This article is a small sample from DISCOVER's special Medical Mysteries issue.
A woman named Ethel Moore* arose one morning in the summer of 1999 and traveled 76 miles from her home in upstate New York to see a doctor in Manhattan. Moore was 74 years old, a stylish, humble woman who looked like someone’s mom. Once in the doctor’s office, she disrobed to reveal a secret that had both plagued and embarrassed her for two years and which she had kept hidden from friends and neighbors. A hairy tan-and-brown rash covered her body from the neck down. She had visited numerous doctors to rid herself of the affliction, but to no avail. The pathology lab of a prestigious Manhattan institution had examined biopsies of her lesions and pronounced them cancerous; her regular doctor had dutifully prescribed chemotherapy. To Moore, that felt like a death sentence. She wanted a second opinion.
Her new doctor, Thomas Bolte, thought that she was more than entitled to one. As he flipped through Moore’s voluminous medical files, he could see that something was destroying her immune system—but he did not know if it was cancer. As a young physician he had worked at a pathology lab, and he knew from experience that labs occasionally made regrettable errors. Under the microscope, a skin cell might look cancerous when it really wasn’t. Histopathology, the microscopic study of diseased tissue, is more art than science. If the lab had gotten the diagnosis wrong, chemo might kill this patient. Bolte had never seen anything like this rash in his life, but he was determined to save Moore from it.
Bolte, who today is still boyish at 45 and still working out of the small one-room office where he first examined Moore, is a doctor obsessed with mysteries. He calls himself an unusual symptoms investigator, his term for a doctor who picks up where other doctors fail. Patients find him on the Internet, and they appear in his consulting room like characters out of a foggy Sherlock Holmes story: The Case of the Migrainous Art Dealer. The Case of the Irritable College Grad. The Adventure of the Chemically Sensitive Sleeper. For fees that are astonishingly reasonable by New York standards, Bolte takes these patients under his wing and tries to ferret out the reasons for their illness. He usually succeeds.
“If a person calls our radio show and says they have a problem that no other doctor has been able to help them with, that they can’t crack the case, I refer them to Bolte,” says Jerry Hickey, a pharmacist and host of InVite Radio, a nutritionally oriented program aired on the New York City–based talk station WOR. “He’s sort of a medical detective. He looks at things out of the box, and he’s solved quite a few cases over the years.”
Like the cranky character played by actor Hugh Laurie on the Fox TV series House, Bolte is a master of the differential diagnosis—identifying patients’ ailments based on a careful analysis of their symptoms. At times cases have taken the doctor into the realm of the weird, as when a patient casually informed Bolte that her psychic told her she was suffering from a parasite, specifically Entamoeba histolytica. “I didn’t know psychics knew that much about parasites,” Bolte says, “but I am always willing to keep an open mind. I said, ‘That’s fine, but why don’t we do a stool test?’” The results proved the psychic correct. Bolte, a spiritual man who is also fascinated by Jungian theory and the workings of synchronicity, chalked that one up to the importance of staying open to whatever the universe slings in your direction. The patient, of course, was miffed that she paid for lab work for the doctor to learn what she already knew.
Unfortunately, many of the patients Bolte sees are victims of iatrogenic, or doctor-caused, illness. Simply put, they have been misdiagnosed, overmedicated to the point of sickness, or given treatment inappropriate to their conditions. On occasion, this has led to shouting matches with more conventional docs, like the dermatologist colleague who burst into Bolte’s office one day and harangued him—in front of another patient—for telling the mom of an acne-ridden teen to stop feeding her child so much junk food. There’s no evidence that diet has anything to do with acne, the dermatologist shouted. Bolte begged to differ and cited the literature. “The pharmaceutical industry has trained even doctors to believe that there’s a pharmaceutical answer to everything,” he says, shrugging.
Bolte’s colleague, Robert Scully, a board-certified internist and medical director of two MediCenter Clinics in Long Island, New York, has followed the younger doctor’s work for the past 15 years. Bolte sometimes consults him for advice. Scully says that there’s a very good reason why doctors sometimes miss what is right in front of them. “In mainstream medicine there’s an expression: ‘When you hear hooves, don’t initially look for zebras.’ And as a result, zebras are missed all the time. Tom’s a zebra hunter.”
Back in 1999, Ethel Moore took a liking to this man who gave her so much of his time and asked a seemingly endless stream of questions. I just know you’re going to find out what’s wrong with me, she told him. I just know it.
Something about the tone of her voice was familiar. If you listened between the words, you could detect a more urgent plea that Bolte knew too well: Please, doctor, help me get well. Please don’t let me die.
Call him Dr. House if you want, but this is not the House you know. You see, before he fixed people, he fixed houses. The houses belonged to his mother, an Irish-American woman named Rosemarie Martin, who bought a handful of dilapidated houses by the seashore in Long Island, hoping to rent them. When the boy was only 11, his family lost five of its dearest loved ones in the span of 16 months. A beloved cousin, three grandparents, and lastly, the boy’s father—all dead from various illnesses. Bolte’s father, felled by a melanoma, had been a dapper Long Island attorney, and when his widow ran out of cash, banks foreclosed on the family’s two homes. Rosemarie, who until then had played the part of the doting housewife, whisked her son and daughter away to live in the slums of Staten Island with her father, her children’s only remaining grandparent. There was talk of sending the kids to foster homes, but Rosemarie vowed to keep the family together, to get a job, make money, and move back to the Island. She sought financial security in real estate.
The pattern went like this: Rosemarie and her son fixed up the houses, the tenants trashed them, and they fixed them again. From a parade of handymen the boy learned to plumb pipes, wire switches, hang drywall, lay brick, and do simple carpentry. He learned that no two tradesmen built a house exactly the same way. They all had their little tricks, their favorite tools, favorite circuits, favorite brands of building materials, and unorthodox pet theories. When something in a house didn’t work, you fixed it by running down all the possible options where the system could possibly break down. You found the leak and patched it; you uncovered the rotten joist and sistered it back together.
Years later, his hands would take him to the hearts of machines: jalopies, used computers, musical instruments, sound equipment. When he was still in his early twenties, studying medicine in Puerto Rico and moonlighting at a San Juan hospital, his hands coaxed newborns into the world, 60 or more before he ever graduated from medical school.
During his residency at New York Downtown Hospital, he was chosen to be administrative chief resident of his class—a high honor—in his last year. “He was extremely bright,” recalls Satish Dhalla, director of general internal medicine at Downtown Hospital and a professor at New York University School of Medicine renowned for his seminars preparing residents to ace their medical board exams. Concurs Bruce Logan, chief of medicine during Bolte’s tenure, “Tom was an extremely reliable, hardworking guy who really cared about the patients. Just a really good guy.”
After Downtown, Bolte worked as many as six medical jobs at a time. Doctors, he thought, were no different than builders, and you should try to learn from as many as possible. Inspired by his parents’ fascination with nutrition and alternative medicine, he apprenticed himself to Robert Atkins, the famous diet doctor, and Leo Galland, another author of best-selling books who blended alternative with conventional therapies. Bolte didn’t think much of Atkins’s famous diet at first, but eventually came to think it worked well for patients with type 2 diabetes. Clearly, he realized, med school had taught him a lot about drugs, but his training had been markedly deficient in the areas of diet, nutrition, and exercise. “There’s not one drug that has been proven to ‘extend’ life,” he’s fond of saying. “The only things that do that are fruits and vegetables.”
The first time Rosemarie saw her son in a white coat, a stethoscope draped around his neck, she wept. Somehow, all the time he was in medical school, she had not connected the dots, had not imagined that this kid in gypsum-spattered jeans spackling drywall was going to be a doctor.
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?”
After the HMO experience, Bolte longed to open a practice that was relatively free from the influence of insurance and pharmaceutical companies. Today he literally runs his own office. No secretaries. No partners. No insurance forms. (Many patients submit his invoice to their insurance companies for reimbursement.) If you call the number listed on his Web site, it rings his cell phone. “Doctor’s office,” he says. “What’s the problem you’re having?” Then, if you agree to his terms—no insurance, $125 for a 25-minute urgent care visit, $290 for a major 60-minute consult, he’ll enter your appointment into his Palm Treo. When you arrive at the office a few blocks south of Bloomingdale’s, he answers the door himself, unless he’s with a patient. It’s like this all day, all week. When it comes time to pay, he runs your debit or credit card through the machine under his desk, prints out an invoice, and asks, “Want me to staple that?”
Although unusual investigations are his specialty, urgent care cases help pay the rent. Hotel concierges near his office know to call him if an out-of-town guest takes sick. He’s the official on-call doctor for MTV Networks, and if someone there calls, he skates over to the studios on his Rollerblades with a knapsack of medical supplies strapped to his back. A number of celebrities—an Oscar-winning actress, the widow of a famous rock star—regard him as their official New York physician. But you don’t have to be famous to get him to your bedside. He’s one of the last Manhattan physicians who makes house calls. He unhesitatingly gives his number to every patient who visits, even if he knows it could later wreak havoc with his social life, dinners out with his fiancée, or an ongoing home renovation project back on the Island. “Please,” he reminded a recent flu patient who was leaving, “I’m completely at your disposal. If you get worse or it doesn’t clear up, call me at 3 a.m. I don’t care.”
He goes to such lengths to stress this because so many patients have been trained by the medical industry to behave deferentially, as if their doctors are always too busy to bother with them. Yet some of his most fascinating cases were solved precisely because he gave patients the time that their primary care physician could not.
“The first time I met him I thought he was a quack,” says Dustin Palmer, a 29-year-old sales representative. “I hate saying that because I feel I owe my life to him.” Palmer’s teens had been hell, punctuated by crippling abdominal pain and alternating bouts of diarrhea and vomiting. Doctors diagnosed him with irritable bowel syndrome. (“A lazy diagnosis,” quips Bolte.) Palmer lost so many days of school that it took him five years to graduate from college. By then, he had lost his faith in doctors and was depressed. “I couldn’t see any future for myself,” he recalls. Dragged to Bolte’s office by his mother, Palmer—then a kid with unkempt dreadlocks—rocked back in his chair and uttered profanities at Bolte, who just chuckled.
“Whaddaya laughing at?” Palmer demanded.
“I’m laughing because I know I’m going to get you well,” said Bolte.
Oh, the kid thought, you met me an hour ago and you know what’s wrong with me? Sure you do, buddy.
Bolte’s rambling interrogatory style threw the kid off. “I think he’s a genius,” says Palmer, “but kind of like an idiot savant. He sits there and he’s nonchalant, but he’s got a lot more knowledge up there than I first expected. You would not expect it.” For Bolte, the key was hearing specifically what foods Palmer had eaten prior to his attacks. Over time Bolte demonstrated that the young man was suffering from celiac disease, a genetic disorder that meant he could not digest gluten, a protein found in most grains and commercial food products. As many as 2 million Americans have the disease, which attacks the intestines, but doctors routinely misdiagnose it. Over the course of several visits, Bolte studied Palmer’s food diaries and helped him nail down which foods were most likely to trigger the painful autoimmune response.
Another patient, an art gallery owner, arrived one day complaining of chronic headaches that he’d had for 40 years. His primary care physician had him on six different medications, some prescribed for migraines, others for depression, and still others for the side effects from the migraine meds. The suffering was so severe that the patient took to bed for days at a time, tracking his headaches on a calendar, hoping to divine a pattern to the pain. Some days the meds worked, some days they didn’t. But no pattern emerged. Every doctor he saw seemed to be grasping at straws: One prescribed an antifungal medication; another, allergy shots. Bizarrely, Bolte seized upon a single symptom: The man casually mentioned an intolerance to egg yolks. If true, this seemingly innocuous point could narrow his problem down to only one or two possible diagnoses, one of them being heavy metal poisoning. Sifting through the file, Bolte found a hair analysis that the desperate patient had commissioned at an alternative pharmacy: The results showed elevated levels of mercury. Yes, the patient said, he had shared that result with his original doctor, who pooh-poohed the test and told him that if he was concerned about it, he might want to reduce his fish intake. Bolte ordered a DMSA challenge test, in which a drug is taken orally that extracts heavy metals—if they exist—from tissues and excretes them in urine. The urinalysis revealed extremely high levels of mercury. The man responded well to medication and a new diet that flushed much of the dangerous toxin out of his body. Two years later, he celebrated his first headache-free month.
Another time, a woman presented with headaches, fatigue, hives, rash, and countless chemical sensitivities. After a lifetime of fine health, she broke out with the most annoying physical symptoms from using soaps, shampoos, and cleansers.
After a blood workup revealed the presence of hexane, a petroleum derivative known to cause nerve damage, Bolte asked her about her living conditions. What, he asked, makes your home different from other people’s? She boasted that she had a fine new home. After living in a one-bedroom apartment for years, she bought and renovated the apartment next door after the birth of her first child. Now she had a roomy three-bedroom apartment, the kind of place New Yorkers would kill for.
What happened to the extra kitchen? Bolte asked her.
Now it’s my master bedroom, she replied.
You have a gas stove, right? Where did the old stove in the old kitchen sit, exactly? Can you tell me? Do you remember?
The patient’s eyes widened. My bed is right up against the spot, she said.
A few days later, at Bolte’s insistence, the woman had the gas company inspect her apartment. They located and corrected a leak in the woman’s bedroom, not far from her headboard. The patient bought and installed a small sauna unit, which she used to sweat out the toxin. Her symptoms resolved in six months.
Ethel Moore’s was the grandmother of all these cases. When the chemical analysis came back from the lab, Bolte was stunned. He picked up the phone. He told Moore that her blood test had uncovered high levels of two toxic chemicals—2-methylpentane and 3-methylpentane—both derived from petroleum products.
Could there be something in her environment that was exposing her to abnormally high levels of petroleum products? Moore said she didn’t know how that was possible. She’d already had the local board of health to her home to test her tap water and check for natural gas leaks.
He pressed on. Okay, so we’re looking for something outside the house. Have other neighbors been ill? She knew that one man who lived behind her had kidney cancer; that was all. Did she or anyone in her family work in a gas station? Was there a gas station near her home? She said no; she lived in a very nice trailer park in upstate New York, not far from I-87, the New York State Thruway. There was nothing on the site but homes just like hers, all arranged in a subdivision with Hawaiian-sounding names.
In all his years of working on houses, the doctor had never visited a trailer park. He asked Moore to describe what they looked like. How were the homes constructed? In the industry, he learned later, the correct term is “manufactured home.” The structure is built off-site and designed to fit on a trailer bed towed by a big-rig truck. Once at the site, the home is craned off the flatbed and placed onto concrete piers or cinder blocks, or permanently mounted to a custom-built foundation.
Which does your home have? Bolte asked. A foundation? Or does it sit right above the ground?
Above the ground, came Moore’s answer.
Do you know what was on the site previously?
She didn’t. But she promised to look into it and get back to him. He hung up reluctantly, half wondering if he should drive up north to help her, have a look around, and maybe photograph the site for his files. If she had lived there a long time in the presence of contaminated soil, her senses may have become inured to a faint petroleum smell that he would notice immediately.
When she was younger, perhaps, her immune system had been able to fend off the daily onslaught of toxins. But as she got older, they had gained the upper hand. If she spent time outdoors working, living, or gardening, she would have inhaled toxic fumes and consumed particles as part of her daily routine—and at night as she slept.
A few weeks later, Moore called with news. At her urging, the local board of health had pulled the real estate records and discovered she and some of her neighbors were living on the site of a former industrial train depot used by Standard Oil in the late 19th century. An independent lab tested the soil for petrochemicals.
Shortly after, the owners of the property voluntarily offered to excavate, remove, and replace the soil under the homes of Moore and some of her neighbors. Moore’s lesions had begun to disappear. By January 2000, the levels of toxins in her body had dropped to almost nothing, and she was living a normal life once again.
The doctor wishes he knew more about her, but she dropped out of sight sometime after their last meeting in August 2003. Beyond that, the case file is silent on the Adventure of the Petroleum-Poisoned Senior. He thinks he may have a Christmas card from her somewhere in his files. “That’s the problem with my practice,” he says. “They get well and I never hear from them again.”