No two doctors are alike, not in who we are nor in how we practice. We do fall into patterns, though. One way to sort physicians is along continuum that runs from flea to blade. Fleas take tiny bites. Blades take slices. 

The most extreme flea is the internist who pieces together data from the patient’s story, their physical exam, lab and radiology studies, documentation of previous medical encounters, etc. The doctor keeps turning the data crank until satisfied that the patient is on the right course. A flea’s workup may involve nothing more invasive than blood draws (flea bites). Their method is similar to the one Sherlock Holmes uses to deduce who committed a crime by constructing a picture based sometimes on the smallest of clues.

The ultimate blade is the trauma surgeon who wields a scalpel to get right to the source of a threat to life or limb, like so many of the heroic doctors who populate TV medical series.

There are all sorts of gradations along the flea/blade spectrum. In my humble opinion, the best physicians are flexible enough to know when to be more flea-like and when more blade-like.

BY MARC RINGEL, M.D.

As a family doctor (retired), I myself lean more toward fleadom. Most of the problems I encountered in day-to-day practice were not urgent life-and-death issues. There was usually plenty of time to figure out what was going on and, if needed, order more tests, prescribe another drug, counsel the patient on different ways to manage their affliction or simply wait and see if things got better. On the other hand, in my rural practice, when it was my turn to cover the ER or if things went south in the delivery room, I had to be prepared to jump in and do whatever aggres-sive maneuver the situation called for.

The flea/blade distinction recently was brought home to me in quite a personal way. I described to my friend, a seasoned general surgeon, some mild digestive symptoms I’d had. He definitely does not suffer from the arrogance that is a hallmark of the derisively termed overly aggressive “surgical personality.” He is thoughtful, patient, and listens and explains well. Pius tuned in as I described over the phone my symptoms and enumerated my own theories about the cause of my discomfort, ranging from medication intolerance to, God forbid, pancreatic cancer (an unlikely diagnosis that passed through my mind, no doubt because our mutual dear friend, another physician, was in the final stages of it). I had tried antacids to no avail. Pius recommended getting an abdominal CT scan, a moderately big deal in terms of cost and radiation exposure. From his surgical point of view—having directly seen and repaired or excised hundreds of diseased appendixes, gallbladders, intestines, pancreases, stomachs and esophagi—the first step was to definitively identify the cause of my problem, then to address it decisively.

Eventually I gave its due to the old saying, “A doctor who treats himself has a fool for a doctor and a fool for a patient.” I visited my internist, another great doctor. We spent an unhurried 25 minutes together in his exam room. (He used an EMR but typed only during pauses in conversation. When he did address the computer, he mostly chose to write prose rather than to check boxes.) I told Steven my story. He listened patiently to the differential diagnosis (list of possible diagnoses, ranked by likelihood) I’d come up with myself. He asked good questions, waited for complete answers and followed up to be sure he understood the exact timing and description of the symptoms. Then the doctor did a focused physical exam, concentrating on my abdomen, heart and lungs. He ordered some blood tests, which turned out just fine, and told me that if my symptoms persisted, he’d send me for an abdominal ultrasound or CT. Steven thought my symptoms were probably caused by a drug I had just started taking. He didn’t prescribe a thing. He did ask if I’d had flu and COVID vaccinations.

I was better within a few days, in large part, I believe, because, my doctor had healed me with his intelligence, attention, concern, kindness and touch.

On this occasion, the internist, a flea, arrived at a diagnosis with a minimum of testing and zero radiation. He was poised to order imaging studies and certainly would have referred me to a surgeon, if he deemed that was what I needed.

Surgeons heal so many people with so many different problems, sometimes heroically. We could not practice medicine without them. They identify disease and go inside the body to fix it. I’m awed by their skill, both diagnostic and procedural.

Nor could we practice medicine without the non-surgeons who assess and treat the lion’s share of problems that pass through the clinic or hospital door. There are far too few of us, based in large part on the dramatic potential of the opposite ends of the flea/blade spectrum.

Scalpel blades are way sexier than flea sty-lets (the blood-sucking mouth parts), which explains why you see so many surgeons and so few pediatricians, internists and family doctors on those TV dramas, and, partially accounts for why there are too few fleas in real life. Though the rewards may come in a different form, non-surgical medical careers, with their powers to heal based in large part on relationships, are at least as satisfying as surgical ones.

I started out to write a general piece about an aspect of medical culture not well known to the layperson and found myself where I always do when I talk about healthcare from my family physician’s point of view, under-scoring the value of primary care. Trust me. I’m not being self-congratulatory, not to myself nor to my generalist colleagues. The goal is to educate readers about the value of having a flea-like doctor (or nurse-practitioner or physician assistant) who knows all about you and whom you consult first or most health problems. If they cannot fix you with some testing and medical therapy, they’d better know a good blade to refer you to.