Diary from a Week in Practice
Am Fam Physician. 2003 Dec 1;68(11):2158-2161.
A history of cough and fever for a week was the chief complaint of Victor, a young man who was the last patient of the day. But, he also complained of fatigue and malaise for at least two months. The reasons became more evident as he told his story. A native of Columbus, Victor had completed three years of college but, according to his mother, had “never grown up.” His father, with whom he was very close, died six months earlier. He had lost his job, and recently his unemployment check had stopped. Staying with a friend was an option until his money ran out, and now even she had lost sympathy for him, leaving him on the street. His brothers had tried to help him by buying a pickup truck for him, but he had fallen asleep at the wheel and destroyed his means of transportation. Working for a temporary agency was hardly steady employment, and being turned down for other work had brought him to the brink of despair. He was not suicidal, however, and mentally and emotionally he seemed to be handling his problems well. The social workers inside the shelter had other opportunities for him to consider. Steady employment would go a long way toward curing his malaise and getting him back on the road to recovery.
“I have 47 grandchildren and 17 great-grandchildren, and they all depend on me.” Life is supposed to get better as we age, JOH thought as he talked with his patient who had run out of her blood pressure medication because of lack of funds. Her sister had died suddenly in another state, causing her to miss her regular physician's appointment, so she returned to the mobile clinic knowing that she would be helped. But, the real problem was teased out as she sat stoically on the examination table—she had been thinking of ways to take her life because it had become so difficult. She had faith in a higher power, “but that might not keep me from doin' somethin.'” This was not a problem that could be ignored. Emergency mental health services personnel were called, and they talked to the patient at great length. She was calm, controlled, and rational, and the outcome was a reprieve of sorts. She had things to do today and a companion was able to stay with her. She promised to follow up the next day with the doctor and agreed not do any thing rash. JOH had to believe her. As she left, the nurse gave her a warm, caring hug and reassured her—“we love you.”
As physicians, do we sometimes rely too much on pharmacologic treatments? “Never let a patient leave your office without a ‘script’” was the misguided advice of a newly minted physician whom JOH knew during his residency. Many people would rather take a pill than lose weight, exercise, stop smoking, or perform any of the multitudinous activities that could improve health. So, when Cecelia, a patient with more than 30 years of head and neck pain, reported tremendous relief from massage therapy, JOH was ecstatic. A magnetic resonance image had shown some degenerative disc disease and facet arthropathy. Numerous treatments such as analgesic medications, muscle relaxants, antidepressants, and triptans had shown little or no effect. Through her own research, however, Cecelia read about the benefits of massage in such conditions and enlisted the help of a coworker who was “strong like a bull.” The relief was immediate after the first massage. The situation is a win-win-win—Cecelia receives temporary relief from her pain, she saves money on formal and costly massages and medications, and the “masseuse” has the satisfaction of relieving a fellow human being from suffering. What could be better?
Although JOH left his rural practice 14 years ago, former patients occasionally make their way up the 30-mile stretch of road from Lancaster to Columbus. Today was almost like a homecoming. A husband and wife from Lancaster had an appointment, and together they filled in the missing years of medical history—gallbladder surgery, pneumonia, a depressive reaction to steroids and, now, confusion about new medications ordered by a subspecialist for apparent reversible airways disease. They wanted guidance more than treatment, and a listening ear rather than an autocratic pronouncement. “Would the inhaled steroids trigger another downward spiral?” “How can we face the prescribing doctor if Tom stops taking the medication?” “Will he refuse to care for us anymore?” The litany was long, but not entirely unfamiliar. JOH ordered a spirometry, which showed normal lung function with an FEV1 of 100 percent of predicted. With this evidence, he counseled continued avoidance of the inhaled steroids and promised to contact the subspecialist personally. It also would afford JOH an opportunity to renew an old friendship with the subspecialist, who happened to be a tennis opponent from years past. A physician who has changed careers has many ties to his former life. Every so often, they draw him back.
As if homelessness itself is not ignominious enough, those unfortunate enough to be in such a situation often bear the brunt of their fellow humans' malice. The unfortunate man seen today had been the target of several teenagers with a high-powered air rifle. While resting in a park, they had shot him several times. Fortunately, the blows were all below the neck, but one of the BBs had lodged itself in the lateral aspect of his left elbow. The others had either not penetrated his skin or else were extracted by the patient himself. The x-ray showed the remaining BB to be superficial enough for simple excision, and JOH was happy to supervise DP, the fourth-year medical student, on his first BB extraction. A No. 15 blade was used to open the skin after anesthetizing the tissue around the lesion, and the BB was removed with a hemostat. The patient was grateful for the service and plans to avoid that particular city park in the future. Knowing the power of the streets, JOH expects to see the perpetrators themselves eventually in the role of the victims.
The young East African man had been seen the week before by AS, the family practice resident. His complaint, pain all over his body, did not fit into any disease category. A metabolic blood screen had been ordered and returned with a slightly low magnesium level. JOH faced the same difficulty as AS had the previous week, and still he had little sense of what the problem was. “What do you think is causing your problem?” JOH queried. The young man looked at the interpreter and said that he would have to leave if he were to explain further. The patient's English was satisfactory for conversation, although there was some struggling with pronunciation. The words, “The government has poisoned me,” coming from the man's mouth brought the diagnosis into sharper focus. The patient claimed that illicit drug use had led him to say things against the government, and now the government was exacting its retribution. Paranoid schizophrenia was the true culprit here, and it had taken away any insight or understanding of the man's true state of affairs. “I have been poisoned with HIV” (although numerous tests had proved negative) was the delusion gripping this unfortunate soul. JOH shook his head. “That is not true.” But, the truth bounced off the man like a rubber ball, and only the truth could set him free.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2003 by the American Academy of Family Physicians.
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