From a Week in Practice
Am Fam Physician. 2005 Jan 15;71(2):276-278.
When Ricardo Revelo, an intense, iron-fisted father, comes in for a physical, I’m startled to hear him ask about his 13-year-old son’s urine test. “Urine test?” I ask. “The one we did last week,” he replies. Huh? I haven’t seen Manuel in over a month. Nonetheless, I check our computer and, sure enough, there’s a week-old “urine test,” a toxicology screen ordered by a first-year resident. And what’s more, it’s positive for cannabis. “Why did you want Manuel checked for drugs?” I ask casually. “His eyes looked funny,” Dad says, “and he was cutting classes.” Stalling, I tell him, “I’ll have the results next week.” Later that day, I reach Manuel by telephone. “We’ve got a problem,” I say. Manuel is horrified, almost tearful. “I only smoked it once,” he whimpers. “My dad’s going to kill me.” “You’ve got three choices,” I say. “Either you can tell him, we can both tell him, or I’ll tell him.” Manuel chooses door number one. Meanwhile, I track down my intern. “I didn’t want to order the test,” he says, “but even Manuel insisted.” It takes Manuel nearly two weeks to screw up the courage to tell his father the results. After he finally does, he reports that “It wasn’t so bad. But now,” he continues, “he’s really watching me. I won’t do that any more.”
“I been under a lot of stress lately,” Amelia says of her stuttering efforts to quit smoking. I’ve known Amelia for a long time and am finally accustomed to her many piercings—eyebrow, tongue, breast, labia—which she began accumulating in her late 20s. She’s now 35. “What kind of stress?” I ask. Turns out a neighbor filed a complaint with Child Protective Services, not for abuse (“I’d never hit my kids”), but because Amelia’s three children, ages eight to 12, are unattended at home while Amelia works full-time at a day care center. “It’s a killer during school vacations because I can’t afford child care. What am I supposed to do?” I shake my head. What is she supposed to do? “The 12-year-old is pretty responsible and knows not to answer the door,” she says. “In fact, when the case workers showed up, my kids wouldn’t let ‘em in! They called me on my cell phone—I was in Brooklyn on a field trip!” Amelia’s eyes pop wide. “Talk about stress!” I wonder at the ironies of a child care worker without care for her own children, and of a state that demands child supervision without making sure there are affordable choices. But amid this tumult, I’m cheered by Amelia’s wish to break the cigarette habit. I’ve been raising the issue for years and now, on her own, she’s finally decided that it’s time.
Every month I lead a primary care seminar for first-year students at New York Medical College. For the students, it’s a way to talk with a practicing clinician. For me, it’s a welcome encounter with the fresh-faced idealism that brought me to medicine. Today, one of the students raises his hand. “What happens to your humanity as a doctor?” he wants to know. This question triggers a flood of related concerns: Is it appropriate for doctors to share their emotions—including crying—with patients? How emotionally involved should you get? Does a good doctor have to show empathy? (What about a technically proficient heart surgeon?) Are there emotional criteria for being a physician? Are patients harmed by doctors who have no social skills? I quietly scribble notes as the discussion percolates. Eventually, I take the floor, reciting back the questions that have been raised. “These are important issues,” I say, observing that students worry about becoming too demonstrative with patients, but doctors get into trouble more often by erecting walls around themselves. “Every doctor,” I tell them, “needs human nourishment—from family, from friends and, yes, from patients. How do we stay open to that nourishment?” And how, I wonder, do you remain attuned to suffering—a patient’s or your own—without being swallowed up by it, or without becoming numbed? These questions can fill an afternoon—or a career in medicine.
When smiling, healthy-looking 27-year-old Lorena Quevo presents for a belated “post-partum check,” I anticipate something routine, until I leaf through her chart and notice that she has AIDS. “I got my prenatal care at the medical center,” she says breezily, “but it’s too far away. I want to come here.” A sinking feeling comes over me. The baby? “He doesn’t have it,” she replies. And when I ask about her viral numbers, she bobs her head. “They were good. I’m not sure. Undetectable, maybe?” A few days later, her laboratory report cuts my breath short. Viral load: 746,000 copies. CD4 count: less than 20 cells per mL. Today, she returns for follow-up wheeling Dion, a robust infant. “He was in the hospital,” she reports. “I’m giving him heart pills every single day. And I know you’re going to yell at me. I lost my medicines. I wasn’t taking them.” Our eyes meet. “I’m concerned about you,” I finally say. “And it worries me that you seem less concerned than I am.” We talk for awhile—dogged physician and oblivious patient. “I’m wondering,” I finally ask. “Can you give yourself the same attentive care you give Dion?” I hand her new prescriptions. “Please come back in two weeks, and we’ll repeat your blood tests soon.” Smiling, she steers Dion out the door. “See you!” she cries over her shoulder. What on earth, I wonder, keeps her so cheerful?
When Estela Garcia leaves me a message requesting an urgent appointment, I fit her into my schedule and anticipate a minor problem with a major overlay of anxiety. In the past, Estela has been troubled by a several-year-old “lump” in her left axilla that examinations and scans have never quite pinpointed, migraine headaches, chronic abdominal pain, limb pain, and sweatypalms. Estela is a nervous, 45-year-old woman who is, of course, healthy as a horse. Today, she comes in about a cough that’s been bothering her for two weeks. Unfortunately, she’s no longer on the ACE inhibitor I once prescribed for her blood pressure, so that easy diagnosis is off limits. Instead, her cough looks to be a benign, post-viral condition for which I prescribe a cough suppressant and tincture of time. Estela then becomes tearful, signaling the real reason for her visit: her daughter is being deployed to Iraq. After four years in the military and one in the reserves, Estela’s child is leaving college to return for a second tour of duty. Thinking of my own two girls, I can imagine how maddening this must be. “She’s flying off in two weeks,” Estela says. We discuss the antidepressant I once prescribed — and she never took. She agrees to give it another try. And I ache for this poor, frightened mother.
I pay a call on Helen in the nursing wing of a retirement community. Helen’s husband died of a stroke two years ago. Now, because of advancing parkinsonism, she requires round-the-clock nursing care from a staff that is refreshingly capable and affectionate. Helen’s daughter happens to be my wife, Diane. She and her brother live in distant cities. This weekend, it’s our turn to fly in for a visit. Diane cuts up a salad, which her 82-year-old mom singlemindedly attacks. As her fork nears her mouth, a shred of lettuce flutters down to her lap. Helen doesn’t seem to notice, but pokes instead at grains of rice scattered on the tablecloth. Helen’s comments can be insightful, even pointed. “How’s your mother?” she asks. “Pretty well,” I reply. “If she weren’t happy,” Helen murmurs, “would she tell you?” At other times, her conversation is hallucinatory. “I’m under a hypnotic spell coming from Diane’s shoes,” she says. “And did I mention our study group on the pros and cons of bisexual marriage?” When Diane’s father passed away, Helen’s children offered to relocate her, but she refused. Now, as she drifts in and out of confusion, her children wonder: was this the right choice? As a loving son-in-law, I appreciate their dilemma. And, as a physician, I’m seeing another perspective on the challenge of caring for a distant, chronically ill parent.
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2005 by the American Academy of Family Physicians.
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