PRACTICE DIARY

Chapter 59

 

Fam Pract Manag. 2004 Oct;11(9):57.

Family medicine

Everything that goes on in my office is privileged, but sometimes I get information about my patients that even they can’t know about. It’s often via a phone call from a worried spouse that starts with “If I tell you this, will you promise not to tell my husband/wife that I called?” After receiving my assurances, they then go on to elaborate on some problem that is driving them nuts but they’re sure their significant other won’t mention at the appointment. They’re usually right; the patient typically couldn’t care less.

Ellen called me the day before her husband, John, was to have his annual exam. “Sandy,” she began, “I’m worried. When John isn’t working, all he does is sleep. He seems really depressed. Maybe you could get him to try some antidepressants.”

“How would I do that?” I asked her. “Could I tell him about your concern?”

“Oh, no. He can’t know that I called you,” she said.

Now here was a challenge. How would I get John, a patient who fought me tooth and nail when I suggested the slightest change in his medication, to go on yet another pill? Truth be told, John cut all the pills I prescribed in half, and he rationalized everything. His hypertension was strictly “white coat,” his hypercholesterolemia was of minor import because of a negative heart scan five years ago, and his obesity problem was over thanks to a five-pound weight loss the year before. This was not a patient who was about to ask for help.

Still, I thought I had possibilities. The annual health questionnaire I use asks if the patient feels down in the dumps. Unfortunately, John circled that one “No.” In talking with him, I asked if he had any health concerns. “None.” I asked what he did besides work. “Play music, walk the dog and read.” His appetite? “Good.” Anxieties? “Nope.” Enough sleep? “Yep.” I wanted to tell him that he looked a bit down, but he didn’t. Maybe something will open up on his follow-up visit, I thought.

Two weeks later, John returned for his results. I knew he’d never submit to a depression-screening test, so I simply asked him, “John, over the past two weeks, have you ever felt down, depressed or hopeless, or have you felt little interest or pleasure in doing things?”

“Not at all,” John replied.

After he left, I phoned Ellen and explained what had happened. “That’s OK,” she said. “You’ve done a lot for John already. He started exercising because of you, and things are better. If he backslides, I’ll talk to him about coming in to see you again.”

Getting off the phone, I realized that I had treated not only John but also, in a sense, Ellen. So, I thought, this is why it’s called “family medicine.”

Pearl

It was one of my worst fears. Pearl, my patient and 92-year-old gardener for my practice, had been knocked down by another client’s dog and couldn’t get up. “What should I do?” asked the frantic woman, calling my office for help.

“Be a responsible pet owner and keep your dog tethered when little old ladies come into your yard to work for you,” was what I wanted to tell her. Instead, I said, “If you can get her into your car, bring her to the emergency room. I’ll give them a heads up that you’re coming.”

The X-ray showed that Pearl had sustained a fracture of the subcapital area of her right hip. This wasn’t going to be a simple fix with a pin; Pearl’s bones were so brittle that she would need a total hip replacement. “Make her good as new,” I admonished Vic, my orthopedic colleague. “I need her to get back to work in my garden.”

The operating crew had a hard time accepting that the wizened old woman lying on their table was anybody’s gardener, and the anesthesiologist joked about me drinking mint juleps while Pearl slaved away pulling my weeds and cutting my grass. Truth be told, Pearl would never accept any help. She even unloaded her power mower herself, working all day with nary a break. She was the Energizer bunny in slo-mo.

Pearl sailed through her surgery and was out of the hospital in five days. She went home to rehab with the help of her nearly blind daughter and disabled granddaughter. Vic kept me posted with office notes: “Her biggest complaint today is having to wait to get into my clinic.” It was vintage Pearl.

Seven weeks after her surgery, Pearl walked into my office with only a walking stick for an aid. “Bone doc says I can go back to work,” she said.

“Are you really ready?” I asked.

“Don’t think I can work the mower yet,” she said. “Maybe I’ll just do some weeding.”

Ten minutes later, when I looked out my window, she was using her Maddox to get the grass out of the cracks in the sidewalk. When I got back from lunch, she was thinning and pruning, patiently filling the bucket she toted alongside her with clippings. Pearl, I thought, you are the real deal.

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used without permission.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

 

Copyright © 2004 by the American Academy of Family Physicians.
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