tell our young Dr. Larimore, will you, Reva? How often does that happen?”
“Oh my gosh, Dr. Mitchell. Several times a week. We’ve even had family members come settle a bill after a patient has passed on. Folks around here take care of their bills. May take a while, but you can depend on them.”
“Reva,” Mitch asked, “what’s the oldest bill that has ever been paid?”
Reva thought for a minute. “I suspect it was the Balls. You delivered their last child about seventeen years ago. They came and paid the bill just this summer. Said they didn’t want their daughter graduating from high school with any bills left unpaid.”
“Thanks, Reva.” He smiled as she stood up to leave the room.
Mitch looked at me. “Those big-city practice management experts, they ever tell you about this?”
Now it was my turn to be embarrassed. “No, sir, I don’t think they’ve ever heard about this sort of thing.”
“Wouldn’t look very good if I had thrown them out of the practice, would it? Or if I had sicced a collection agency on them, now would it?”
“No, sir, I don’t think it would either look good or be very wise.”
“Me neither, son.” He turned to leave. “Let’s get back to work. Lots of folks to see and lots left to learn.”
At first I thought he was referring to my ineptitude. But then I realized that wasn’t the case. He was referring to our profession—one in which we continue to learn right up to the day we stop practicing.
Bryson City Tales Page 11