Chapter 51


Fam Pract Manag. 2004 Jan;11(1):60.


It was in 1968, the year after I graduated from college and had my epiphany that I wanted to be a doctor, that I met Fey. I had not yet started medical school but was taking some premed courses and looking for a job to support myself. I decided I wanted to work in a medical environment, mostly to be sure I could trust my epiphanies. So I appeared at the community hospital in a nearby town, presented myself at the physical therapy department and asked if they could use an aide, orderly or anything else. They declined, but from an office close by came a high-pitched voice saying, “Come in here, young man.”

The sign on the door said “Department of Social Services.” Beneath it was the name “Ruth Fey Myers,” and beneath that was her title, “Director.” Fey was a petite, middle-aged woman with a pixie face and a noticeable stutter when she spoke. “Why do you want to work in a hospital?” she inquired.

“I want to get some medical experience,” I explained. Fey said she could use some part-time help and asked whether I would consider being trained as a medical social worker. Would I! That was sure a lot better than emptying bedpans. So began my association with a remarkable woman.

I was the only student Fey had ever had, and she tried to teach me the rudiments of social work – not just how to get concrete services for people but what was going on dynamically within their families. Obtaining wheelchairs, home health care and placements for patients were the easy parts; doing intake interviews was hard. Fey would watch me interview a patient and his or her spouse and then ask me to assess what was really going on between them. I would give her my take, and she would invariably say, “Brown, you don’t even have a clue.” She would then dissect the relationship while I sat there agape. “That’s what’s really going on,” she would conclude.

As time went on, I got better at it, thanks to her tutelage. Then, I went off to medical school and on to become a doctor, and Fey went on to become an adjunct professor at a nearby university. We were good for each other at that time in our lives, me giving her the confidence she needed to know she could teach and she giving me the skills I needed to become a complete physician. Above all, she taught me about families; is it any wonder I became a family doctor?

Is the customer always right? Part II

Every Friday morning we have grand rounds at our small hospital. Usually, this means watching a videotape of grand rounds that happened at a university hospital, but sometimes we have live speakers. This particular Friday, Dr. Seagall from the Palo Alto VA was talking about positron emission tomography (PET) scans.

At these conferences, I try to apply what I learn to patients in my practice. As Dr. Seagall began explaining how PET scans work (radioactively tagged glucose administered by IV concentrates in hypermetabolic areas, particularly tumors, and then lights up on a nuclear scan), I started to think how useful it might be in identifying distant metastases from primary sites. Dr. Seagall answered my question before I could ask it: “PET scans show us cancer metastases that CTs and MRIs miss,” he said. “We’ve had patients’ cancer surgeries canceled when we’ve shown their surgeons that there was more than one metastasis and a surgical cure was not possible.”

Immediately, I thought about Maggie, my patient with a rectal carcinoma that had spread to her liver. Her MRI showed only one lesion, and she was scheduled for curative surgery. She had already undergone a radical peroneal resection for her primary metastasis preceded by chemotherapy and radiation. If she had distant metastases, the surgery didn’t make any sense. Had she had a PET scan?

I rushed back to the office after the conference to call her. “No,” Maggie said, “It was talked about at one point but never ordered.”

I explained to her how PET scans could detect tumors that were missed on MRI and CT. “You don’t want another major surgery if you have tumors in places besides your liver,” I said. “The VA doc said they have a PET scanner at Stanford. You could still have your surgery if you were clear of other lesions. It’s your call.” Maggie’s surgeon told her he didn’t think it was necessary, but she insisted and he acquiesced. The PET scan report came later that week: “multiple hepatic and lymph node metastases.”

“You were right to insist on the PET scan,” I told Maggie, when she returned home for more chemo after her surgery was canceled. “Sometimes the customer is right.”

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.

Conflicts of interest: none reported.

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