Am Fam Physician. 2004 Jul 15;70(2):289-290.
I get on edge when Mr. Torres, a Spanish-speaking man with AIDS, tells me he’s out of antiretroviral medications. How did this happen? Mr. Torres’ Medicaid insurance has a spend-down provision—every month he has to show proof that he’s purchased $170 worth of medications before the Department of Social Services (DSS) will validate the card that covers the rest of the month’s pills. Last week, a glitch—a pharmacist’s hastily scribbled receipt looked more like $120 than $170, so DSS didn’t process his form. Several days later, when Mr. Torres went to the pharmacy looking for his medications, he was told, “Computer says your card’s no good.” A trip to DSS uncovered why—the illegible receipt. He returned to the pharmacy for a new receipt, which he brought back to DSS, and now he’s still waiting for the paperwork to go through. It could take days. Because Mr. Torres’ life depends on taking every dose of these pills on schedule, I could scream. Instead, I call the pharmacist. “How could you do this to Mr. Torres? He’s been your patient for years!” Confronted with an irate, English-speaking physician, the pharmacist apologizes and says he’ll advance Mr. Torres the antiretrovirals today. “Next time,” I tell my patient, “call me!”
Despite years in practice, I still feel caught off guard when a patient is hit by a cataclysmic medical event. Common as they are, these blows are devastating to patient, family, and physician. This morning, Luigi, one of our chief residents, approaches me in scrubs with dark circles under his eyes. “Your patient, Mrs. Davis, is in the intensive care unit.” Mrs. Davis is a 70-year-old woman with end-stage renal disease. I’ve been managing her hypertension, diabetes, and atrial fibrillation in the hopes of preventing the catastrophe Luigi is about to describe. Like a soldier painting scenes of battle, Luigi spills out details—how Mrs. Davis told a dialysis nurse she wasn’t feeling well, then passed out. “She was pulseless when we got there. It took us 10 minutes to bring her back.” Later on, up in the unit, I find Mrs. Davis. She is unrecognizable to me—slack-jawed, intubated, and unresponsive. The tentative diagnosis: anoxic encephalopathy from a myocardial infarct. Until now, Mrs. Davis had been determinedly caring for four great-grandchildren. I wonder how they are managing today. Before putting in a call to her family, I reflexively go over my part in this drama. Is there a health proxy in her chart? Advance directives? Might I somehow have prevented this?
Each day brings adventure, and sometimes a little slapstick. Mrs. Masvidal, a Spanish-speaking, cheerfully irascible 82-year-old woman with bad arthritis, two artificial knees, and a new hip comes to our family health center in pain. This morning she tripped over her walker, banging knees and ribs. Now she’s black and blue, and exquisitely tender. She needs an x-ray, but the problem is how to get her uphill to the hospital? My glance falls on Clara, the kind, capable student currently working with us. Soon they are off, my patient tucked into a wheelchair with Clara at the helm, looking like participants in a medical theme park ride. They return from this trip—a five-minute distance—two-and-a-half hours later, with Clara’s face flushed. “When we got to the hospital, Mrs. Masvidal went to the bathroom, then got trapped inside because she couldn’t get up from the toilet to unlock the door. I had to get a translator to help me figure out what was going on in there. Then, I called a security guard, but he didn’t have a key, so maintenance had to come and unscrew the door handle. . .” Why are Clara and I dissolving into laughter? Is it because the simplest of tasks—a chest x-ray—can turn into a humbling mess so quickly?
What is it, exactly, that has made this morning so trying? Is it the 9:00 a.m. telephone call about 12-year-old Lashayne’s unrelenting belly pain? Is it the line of irritated patients snaking away from our registration desk’s new computer terminals? Is it my realization that our state-of-the-art scheduling system is not only slowing down registrars, it’s also merrily overbooking everyone? Is it the call from a home attendant about cheerful, demented Mrs. Morro—who is now lethargic? Is it nine-year-old Kira presenting with flank pain, fever of 102°F, and vomiting? (The emergency room doctor she visited two nights ago got a urinalysis and prescribed an antibiotic, but never sent a urine culture.) Is it the thought of Mrs. Davis, still unresponsive, up in the intensive care unit? Is it the interruption (“Mr. Tapia’s daughter is outside and wants to talk to you,”) while I’m trying to focus on a medical student’s case presentation? Is it a young man’s droning list of problems that begins with, “I need a physical and want to lose weight,” and grows to include polymyositis, an umbilical hernia, a busted eardrum, an itchy scrotum, explosive snoring, daytime somnolence, elevated liver enzyme levels, and hematuria? Or, is it the combination of these many pebbles, flung from all angles, pinging against my fragile sense of equilibrium?
I’m probably typical of many urban family physicians who rarely give out home telephone numbers to patients. Today, I make an exception for Miguel, a soft-spoken, down-cast 45-year-old man with salt-and-pepper hair whose extended family I know well. Miguel has inherited his mother’s diabetes, hypertension, dyslipidemia, and atherosclerosis—and ended up with a coronary stent while he was still in his 30s. Today, he comes in complaining of shoulder pain, but when I ask about his sad affect he says he’s been depressed. To place their troubled son in a better school system, his wife moved the family a thousand miles away while Miguel stayed behind at his job. His heart condition, long work hours, chronic illnesses, and pain have all demoralized him. Now, with his wife gone, he feels alone and miserable. I ask if he’s thought about suicide. He pauses, then tells me about a sleepless night when he considered jumping from a building rooftop. In the ensuing silence, my heart goes out to this gentle, likable man. A while later, he agrees to call his insurer and inquire about counseling benefits. In turn, I give him my home telephone number. “Tell me you’ll call right away if you feel that way again. Please.”
Plaster’s peeling off the kitchen ceiling. The faucet leaks. I’m presenting grand rounds in three days. Unread journals are piled high. Bills need to be paid. And, that’s why I’m providing family-oriented care to Tweety and Princess this afternoon—by installing their nesting box. Let me explain. Tweety and Princess, yellow and green, respectively, are two parakeets purchased when Nikki, our 10-year-old daughter, decided that our menagerie of two cats, one dwarf hamster, and one guinea pig simply wasn’t enough. (We have since acquired another guinea pig named Oreo.) Tweety and Princess chirp and screech all day long, especially when music plays. Diane, my wife, thinks they are truly bird-brained because, despite our gentle overtures, they are still terrified of us. But I’m fond of the way they nuzzle and share intimacies, like happy little newlyweds. Hence the nesting box, which Diane and Nikki tell me is a prerequisite for making parakeet babies. What we will do with baby parakeets I’m not sure, but with help from a saw, some string, and a bungee cord, the nesting box is now in place. And, if they can overcome their fear of going into it, Tweety and Princess are now fully equipped to make a family of their own. Nikki is delighted. And grand rounds will always be there.
For the past 13 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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