Diary from a Week in Practice
Am Fam Physician. 2004 May 15;69(10):2355-2356.
When a downcast, 54-year-old hypertensive, diabetic, hypercho-lesterolemic woman who is new to me complains of episodic “trouble catching my breath,” I of course worry about coronary artery disease. But, my thoughts soon veer off in other directions—first, when she demonstrates an episode with odd, hiccupy inhalations and asks about “panic attacks”; next, when she’d swallowed her oral hypoglycemic agent but skipped breakfast; and finally, when she tells me about the “angels.” Angels? Her face brightens. “I see them every day.” Huh? What do they look like? “Just like people.” People she knows? Like family members who have died? She laughs, as if I were being silly. “Oh no, they’re not my family,” she responds. She turns wistful. “I wish they’d communicate, but they won’t say anything. They just look at me.” Are they…? I start. “Oh, yes,” she says emphatically. “They’re real, and I wouldn’t want to lose them. They’re like my twins. I just wish they’d talk to me.” My job is seldom dull, I reflect, duly recording “sees angels every day” on her medical record problem list, all the while wondering: are these angels a problem at all?
I arrive expectantly at work today, eager to see what’s going on with Mrs. Hahn’s leg. Mrs. Hahn is a proper, somewhat fussy 82-year-old woman who presented a few weeks back with a deep, spearhead-shaped stasis ulcer above her swollen lateral malleolus. Last week, after a course of antibiotics, I applied an Unna boot. I love Unna boots. The physician who taught me about them years ago would practically sing out his instructions: “Start wrapping anywhere, let the gauze steer you (don’t steer it), cut when it runs too high or too low, and start all over.” Within minutes, I had Mrs. Hahn’s shin and foot twirled in several layers of gooey white gauze and covered with an elastic bandage. Today, I wonder—will the wound look better, or have become re-infected? Like a magician unveiling the rabbit, I snip off the boot to reveal…. Wow! The leg has a puckered, prune-like appearance caused by reduced edema, but the ulcer is pink, healthy, and a half centimeter smaller. “Looks like you’re ready for the chorus line,” I say. Mrs. Hahn manages a smile. After a normal saline rinse, I rewrap the leg to the tune of her nonstop coaching (“A little more over here, and there, too….”), and we schedule another unveiling next week.
“You’re so patient.” When I hear that, I’m never sure whether it’s a compliment or a neatly disguised criticism. Today, my patience is tested by 78-year-old Nathaniel Jones, a grizzled fireplug of a man in a motorized wheelchair. Despite his erratic visits and dreadful lack of adherence to medications, I like Mr. Jones. He’s a trooper—outgoing and philosophical—even after the recent, devastating death of his wife. But today’s blood pressure (170/90 mm Hg), blood glucose level (458 mg per dL), and infected leg all set my teeth on edge. “I know I should have kept my appointment last month,” he says glumly, “but I won’t lie to you, I just wasn’t in the mood. Simple as that.” After contemplating the wound (not quite awful enough to warrant admission) and Mr. Jones’s living situation (alone in a project most nurses won’t venture into), I telephone my last, best hope—the county health department. “Fax me an order, and I’ll see him tomorrow,” a visiting nurse says. Clutching a fistful of prescriptions and the promise of a female caller, Mr. Jones looks happier—and I feel calmer. “I know I should take better care of myself,” he says, “but sometimes I need you to remind me.” My heart melts. How can I stay impatient with this man?
I’m impressed when I read about physicians routinely bringing online sources of evidence-based medicine to the point of care. So today, when 80-year-old Mrs. Garcia arrives complaining of episodic right hand pain and numbness, I’m determined to follow suit. A history of contralateral carpal tunnel release surgery and a positive Phalen’s test make Mrs. Garcia’s diagnosis easy. The question: what to do when she rejects anything involving a needle? I vaguely recall reading about vitamin B6 and oral steroids. What’s the latest evidence? I dash into our conference room, where high-speed Internet access brings me to the National Library of Medicine (http://www.nlm.nih.gov). A PubMed search of “carpal tunnel and steroids” unearths a 2003 Cochrane Database review. Bottom line: thumbs down for vitamin B6; thumbs up for prednisone. Another abstract describes one studied regimen—20 mg daily for a week, followed by 10 mg daily for another week. My smug feeling lasts until evening, when I find myself holding the July 15, 2003 issue of American Family Physician. There on the cover, large as life: “Management of Carpal Tunnel Syndrome,” with evidence galore, and no doubt the source of my vague recollection. Oh, if only all that evidence came with a memory chip for my poor brain!
When my wife, Diane, returns from seeing a new doctor for a pelvic exam and Papanicolaou test, her tale provides an instructive view from the other end of the stethoscope. “In the waiting room, the receptionist didn’t look up from her telephone conversation for several minutes, even though I was standing right in front of her. She finally took my name, but then she turned away. I was confused. Was I supposed to wait there—or sit down?” Not a great start. Once in the examining room, Diane was told to change into a gown. “After 35 minutes, the doctor walked in, introduced herself, and started firing questions—all without looking at me.” “Did she discuss the exam after you’d gotten dressed?” I ask. “No.” Not a great finish, either. And, even though the visit was routine, Diane recently finished writing a magazine article about ovarian cancer, which of course has her worrying. These concerns were never elicited during a brisk pelvic exam. And now … “I wonder if I should go somewhere else for a more careful check,” Diane says. “I’m certainly never going back there.” Stories like this remind me to be attentive, and grateful to be part of a specialty that trains its residents to inquire about patients’ concerns—and to look them in the eye.
“How are you feeling about your body these days? What about your weight?” These are questions I commonly ask teenage girls, who are at high risk for self-doubt after being bombarded with unrealistic body images in magazines, on television, and in music videos. I ask my daughters the same questions. In moments of candor, my lovely 12-year-old will acknowledge her dismay when she looks in the mirror and is drawn to perceived imperfections. What are parents to do? This evening our antidote is a wonderful, coming-of-age movie on video, Real Women Have Curves, directed by Patricia Cardoso and starring America Ferrera. The film tells the story of Ana, a bright Mexican-American high school senior whose mother wants her to stay home, work in the family business—and lose some weight. Winner of the Audience Award and Special Jury Prize at the Sundance Film Festival, this movie presents a role model that girls don’t usually get to see—a female who defies standard images of beauty and is willing to speak up for herself, even while sorting out who, exactly, she is. Diane and I find it funny, touching, and unflinchingly true-to-life. And, in the morning, our two preadolescent critics-in-residence rush downstairs to watch Ana’s journey to independence all over again.
For the past dozen years, Dr. Paul Gross has been on the residency faculty of New York Medical College at St. Joseph’s in Yonkers, New York (a city of 196,000). He divides his time between patient care, resident supervision, teaching, and life with his own family—a wife and two daughters.
Address correspondence to Paul Gross, M.D., (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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