Diary from a Week in Practice
Am Fam Physician. 2003 Nov 15;68(10):1951-1952.
A cough, vomiting, and belly pain bring 80-year-old Mrs. Conte to the emergency room this morning. Mrs. Conte has advanced nonalcoholic cirrhosis and recurrent bouts of hepatic encephalopathy. As I examine her, I'm dazzled by her smile, which is warm, gentle, and sad. Today's laboratory studies look awful: white blood cell count: 18,000 per mm3 with eight bands; blood urea nitrogen: 75 mg per dL; creatinine: 4 mg per dL; total bilirubin: 11.5 mg per dL; and a chest x-ray shows a right middle lobe infiltrate. The funny thing is, the patient herself looks pretty good—alert, joking, and chatting easily. Despite the tender abdomen, she says she's hungry! As an afterthought, I request a lipase level, then review advance directives with Mrs. Conte and her daughter. The patient signs a “do not resuscitate” order. When her lipase level comes back at 2,208 U per L, pancreatitis is added to a problem list that includes pneumonia, sepsis, and renal failure. Her chances grow bleaker from hour to hour. When Mrs. Conte quietly passes away with her family at her side, I'm reminded that I rarely pull patients back from the brink, but there are a number I've rescued from unnecessary heroics. I'm relieved that Mrs. Conte's transition to the hereafter was as dignified as her smile.
“Dr. Gross? I'm calling about my father, Gus Turner. He was admitted on Saturday.” Gus Turner? We have no Gus Turner on our service. I'm certain that the daughter is looking for a geriatrician Dr. Gross, but no, her dad was not admitted from a nursing home. “I just spoke with his nurse. Your name is on his chart, and no one seems to know what's going on with him.” I take her number and rifle through my weekend index cards. Three admissions, all women. No emergency room calls about any Gus Turner. Could the emergency room have sent him to the floor without notifying me? (But, our residents would have picked that up.) Could our senior resident have admitted him and not told anyone? My mind goes back to medical student days, when a patient belonging to our team suddenly materialized at the end of a hall. At change of service, the prior team had forgotten to sign him out to us—and it was days before anyone noticed. I nervously page our family practice senior resident who heads off to investigate and soon returns to my office, smiling. “Teaching medicine (another service) is looking after him. Someone put your name on his chart by mistake.” Whew! (I wasn't really worried, was I?)
As we become better acquainted with our new class of upbeat, conscientious interns, our faculty is still head-shaking over this spring's Match Day. While our program had the good fortune to fill, we noted with alarm a continued downward trend in the popularity of our specialty: nationwide, 252 out of 489 family practice programs did not fill. Only 1,234 U.S. medical school graduates matched in family practice this year. Compared with five years ago, that's a drop of over 40 percent. Why? There are many reasons, one being the huge financial debts incurred by medical students. Nonetheless, I'm stung by the disconnect between the value that I (and our patients!) assign to family physicians and the seeming obliviousness of others, including third-party payers, politicians, and now, medical students, all of whom hold keys to our fate. How do we convey our vision to them? With logic, passion, and persistence, I suppose. Meanwhile, as I conduct a conference for our diverse group of interns—who come from as close as New York and as far away as India—I'm appreciative of the talented international graduates who have joined our ranks over recent years. My program, our specialty, and communities across the country owe them a debt of gratitude.
Pancreatitis is in the air this week. Mrs. Romero, a flamboyant, red-haired, Rubenesque 60-year-old hypertensive woman with diabetes who loves to dance but struggles with her diet, presents to the emergency room with severe abdominal pain and a lipase level of 900 U per L. The diagnosis is easy. The question is—why? Mrs. Romero had a cholecystectomy years ago. Radiologic studies today tell us that her common bile duct is not dilated and that the pancreas looks normal. A consultant suggests that her thiazide diuretic or angiotensin-converting enzyme inhibitor may have triggered this attack. Really? Yes, it's infrequent, but it's been known to happen. Two days later, when a repeat computed tomographic scan shows fuzziness in the tail, but not the head, of the pancreas, it indeed appears that the culprit is neither stone nor sludge, but maybe, just maybe, one of her antihypertensives. We switch to a calcium channel blocker. Mrs. Romero takes the news that I may have caused her pancreatitis with a good-natured shrug. “Bueno, mi hijo. Esas cosas pasan.” (“Well, my son, these things happen.”) After several days of intravenous fluids and rest, she's feeling good as new again. Having survived this atypical weight-loss program, she's itching to go home, dance,…and eat. I okay the first two, but suggest she go easy on the third.
Marlena greets me with wide eyes and excited chatter—about her sister (who just had a sweet 16 party); high school (it's her senior year!); and future plans (college and a career in law). Everything except the reason for this visit: sex. Marlena's mom called me yesterday. “Marlena is very smart,” she said. “She won't have to clean houses like me. But, now she has a boyfriend. ¡Ay, doctór! Things have changed since I was a girl, but my husband doesn't understand. Please help her.” Marlena hears her mom's anguish, but doesn't tune into her support. Meanwhile, she worries. “We use condoms, but what if they break?” she says. “My boyfriend wants me to talk with my mom, but I don't know. My father would kill me.” Marlena's dad, who works 16-hour days, seven days a week as a waiter, stirs up his household with furiously expressed ironclad beliefs. As a dad myself, I ache for him. I review with Marlena how to keep herself from getting pregnant or picking up the human immunodeficiency virus, give her reading material about contraception, arrange for follow-up, and praise her maturity. “You and your boyfriend are acting like adults.” She sails off, beaming. Now I, too, will worry—and think about my own blossoming daughters, whose time will come.
At today's memorial service for my father, I reflect upon this man who shaped my life. My dad was not a physician, but he was an idealist. As a young man in dictatorial Cuba, he faced serious choices: dying for his beliefs (he'd been imprisoned, then pursued by the secret police); or picking up stakes and leaving. He chose the latter and arrived in New York in the 1930s, where he served in the army, married my mom, started a small business, and raised a family. He was a kind man, principled in his business dealings, meticulous in his habits, and thrifty with a dollar. At today's service, I recall his working methods (an exhausting, ritualized setup for even the smallest of tasks) and his business tools (a vintage typewriter and carbon paper reused until it was translucent). Today, most of my patients are Spanish speaking. Many are poor. They are here for the same fresh start my father sought. In caring for them, I pay homage to him. My assiduous notation of laboratory tests and telephone calls, my (sometimes overwrought) attempts to do things perfectly—these are his legacy. As is my idealism. He's gone, yet I feel his consoling presence—as if, despite all, we are still connected in ways that matter most.
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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