Diary from a Week in Practice
Am Fam Physician. 2003 Jul 15;68(2):257-258.
This morning I arrive early to orient two third-year medical students about to start their family medicine clerkship. Today’s students are the kind I like best—nervously eager, attentive, and thoughtful. One is leaning toward pediatrics, and the other, adolescent medicine. “I just finished surgery,” one confides. “They didn’t like it when I spent time talking to patients.” I assure her that family medicine will be a little different, and then I remember my own surgical clerkship, which was my first clinical rotation. As we gathered in the pre-dawn hours to round in the intensive care unit, I was overwhelmed by how ill the patients were, by how oblivious we seemed to their suffering, and by how unsure of myself I felt. When a resident asked me to examine one patient’s lungs, I placed my stethoscope on his back, furrowed my brow, and was still struggling to hear something—anything—when I noticed the surgical team leaving the room, and then felt my punctured ego deflating. I tell both students that they have more to offer than they realize. When they confess to feeling shaky about their physical examination skills, I reassure them. “Give it time. I’d only worry about you if you said you felt confident.”
This afternoon, I get a call from our hospital’s home health care program. Delightfully sweet and terribly anxious, 82-year-old Mrs. Perez, who was in good spirits when I last saw her, is suddenly beside herself—possibly suicidal. Maybe if I could give her a call … ? Mrs. Perez lives with her husband and son. “¡Ay, doctór!” she greets me before tumbling into her story—a weekend emergency room visit. One of our interns had insisted she come in because a routine chemistry panel had produced a panic value potassium of 6.9 mEq per L (6.9 mmol per L). “You might have a heart attack,” she was told. Many hours later, she left the hospital with a big hematoma and a worse-than-usual case of nerves. The fact that her repeat potassium level was 4.9 mEq per L (4.9 mmol per L) did not cheer her. “¿Porqué?Why did they scare me like that?” I struggle in Spanish to defend my intern, even though I wouldn’t have done it quite that way, knowing as I do that Mrs. Perez is not on potassium, that her renal function is fine, and that such scary values in elderly patients are generally caused by hemolysis. When my explanations fail to calm her, I invite her to come in tomorrow for a second dose. She sighs, “Bueno,” and accepts the invitation.
Mrs. Perez’s son brings her in—frail, jittery, and despondent. I get ready to explain the abnormal potassium level again and prepare for psychosocial heroics, but our interaction, as usual, takes unexpected turns. “I’m going to die,” she says. “Look at me. Ninety-five pounds! I can’t take it. My husband is seeing bugs again! He combs the bedsheets. ‘Don’t you see them?’ he asks.” Manuel, her spouse, is on dialysis and suffers bouts of debilitating pruritus and hallucinations. Once, he tried to dispatch these “bugs” with a kitchen knife. Lately, he’d been doing better on antihistamines and risperidone (Risperdal) … or so I thought. I piece together a plan: for Manuel, an appointment; for Mrs. Perez, an increase in her nutritional supplement, more home health attendant hours, and maybe a new psychiatrist. (“The last one I saw just yawned.”) Next time, we’ll again discuss her antidepressant, which she barely takes. I think we’re done, but not quite. “¡Doctór!” With stiff hands, she tugs open a bag of gifts: decorator dolls and picture books. “For your wife and daughters,” she beams. Later at home, I climax the tale of my dramatic “suicide rescue” by ruefully holding up the frilly skirted dolls meant to cover toilet paper rolls. My wife looks at the dolls—then at me—and bursts into laughter.
“He doesn’t listen,” Mrs. Zambrano says of Ramón at his yearly check-up. “His room is un desastre. I tidy it up, and two hours later it’s a mess again.” As 12-year-old Ramón studies the ceiling, I contemplate my own expertise in this area. My two daughters, nine and 12, toss nearly every article of clothing they wear—or consider wearing—on their bedroom floor. I’ve achieved very modest results with many repetitions of, “Girls, could you please tidy your room?” Most importantly, I’ve discovered that a patient tone while reciting this broken record avoids the cascade of tears, injured looks, and sour faces caused by yelling. I share my experiences with Mrs. Zambrano, but when I learn that she is particularly frustrated by her husband’s indifference, I decide that here is where the money is. “The most important thing,” I counsel (out of her son’s earshot), “is that you two support each other. Let your husband know how hard it is for you.” I have mixed feelings about dispensing glib advice; life is rarely so easy. But, today I’m unable to resist. So, like psychiatrist Lucy in Peanuts, I offer up my pearl to Mrs. Zambrano, hoping it’s more useful than the five-cent gems that Lucy dispenses.
Mrs. Bragg, a depressed 60-year-old woman with chronic pain, comes in looking poorly. Her knee replacement at the medical center was complicated by a horrific postoperative course, including a cholecystectomy and sepsis. She was finally sent home with a central line and intravenous antibiotics, but then spiked a fever and was re-hospitalized. Five days ago she was discharged again, this time on an oral antibiotic to cover vancomycin-resistant Enterococcus. At first, no pharmacy had these fancy pills in stock. Then, after they’d been ordered, Medicaid wouldn’t cover them without prior authorization. So, as of today, she still hasn’t gotten a single dose. “I had chills last night,” Mrs. Bragg moans. When I examine her right knee, it is noticeably warm. What now? I call her orthopedist, but he’s on vacation. His secretary assures me that if Mrs. Bragg can make it to the medical center, she will be evaluated by orthopedic residents who know her well. Sounds simple, but because the medical center isn’t our closest hospital, we can’t get an ambulette to take her there. Is there no end to these obstacles? “It’s all right, doctor,” Mrs. Bragg sighs. “My son will drive me after work.”“Okay,” I reply. “Call me when you get there.” Translation: we’ve got to do better than this.
I get a call from my mother. It’s about Dad. Now 88 years old, he’s had a tough year. It all began a few months ago, days after a cystoscopy, when he became agitated and confused—and landed in an intensive care unit with acute urinary retention, renal failure, and life-threatening hyperkalemia. He eventually made it out of the hospital and returned home, but is now encumbered with a Foley catheter, a walker, and the knowledge that his longstanding prostate cancer has metastasized. Of all these setbacks, the most debilitating has been his Foley catheter, which he hates. Over the telephone, I detect fatigue in my mother’s usually energetic voice. “One day up, the next day down,” she says. “Today, he could barely walk.” Even my tireless mom seems to be flagging. But, when I mention the possibility of hospice, she is quick—too quick—to say, “I don’t need any help.” I can understand her denial. Looking at Dad, I don’t see a terminally ill octogenarian; I see the vigorous 50-year-old father I played with as a boy. Despite all I know, some part of me can’t believe that my dad is this old, this sick. Family practice is never straightforward, especially when it hits this close to home.
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2003 by the American Academy of Family Physicians.
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