Everyone cheers when a ballplayer steps up to the plate and hits a home run the first time at bat, or when the underdog rallies in the final lap and wins the race. Would you cheer in this case? Today a 44-year-old man visited JRH for the first time. He was accompanied by his wife, who has been a long-time patient. The patient had just come from a local chiropractor's office following two days of treatment, which had only somewhat relieved the heavy substernal chest pressure he was experiencing. A careful physical examination revealed only the obvious: he weighed 320 lb. However, the electrocardiogram was typical and diagnostic. After explaining to the patient and his wife that a myocardial infarction was evolving, he was transported to the critical care unit and was then seen by a cardiologist, catheterized (and found to have blockage of the left anterior descending coronary artery after the first diagonal branch) and transported to an Orlando facility by helicopter. He eventually underwent angioplasty and stent placement, all in the space of 12 hours. So now what? Will the patient be the first to stand up and cheer that the medical establishment has done its job well today? Or will he conclude that it's dangerous to go to the doctor's office, because you never know what they may do to you?
As a physician who believes strongly in breast feeding, SEF is familiar with all of the usual reasons to choose this option—bonding, increased immunity, etc. Today SEF performed a new obstetric work-up for a 24-year-old woman and asked her if she planned to breast-feed. The patient looked at her husband, laughed, and said that of course she was, because of the future. Puzzled, SEF inquired as to why. The patient said that because of the Y2K virus and impending economic ruin, there would be no other choice, and she just wanted to be prepared. SEF smiled and thought, “To each his own.”
Today, a pleasant elderly woman visited JTL as a new patient and requested a number of referrals to subspecialists for her heart condition, gynecologic care, etc. Embarking on one of his many passionate defenses of family practice as a specialty for the whole patient, in the context of his or her entire family, JTL suggested, “Perhaps you might let me serve as the ‘quarterback’ for your health care, and let me decide when and if I need to hand some aspect of your care over to another physician?” The woman very politely replied, “Dr. Littell, I have had three different family doctors over the last three years, but the same cardiologist for 10 years and the same gynecologist for 12 years. Now I ask you, who would you expect me to choose as my quarterback?” JTL certainly could not argue with her logic and could only hope that, in time, this lovely patient would come to trust his judgment sufficiently to allow him to serve her as he had been trained (and not as certain managed care plans might dictate).
“That urologist just won't answer my questions,” complained a 55-year-old patient with recurring uric acid stones. “I even made a list of my concerns for him.” CAG asked to see the list, which contained the following: “Why am I so tired? . . . My wife says I am depressed . . . My hands swell sometimes . . . Leg cramps bother me at night . . . I snore a lot.” Buried at the bottom of the list was a concern about chronic flank pain and a question about why he continues to get stones despite taking allopurinol and a medication to acidify the urine. CAG chuckled, thinking how overwhelmed the urologist must have felt by the end of the list (as did CAG). After a commitment to help the patient deal with these problems (most of which appear to be related to obstructive sleep apnea) in a stepwise fashion, CAG tried to educate the patient about better ways to communicate with the subspecialist. He and his wife seemed to appreciate this, and they are no longer dreading the follow-up visit with the urologist.
“Dear Mrs. J.: I am writing to inform you that, regretfully, I am unable to fulfill your expectations as your family physician and to wish you well as you look for a physician who might better respond to your health care concerns.” JTL must have prepared a dozen drafts of this “farewell” letter to a patient who, having first been embraced as perhaps his most challenging case ever, ultimately proved to be the most exhausting and frustrating patient he had ever managed. Fortunately, another physician in the practice had cared for the same patient and had commented on her classic borderline personality features, relieving JTL of some of the guilt he felt in having failed to meet this patient's enormous demands (often in the form of repeated midnight pages). Recalling the excellent training in behavior science that he had received during his family practice residency and faculty development, JTL was certain he had never learned how to “disengage” those patients whose behaviors become mutually unproductive, if not downright destructive.
After a long period of discussion, thought and prayer, TBS and her husband have made the decision to leave Florida and Heritage Family Physicians in order to move closer to family members in Virginia. It has been almost six years since TBS joined the practice and began writing entries for “Diary from a Week in Practice.” During this time, TBS has been through numerous changes, including the transition from residency to full-time family practice, partnership, pregnancy and the birth of twin daughters, the constant struggle to balance motherhood and medicine, and, now, the decision to change location and begin to build a new practice. Many readers of this journal have taken the time to write or call after reading a particular Diary entry, and this has meant a great deal. TBS believes that she has received more than she has given in writing for American Family Physician and would like to say, “Goodbye and bless you,” to the readership and staff of AFP.