Diary from a Week in Practice
Am Fam Physician. 2003 Oct 1;68(7):1303-1304.
“Well, Poppy's doing better today!” Poppy is Eustace Conrad, a vigorous 75-year-old man whose philosophic bent (“A man of my age doesn't like to be denied one of the few pleasures he has left—I'm talking about food.”) and literate repartee (“When they get on my case at work, quoting Rabelais usually shuts them up.”) might obscure the fact that he's been battling a severe case of post-herpetic neuralgia for the past two months. “This is the worst pain I've ever had,” he says. “Of course, women say that men don't know anything about pain, but that's another story,” he adds. Mr. Conrad's dance with age and its attendant ills generally causes him angst (“These younger guys I work with are always boasting about their, shall we say, performance, and I'm wondering, do you think I'm missing out on something?”). But, today's upbeat attitude tells me that either tincture of time or the gabapentin (Neurontin)—now at 900 mg, three times a day—has finally put a dent in his unrelenting distress. “Yeah, I'm still taking those placebos (just kidding)—and the pain's down to five out of 10,” he says cheerfully. “I can handle it. But man, I tell you, this has been like childbirth for me.”
No good deed goes unpunished. When 60-year-old Andrea tells me that Marissa, her depressed, hyper-anxious 52-year-old roommate, was bitten by a cat, has a red swelling on her arm, and is sitting in our waiting room, I say, “No problem! Let's bring her in and take a look.” Poking at Marissa's biceps a few minutes later, I'm relieved to see a week-old puncture wound that's just about healed. But, Marissa now veers off in a new direction. “It's my fingers that worry me,” she moans, showing me some reddened cuticles. She adds, “From scrubbing the stove with a new cleanser.” I hand Marissa a few adhesive bandages and tell her, “Just wrap the fingertips with these.” Marissa's face shows alarm, “And what about my diabetes medicines? The pharmacy won't give me a refill!” In my experience, an expert nervous wreck can outpace and outmaneuver any doctor. Trying to calm Marissa's fears is like trying to blow out trick birthday candles. Almost instantly—poof!—the flames of anxiety reappear, dancing as brightly as ever. After tracking down her chart, calling two different pharmacies, writing a couple of prescriptions, and patiently explaining the correct dosing of each, I finally usher Marissa out the door, my head ready to explode. “Please,” I say with exaggerated calm, “make an appointment!”
When Susan Parker brings her boys in today, I think of jazz and perseverance. Jazz because her younger son is named Charles. Perseverance because Susan, who has diabetes, is patient, kind, and upbeat with her sons, who both have attention-deficit/hyperactivity disorder, persistent developmental delay, and autism. William, 11, is slender. Charles, nine, weighs 125 lb. Both greet me with pale, worried expressions, like adults trying unsuccessfully to remember something important. Then they begin pestering their mom about lunch. “Charles has been thirsty and urinating a lot,” Susan reports. “Two or three times each night.” Now, I'm the one who's worried. I wheedle Charles into allowing a finger stick glucose and flinch at the reading: 215 mg per dL (11.9 mmol per L). “It looks like Charles has diabetes,” I tell Susan. Given his weight, family history, and robust appearance, I'm fairly confident that it's type 2 —even though he's only nine. I can see Susan sag. “I'm so sorry.” As a father, I know firsthand the challenges of raising children, but I can only imagine the enormity of this single mom's burden. We discuss diet, laboratory tests, a specialty referral, and follow-up next week. Charles, who has been paying no attention, now pipes up. “Can we get a hamburger?” This is going to be so hard.
Mrs. Ruiz is here with her daughter-in-law, Miranda. I love Mrs. Ruiz. With her diminutive, frail physique and beaming face, she reminds me of a delicate bird. I never tire of telling medical students that she is unusual because her age (89 years) is greater than her weight (76 pounds)—not an easy feat. “Mi hijo. My son,” she calls me. “¿Y las nenas? And the darlings?” Ever since my daughters came with me on a home visit years ago, Mrs. Ruiz begins every visit by asking about them. She ends every visit by sending them a kiss. In medical school, I learned that congestive heart failure doomed patients to short life expectancies. Because of Mrs. Ruiz and others, I now believe differently. About seven years ago, when an echocardiogram showed an ejection fraction of 15 percent, she was intubated three separate times for congestive heart failure exacerbations. Once Miranda took charge of her mother-in-law's medications, however, the hospitalizations ended. I see Mrs. Ruiz monthly, check her weight, blood pressure, and blood work, and titrate her medications—a regimen that keeps her teetering between heart failure and pre-renal insufficiency. “I feel good today!” she says. Then, wrapping up our visit, she grabs my hand and pulls me closer. “Give the girls a little kiss for me.”
Be careful what you wish for. When our daughters were little, I confidently told myself that as they grew I would respect—and even welcome—their push for independence. I vividly recall an age when it felt mortifying to be seen in the company of my parents (and still cringe over one particular episode, when my mother yelled at some schoolmates for littering). But, now I'm discovering what an embarrassment even this attuned father can be. This morning, I'm driving 12-year-old Ariel to school. A red light halts us by a school bus stop, where a group of her peers are waiting. Because she is a typical middle schooler, my daughter does not make eye contact, nor does she wave. Instead, she stares straight ahead and hunches her shoulders, as if this might render her invisible. As the seconds tick by, my scalp starts to tickle; I reach up. “Don't scratch your head!” she snaps, then adds, “It makes you look like a dork.” My fingers freeze, then inch back to the wheel. Dare I laugh? As I learn new things about myself these days (particularly about unsuspected dork-like tendencies), I am coming to realize that parenting, like practicing medicine, offers limitless opportunities for wiping egg off my face—and practicing some humility.
I've helped patients and their families cope with death. Today, it's my turn. We're hours from home, visiting friends in the Catskill Mountains, when my brother Eric calls about my dad. “His breathing's irregular. You don't have much time.” Luckily, my brother is a physician; and luckily, unlike me, he'd had the good sense to visit with my mom this Sunday. We pack hastily, say good-bye, and drive south. When nine-year-old Nikki later writes a poem about losing Abuelo, her Cuban-born grandfather, she will describe this upsetting ride and Daddy's unnatural quiet. Arriving at my parents' home, we find my mom weeping, Eric somber, and my father, still as marble, on his marriage bed of 50 years. I kneel by his frozen form. “Bye, Dad. I love you.” Is some conscious part of him still hovering, I wonder? Diane and the girls tiptoe in to say farewell. These last few months were awful for my independent dad—unable to walk, or even urinate, without help. “I'm a burden; let me go,” he told my mother. His slow decline did bring some gifts: chances to hug and say, “I love you.” I feel lucky that there's little left unsaid, even as I wonder what tomorrow will feel like without this man. My hero. My father.
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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