Diary from a Week in Practice
Am Fam Physician. 2002 Aug 1;66(3):415-416.
The patient sat in the holding area of the mobile clinic, furtively eyeing JOH as he completed a chart. JOH knew him well, and he also knew what he wanted from his visit. The patient had a history of asthma, and he had come for a refill of his albuterol inhaler. The only problem was that the patient was going through one inhaler every two days. Inhalers typically last about 25 days, even if used at the maximal dosage, so something did not compute. JOH had refused the man's request for an inhaler the last two times he had shown up at the mobile clinic. But emergency room visits had gotten the patient what he wanted, and he still returned with an empty cannister. JOH knew that albuterol inhalers have a street value because they enhance the high of smoking crack, and he suspected that the patient was diverting the medication for this purpose. JOH knew the man would not admit to this, but JOH could still refuse to supply him with any more inhalers when he was so blatantly misusing them. The patient also smoked a pack of cigarettes a day, a fact that attested to his lack of insight and unwillingness to take responsibility for his illness. “But what can I use for my asthma?” came the patient's reply. “How about if you stop smoking or at least cut back?” JOH offered. In the end, JOH agreed to provide a steroid inhaler, but he doubted the message had sunk in.
It is not always evident why a patient visits the mobile clinic, even after the nurses describe in detail the symptoms and history. When the chief complaint does not seem to warrant a doctor's visit, JOH tries to probe deeper for what is on the patient's mind. Today, a bearded middle-aged gentleman was concerned about his health. But why was he seeking treatment now, after years without medical care? JOH learned that the man's father had died of prostate cancer, and he wanted reassurance that he would not suffer the same fate. But, it was after a negative history and examination that JOH learned what the patient really wanted to talk about. His only son had been recently shot to death at the age of 24, leaving six young children. The patient was not only their grandfather now, but also in many ways their father as well. The sudden responsibility foisted on him by such a tragedy made him look at life from a different vantage point. Now, staying alive and remaining healthy were major priorities in his life. His world would never be the same again.
Today we provided medical care to one of the most medically under-served counties in Ohio. The mobile clinic traveled to the southern part of the state to the local high school. The staff left at 6:00 a.m. so they could open the doors by 8:00 a.m. JOH drove down on his own with directions from the operations manager. Unfortunately, the wrong road number was given, and by the time he realized the mistake, he was close to the Ohio River—50 miles from the intended site! Thank goodness for mobile phones. The mistake was corrected, and JOH arrived in time to see the steady stream of patients, which lasted through 6:00 p.m. The day was cool and rainy, but the patients were warm and appreciative of the care. During the drive back to Columbus, JOH reflected on the beauty of the rolling hills and farmland. Fourteen years of practice in a rural area had left its mark on his psyche, and this scenic and meandering drive provided him an opportunity to “step back in time.”
A swollen, painful thumb and a flare-up of asthma were the reasons for the middle-aged man's visit to the mobile clinic today. Three weeks earlier, a cellulitis of his thumb had been incised, drained, and treated with antibiotics. The wound continued to be swollen and painful, and it now required more antibiotics and physical therapy. JOH also treated the asthma. But the real story was the man's recent false arrest for forgery. He had been a day laborer at the shelter, hiring himself out for construction work on a daily basis. The employer had paid him by personal check on a weekly basis. When he tried to cash the second check, he was picked up for forgery and kept in jail for 30 days before the mistake was realized. Being homeless had left him exposed to an unscrupulous employer who was using people and then discarding them without remuneration. If this had happened to a prominent citizen, it surely would have created an uproar. However, JOH reflected, no one takes notice when a homeless person is involved. He was reminded of the Haitian proverb: “No one listens to the cry of the poor or the sound of a wooden bell.”
The hijab and thick sweater worn by the 19-year-old Somali girl hid a body that was slowly wasting away. Her beautiful face also obscured the unhealthy weight loss. She lived with her mother and seven siblings, even cooking their meals for them. But she ate only one small meal per day, and some days she ate nothing. There was no vomiting or diarrhea, and the physical examination showed nothing abnormal other than a markedly underweight frame. There was no history of abuse or exposure to torture prior to coming to our shores almost two years earlier. A hemoglobin test was normal. JOH puzzled at the lack of clues for any eating disorder or physical problem. She did eat a donut that was offered to her, and she agreed to begin eating three meals a day. Not until she was ready to leave the mobile clinic was any clue to the puzzle forthcoming. She then mentioned that she didn't eat “fast foods” because one of her friends told her they would make her fat. If this was anorexia nervosa, it was a rarity in the Somali population. A distorted body image may be making her avoid food. Close follow-up and working with her family members will be necessary to reverse the downward process that has already taken its toll.
Anger and hatred toward others can cause pain and sadness, but their effect on the person harboring them is even more destructive. Today, JOH observed the ravages of these emotions on a retired woman who came to him for the first time. This woman provides care to her mother with Alzheimer's disease, but feels no love for her because of the beatings she received while growing up. The patient's marriage had failed after five years, she was retired from a job that she despised, and she did not have “one friend in the world to talk to.” She described her life as “miserable and devoid of any dreams or solace.” She slept poorly, ate mainly junk food, and got no exercise. She asked for a pill to make her better. She had received counseling, antidepressants, anxiolytics, and sleep medication from her former physician, but in her opinion these had merely dulled her cognition and memory. JOH knew that a pill would not cure this patient. A major attitude adjustment and healing were what was needed, and he told her so. Though this was not what she had come to hear, she did not storm out. A nerve had been touched…a seed planted. She was asked to follow up. If she returns, perhaps the healing can begin.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2002 by the American Academy of Family Physicians.
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