Diary from a Week in Practice
Am Fam Physician. 2003 Dec 15;68(12):2375-2376.
“You have not been able get my name off of the lawsuit?” KS echoed in disbelief to her attorney. Several weeks earlier, a constable showed up in the waiting room during a busy morning clinic to deliver a notice of suit. KS remembered how distraught she had been trying to read the paperwork, pull the patient's chart, and manage her office full of patients all at once. The plaintiff's name had not been familiar, and when KS finally was able to review the chart at lunch time, she was puzzled to find that her name was nowhere on the record. That evening, she called the medical records department and was assured that the patient had never been admitted to the hospital. KS was perplexed. She had heard that lawyers sometimes sue every doctor who saw a patient, even if he or she had nothing to do with the actual malpractice event. But, she assumed that the doctors were in some way connected to the case. She had never even seen this patient, and she was being sued anyway! Now, her attorney was telling her there was no absolute certainty that she would be dropped. “I find this whole situation very frustrating,” KS complained. After she had a chance to think it over, she was reminded how often she had told patients, “I am 99.5 percent certain this is not serious …” That .50 percent certainly can cause a lot of anguish!
“Every time you see a patient with diabetes, think about their eyes, heart, kidneys and feet,” suggested KS. She was discussing a 52-year-old patient who presented to the Family Practice Center with diabetes and hypertension. The resident reported that his patient had no complaints and was primarily there for medication refills. His blood pressure was normal, and the most recent hemoglobin A1C was 6.5 mg per dL. When KS asked about his lipid levels and renal function, the resident began to flip hurriedly through the chart. He was chagrined to find that the last lipid panel, done a year earlier, revealed a low-density lipoprotein cholesterol level of 152 mg per dL. The patient's creatinine level was normal, but it had been two years since a urine test for microalbumin was done. The resident had no idea when the patient had had his last eye or foot examination. It only took a few minutes to devise a more comprehensive treatment plan. He decided to repeat the laboratory tests, begin lipid-lowering medication, examine the patient's feet, and refer him to ophthalmology. The day-to-day care of a patient with diabetes is challenging and requires constant attention to detail. The resident realized there is no such thing as a patient with diabetes who just needs “medicine refills.”
“I am so concerned about you!” KS repeated. “No matter how busy you are, you must come in once a week until we get this blood pressure under control.” KS truly was worried. She had known this 47-year-old woman for more than 20 years. Doctor and patient had been through a lot together. They had first met when KS was a young, second-year resident. She could still remember delivering her third baby—who is now 21 years old, 6'4” tall, and playing college basketball. Over the years, her patient had fought and won many battles, including chronic depression, an abusive marriage, and drug and alcohol problems. Two years earlier she had “adopted” a troubled 23-year-old woman who experienced many of these same problems. Together, they were rearing her three young children, which enabled the young mother to attend school. Now that she was making a big difference in the lives of another family, KS had seen a profound change in her patient. She seemed much more confident, more satisfied and, despite the obvious stress in her life, much happier. On the other hand, her blood pressure was sky high and her triglyceride level over 1,000 mg per dL. “I have been out of my medications,” the woman confided. “You don't say!!” KS retorted. “Please get back on them, and see me in one week.”
“My patient's gynecologist insists that she sign a waiver in order to continue on hormone therapy,” commented the third-year resident. “Don't you think that is a good idea?” KS took a minute to think it over. Over the past 20 years, she had tried to convince every postmenopausal woman to take estrogen. Not only did estrogen prevent and treat osteoporosis, but it was widely thought to confer protection against heart disease. Last year, data from the Women's Health Initiative concluded the opposite. This large study showed that the combination of estrogen and progesterone slightly increased, rather than decreased, the risk of heart attacks and strokes. The numbers are small, but authorities now agree that the risks outweigh the benefits, and most women have discontinued taking hormones. But, some patients choose to continue therapy, mostly for the relief of hot flushes. The risks are far less than 1 percent per year. KS thought about what would happen if it became standard for patients to sign waivers for small risks. Over time, patients might be signing waivers for dozens of medications. The waivers would become increasingly complicated and difficult to understand. She thought about the amount of paperwork patients must wade through now, just to get in the office. For now, KS will stick with the practice of explaining treatments, describing common side effects, and answering questions.
“To tell you the truth, Doctor, I honestly don't know how old I am,” the elderly woman explained. That did not particularly surprise the two physicians in the examination room. After all, the patients evaluated in Geriatrics Assessment Clinic often present with memory problems. What got their attention was when she added, “I am either 99 or 100 years old!” This vibrant woman walked into the office unescorted, and had been joking and laughing with the staff. She denied any medical problems, had never been hospitalized, and was taking no medications. She went on to explain that many years earlier she had discovered that the year of birth on her birth certificate was different from the year of birth on her baptismal certificate. “I think that was when I applied for Medicare,” she explained. KS did the math, and figured that was at least 35 years ago. The patient's only complaint was mild memory problems and difficulty finding words. She was diagnosed with early Alzheimer's dementia and began her first prescription drug for a chronic problem that day, three months shy of her 100th—or 101st—birthday. “I am over 60 years younger and on medication for hypertension!” lamented the resident as he wrote up her chart.
“There is a whole new crowd of family members in his room,” whispered JB, the third-year resident on the inpatient rotation. It was Saturday, so KS was not surprised. Weekend visits always feature friends who work during the week and family members from out of town. This particular patient had experienced a large hemorrhagic stroke a week earlier. The stroke was devastating, and he remained unresponsive and immobile. His wife of 46 years knew that her husband would not have wanted heroic measures—she therefore chose to forego tube feeding and cardiac resuscitation. This close-knit family consisted of nine children and their spouses, numerous grandchildren, and several great-grandchildren. It seemed as if each one needed to review the treatment plan and the prognosis with the doctor. The resident had become frustrated when he found himself saying the same thing over and over to different relatives. KS remarked that at the end of life, it is just as important to treat the family as to treat the patient. The “weekend crowd” often consists of those who make a special effort to be with their family member. With practice, it takes just a few minutes to address their particular concerns. Those few minutes make a big difference in helping families come to terms with suddenly losing a loved one.
Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.
Address correspondence to Kathy Soch, M.D., 2606 Hospital Blvd., Corpus Christi, TX 78405.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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