Diary from a Week in Practice
Am Fam Physician. 2004 Apr 1;69(7):1659-1660.
Afterthoughts can often make the difference in arriving at the proper diagnosis. Sarah, a patient with diabetes, was having low back pain and diarrhea. Her pain increased during each bowel movement, and never went away entirely. She had no nausea, and no dysuria or increased urinary frequency. Her examination showed some tenderness over the right posterior iliac crest. She had a history of hypochromic anemia in the past year and had been scheduled for a colonoscopy, but never followed through. JOH went ahead and ordered a colonoscopy. He also recommended checking a stool sample for ova and parasites, and for fecal leukocytes. FL, a physician from El Salvador who was working with JOH, suggested checking a urine sample as well. The urine test immediately showed leukocytes and positive nitrite on the dip-stick. A diagnosis of urinary tract infection was made. The history had not been typical, and JOH was thankful for the extra pair of ears and eyes.
“Little things mean a lot.” The song has more truth in it than Kitty Kallen, a popular singer from the '40s and '50s, ever realized. It was the week before Christmas, and the Outreach gang was distributing gifts to the men of the Open Shelter. Many had children and lacked the resources to give them gifts, so they were most grateful for the toys and clothes provided by Outreach. JOH did not like to play favorites, but he had a special patient who was a work in progress. Dave, a street hustler originally from Detroit, never seemed to be able to break the bonds of alcohol and life on the streets. A hooded sweatshirt was wrapped in golden paper and surreptitiously given to him. The reaction was unexpected—tears began streaming down his face. The words “You don't know what this means to me” were more thanks than JOH could have imagined. Dave was back to the mobile coach window in five minutes, wearing his new gift and giving JOH the high sign from the sidewalk. Talk about making one's day …
The practice of medicine can be a study in contrasts. There are patients who fly to a physician after two days of upper respiratory symptoms, and others who delay their visit until the symptoms have escalated beyond belief. This afternoon, JOH was confronted with the latter. A young man had developed a painless small ulcer on his scrotum six weeks earlier. It had now grown into a 6-cm (in diameter) red, weeping lesion. In addition, he had developed nodular pustules over his entire body. The patient had no explanation for his delay in care. In this age of ready access to medical information, how could a person fail to act when his body was shouting that something was drastically wrong? Even without a confirmatory rapid plasma reagin test or darkfield examination of the gummatous discharge, the diagnosis of secondary syphilis was obvious. Fortunately, the treatment with penicillin was uncomplicated. JOH could only shake his head in disbelief. What was this patient thinking?
As a general rule, physicians can be more therapeutically effective when they are able to relate to their patients' problems. Can a physician who has never had a weight problem really understand the patient who has been obese since childhood? Can a physician understand the nerve pain from a herniated disc if he or she has never experienced it? Stan's complaints were ones to which JOH had difficulty relating—constant anxiety, trouble getting to sleep and early awakening, no real enthusiasm about life. His failure at higher education, multiple jobs, and present unemployment compounded the problems. His difficulty relating to others seemed to stem from a persistent feeling of being an outsider, leaving him with a bleak outlook on life. The fact that he had no faith in any power beyond himself added to the despair. Selective serotonin reuptake inhibitors prescribed by other physicians had “only made me worse,” he noted. JOH was less than sanguine about making an abrupt change in the course of this patient's life with medication, but he did recommend an anxiolytic and antidepressant. However, his major prescriptive advice was exercise—aerobic in quality—for at least 30 minutes five times per week. Some basic laboratory work was done, including lipid levels and thyroid function, but JOH knew that a fundamental attitude adjustment was the key to diverting the downward spiral of Stan's life journey.
Today, there was no joy in Mudville. A colleague phoned JOH to inform him of the sudden and unexpected death of JM, who was two years out of residency, the father of two young girls, and a devoted husband. Medicine had been his third career. A world-class opera singer, then a charter boat captain, JM had gone to medical school during his late 30s. He began an emergency medicine residency, but later chose family medicine. He entered Mount Carmel's program as a second-year resident. His many talents were immediately evident, and in his third year, his peers elected him Chief Resident. JM chose a solo practice, and quickly became busy. His people skills were exceptional, his energy boundless, and his devotion to his profession and family unparalleled. “Why was such a good man taken so early in life?” was the question on everyone's mind. The grief that remains for family and friends will endure.
Everyone wants to make a difference in this world, to leave it a little better than they found it. The mobile clinic ministers to the health care needs of the poor and homeless, but while physical health is important, lives often can be affected in other ways. Marcus had a painful shoulder seven months earlier, when he was first seen on the mobile clinic. At that time, he had been addicted to drugs and alcohol. His despair had led to thoughts of suicide, but JOH encouraged him to look at the blessings that he did have. When Marcus returned to the clinic this evening, he talked first about his problem shoulder. The pain had waxed and waned during the intervening months, and he had been to several other health clinicians. He now had a frozen shoulder as well. He requested help from the Outreach staff for this problem because he was unable to work or afford the orthopedic care that he needed. However, the words that came from him next were not complaints, but words of gratitude. “What you said to me last time really stuck with me. I've been clean and sober since then, and I've been helping others get clean and sober.” Sometimes, simply talking with people helps them. JOH felt a lump in his throat; the words struck his heart and stirred him deeply. The power of words can change a life; the power of words can make a difference.
After years spent in private family practice and academia, John O'Handley, M.D., is medical director of the Mount Carmel Outreach Program in Columbus, Ohio. The program provides free medical care to uninsured and homeless patients throughout the city on a mobile coach clinic. Dr. O'Handley continues to see private patients two mornings a week.
Address correspondence to John O'Handley, M.D., 4040 East Broad Street, Columbus, OH 43213 (e-mail:firstname.lastname@example.org).
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2004 by the American Academy of Family Physicians.
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