Nowadays he remembers how he and Rosemarie crouched atop those houses, the blue of the Atlantic at their backs, nailing shingles to the roof. He made his hands do her bidding. The mother did not know, and the boy did not tell her, that at night in his bed he bargained with God. He had attended five funerals in little more than a year, and they had terrified him. Over the graves of his loved ones he learned the words of the Lord’s Prayer for the first time. At night, he prayed: Please, God, don’t let my mom die. Please don’t take her from me.
His prayers were answered. She lived long and prospered. When she died four years ago at the age of 69, she was a wealthy woman. When she took sick with lung cancer, he gave her the greatest gift he could. He shut down his practice and cared for her 24/7 for the last seven months of her life. “It was the most rewarding thing I’ve ever done,” he says.
There is an art to interviewing patients. The doctor asks numerous questions of the patient, like, “You say you have a throat pain. Is it a stabbing pain or a dull, sore pain?” Depending on the patient’s responses and lab evidence, the doctor works his or her way down an algorithm to the correct diagnosis. In medical textbooks, the diagnostic path is sometimes represented by a tidy chart, but in real life the process is rarely so pat. Interviewing patients is laborious work. While you are seemingly carrying on a simple conversation, your mind is sifting through everything you have ever learned about medicine.
More often than not, Bolte is guided by intuition. He tries to bond with the patient as quickly as possible, hoping to forge an alliance in which the patient feels comfortable confiding even the most intimate details. He chatted amiably with Ethel Moore, cracked jokes, told her about himself, his practice, his patients—and gradually disarmed her. Over the course of that first meeting, he learned that she smoked Nat Sherman cigarettes, which she ordered by mail; that she sometimes had a burning sensation on her tongue; that she’d had a history of dental work; that she enjoyed eating fish. A couple of times a week, she experienced a tingling or numbness in her hands. Just before the rash started, she remembered being bitten by an insect at the base of her neck.
Huh, the doctor thought, maybe a biological infection?
He asked her if she spent a lot of time outdoors. She said yes, of course, she lived in the country. She estimated that she’d used hundreds of cans of DEET insect repellent over the last 30 years.
Hmm, the doctor thought.
On and on the talk went, the agreed-upon hour stretching, as it often does, into two hours. When he had looked through her case file, he noticed that her physicians had ordered three biopsies on her lesions, which led to the cancer diagnosis. But they hadn’t analyzed her blood for the presence of unusual chemicals. Such a test is hardly standard. It has to be specially requested. On her second visit, Bolte took a blood sample himself and sent it for testing to a lab in Texas that he trusted implicitly. Her previous doctors probably had not requested such a test because she didn’t mention anything to them about her generous use of household chemicals. She hadn’t mentioned it because they didn’t ask.
It’s all about the questions—and the time it takes to ask them.
Over the years, to help streamline the Q&A process, Bolte has formulated a questionnaire, which he asks patients to fill out after their first visit. The 32-page document is comprehensive, asking after family medical histories, social history, habits, hobbies, employment, exposure to household products, industrial chemicals, foreign travel, and so on. Bolte estimates it takes two to four hours to complete. He does not apologize for such complicated homework. Humans are complex, and a doctor never knows until much later if a patient’s response was significant or just a red herring.
He is currently working with software developers to create a questionnaire program that may help target areas for follow-up by physicians who do not have the luxury of time in which to ask questions—which is to say, nearly all physicians. The economics of modern medicine is not conducive to leisurely interviews. In order to handle all the patients funneled his way by an insurance company, a doctor is obliged to hire numerous staff to handle the paperwork and make sure his invoices are paid. The more staffers on the payroll, the more patients a doctor must see to cover it and ensure a profit for himself and his partners. The more patients he can crank out in an hour, the more profitable he will be.
When Bolte worked in such a practice, he was horrified to find that the HMO actually generated “batting averages”—the average number of patients seen per hour by each physician—which the manager posted in a back office. Bolte almost always finished dead last.
“There was a time in this country,” he says, “when doctors made house calls and when they were done, they sat down to dinner with the family. That’s how they got to know you. The next time someone in your family took sick, the doctor knew their context. He knew what their home life was like, knew what they did for a living, and so on. Today, you’re lucky if your doctor sees you for 12 minutes. How can you possibly find out all you need to know about a patient in 12 minutes?”
