From a Week in Practice
Am Fam Physician. 2004 Nov 15;70(10):1901-1902.
“I hear a phone ringing in my chest.” Now that’s a new one. “The first time,” Mr. Jones goes on, “I picked up the receiver in the kitchen, but no one was there.” Mr. Jones is a grizzled 79-year-old man. In addition to longstanding hypertension and diabetes, he has every other criteria of the metabolic syndrome (abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, and microalbuminuria) as described in the June 15 issue of AFP. When he tells me that the “ringing in the chest” is sometimes accompanied by chest pressure and shortness of breath, I have to wonder: could this be an odd presentation of angina? But given that the telephone doesn’t ring on exertion and that the calls usually arrive when he’s lying down, maybe reflux is more likely. An electrocardiogram shows left ventricular hypertrophy with strain. Because Mr. Jones’ adherence to his pill regimen is erratic, I keep my intervention simple: a proton pump inhibitor and, just in case, sublingual nitroglycerin. Given his likelihood of coronary artery disease, I’m not sure that a stress test—even a positive one—will illuminate matters, but I might reconsider if the symptoms persist. “Let’s see if we can’t disconnect this line,” I conclude to this high-risk patient. Hopefully, I tell myself, it’s not God calling, just a telemarketer.
Ten years ago I met Marshall, a sweet, waif-like 13-year-old boy whose oldest sister had just committed suicide. I tried my best to interest him in counseling. “No, I’m okay,” he insisted, his uncertain gaze evading mine. Two years later, Marshall was cutting classes and hanging out with other troubled kids. “Talk with him,” his mom said, and I did; he looked down at me, nodding politely. Time passed. One day his mother mentioned a front-page crime. “He was there,” she said, “but it wasn’t him who did it.” Arrests soon followed. This year he was hospitalized with a gang-inflicted gunshot wound; I stopped by to see him, but he’d just been discharged. Today, I see Marshall’s mother, looking haggard. “The gang is still after him,” she says, “and the police have arrested him for armed robbery.” Meanwhile, she’s lost 30 pounds, is behind on her rent—criminal lawyers are expensive—and is being evicted. “He’s still my son,” she explains. Had I never met Marshall, her story might not affect me so, but I can still picture his doe-like expression, still recall the innocent gaze that slid away from mine, and still remember how I liked this kid who lost his sister in the worst possible way, this American tragedy whose youthful promise, despite everything, I still believe in.
How to respond when a patient teetering on a ledge kicks away the ladder you offer? Often, I tear my hair out. This morning I’m visited by Sonora Tola, whose chief complaint is “pain in my legs when walking.” Before I can ask, she makes a V with her fingers. “Two blocks,” she says. The pain—in her calf—goes away with rest, then predictably returns with more walking. I’m not surprised that Mrs. Tola has claudication. This slender, emphatic 69-year-old woman has a history of angina, diabetes, dyslipidemia—and stubbornness. After her most recent blood test, I wrote her a letter suggesting that we increase her statin dose. Today, as I raise the issue, she stops me with one hand: “No. I’m already taking too much!” An avid radio listener, she’s heard that a puree of garlic, pineapple, and grapefruit works better. “It doesn’t hurt your liver like the pills can,” she says reproachfully. We reach a compromise: in addition to getting noninvasive arterial studies and trying a new medication for her symptoms, she’ll attempt the touted concoction for a month, then we’ll see if it’s had the desired effect on her lipid panel. And perhaps by then some of my hair will have grown back in.
When medical coverage is a loose patchwork, our most vulnerable patients find themselves exposed and hurting. Today, I sit with a medical student and an anguished-looking Miguel Sanchez. Just 45 years old, Miguel has a history of two coronary angioplasties, a coronary stent placement, and mild congestive heart failure. When recent dizzy spells led to the implantation of an automatic defibrillator, he finally left his physically demanding maintenance job of 14 years, crippled by a combination of heart disease and arthritis. Today, he is distraught: his disability application was denied. He has no job, is physically unable to work, has no more medical insurance, and his medications will run several hundred dollars a month. “Welcome to our health care ‘system,’” I mutter inwardly. After discussing a possible disability appeal, a deep, mournful silence fills the room. “Maybe,” Miguel finally says, “my family would be better off if I weren’t around.” He shakes his head. “At least they’d get some money.” Does he have any concrete suicide plans? He dabs his eyes. “Yes.” A little while later, the medical student, wiping her own tears, is accompanying Miguel up to our hospital for an emergency evaluation by a psychiatrist. Why, I wonder, should someone like Miguel have to suffer so? Why must he hurl himself against our gates in the effort to receive appropriate care?
For days I’ve been wandering about in a fugue state, unable to remember my schedule, pressing tasks, or drug doses. It all began when my two-year-old personal digital assistant (PDA) crashed. The next day I went shopping for the latest model, but when I tried to download my programs—uh-oh!—it, too, crashed. I spent the next few cheerless evenings perspiring over our family computer, launching my new PDA into repeated death spirals. By day, meanwhile, I felt singularly clueless. “I’m supposed to be doing something important right now,” I mumbled to a colleague, “I’m just not sure what it is.” Last night, I cleverly removed, then reinstalled, the PDA program on my hard drive. Oops. Too late, I had second thoughts. Where did my data go? Had I just erased the only backup of my daily calendar, to-do lists, telephone numbers . . . ? Was I about to become permanently amnesic? This evening I place an anxious call to PDA technical support—“Russell” in Bombay. “Your data are safe,” he says, yanking me back from the abyss. A few quick programming maneuvers and—poof!—my life has rematerialized; the new PDA is purring. “Brilliant!” I exclaim. “You’ve cured me!” Still, I have to wonder: is my professional life too vulnerable to the quirks of this seductive gadgetry?
I’m looking forward to a quiet day at home when the telephone rings. It’s Loretta, a member of our religious congregation. “Tom passed out last night and was admitted to your hospital, where his doctor doesn’t have privileges. He’s in the intensive care unit on a breathing tube. Help!” Actually, she doesn’t say, “Help!” but the plea is understood. I close my eyes. What’s my role here? And, what about my quiet day? I’m soon driving to the hospital where I find Loretta, looking confused and lonely beside her sedated, intubated husband. Assuming the combined attributes of friend, personal physician, and busybody, I review Tom’s chart, labs, and x-ray, then speak with the attending intensivist. To my relief, all the bases have been covered, including cardiac enzymes, scans, and compression boots. Best of all, it looks like Tom’s suffered a mere vasovagal episode on top of a startling flare-up of chronic lung disease. Because the thought of becoming Tom’s doctor feels awkward to me (perhaps other physicians would feel differently), I offer Loretta the services of our family practice inpatient team, led by a trusted colleague. She readily agrees. “I’m so glad you came,” she says. I am, too, relieved that Tom is okay and that I’ve navigated an ill-defined situation—being both physician and friend—without mishap.
For the past thirteen 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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