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Fam Pract Manag. 2004;11(10):74

Horses vs zebras VI

Ron appeared in my office without an appointment asking to see me. It was a busy morning, but I squeezed him in. I never turn away a patient who shows up at my doorstep. Talk about open-access scheduling!

“Doc, I’m really short of breath,” he said. “It’s been getting worse these past three months. Yesterday, I got so short of breath hiking that I nearly passed out.”

After a cursory exam of Ron’s chest, I said, “Your breath sounds are diminished. I’m going to send you for a chest X-ray and some blood tests. I’ll see you back here in a few days. In the meantime, take it easy.”

The next day, I received the radiology report: “Chronic lung changes with fibrosis in the lower lobes with diffuse pleural thickening. Scarring is greater on the right than on the left.” Ron had pulmonary fibrosis! I wasted no time and arranged for a pulmonary consultation in a nearby city.

“Do you want me to start him on steroids?” I asked the pulmonologist.

“No, let me see him first,” Dr. Bela replied. “I have an opening later this week.”

Dr. Bela’s note came a week later: “Twenty-five pound weight gain in two months … Bibasilar rales … Edema to the mid legs … Abdomen is protuberant with probable ascites … Chest X-ray demonstrates bilateral pleural effusions with bibasilar edema and infiltrate. Although fibrosis is recorded as the diagnosis, I do not see clear evidence of that on the plain film. Impression: Dyspnea secondary to congestive heart failure.”

Duh, I thought, no zebra here.

I apologetically called up Ron. “I’m doing much better,” he said. “Dr. Bela put me on Lasix, and I’ve lost 15 pounds and can breathe again.”

“That’s great, Ron,” I said. “I’m sorry I didn’t give you a better exam. That chest X-ray report threw me off. Let’s get a follow-up picture, see how much better your lung fields look and let the radiologist eat crow too.”

The follow-up report came the same day: “No change. Scarring and pleural thickening. Right greater than left.” It was time to visit my radiologist friend, Russ, and look at Ron’s films.

Sure enough, the infiltrates hadn’t resolved. In fact, if anything, they looked worse. “Let’s get a chest CT and see what’s going on,” Russ suggested. In the meantime, I had Ron come back to the office. On exam, he had clear lungs, but I noted an irregularly irregular rhythm with a heart rate greater than 100. An office electrocardiogram confirmed atrial fibrillation with a rapid ventricular response. “Ron,” I said, “Here’s what I think happened. You have some kind of chronic pulmonary disease that has been progressing. In the meantime, you’ve gone into a rapid, irregular heart beat that, coupled with what’s been happening in your lungs, put you into congestive heart failure. The Lasix helped the heart failure but didn’t affect the underlying process. You’re going to need more tests, more drugs and more consultants before we straighten this out.”

Ron thanked me for my care and attention. Before he left, I set him up for pulmonary function tests, scheduled an echocardiogram, started him on a low-dose beta blocker, an ACE inhibitor and some Coumadin, and arranged to see him back in a week. This was beginning to look like an interesting case. What, I wondered, do you get when you cross a horse with a zebra?

A missed appointment

We always call our patients the day before their visits to remind them about their appointments. They appreciate the service, and over the years it has resulted in far fewer holes in our schedule. Still, we occasionally get no-shows. When it involves a 15-minute appointment, I shrug it off and have Dalia, my office manager, call the patient to reschedule; for a missed hour-long physical, I send the patient a bill for $50. My time is important too, and I want my patients to know and respect that.

Today, Carlos called to cancel 15 minutes before his annual exam. Dalia told him about the missed appointment charge, and he was surprised. “Dr. Brown wouldn’t do that, would he?” he asked.

Carlos was a long-time patient and my plumber besides, but his inconsideration upset me, so I called him right back and told him so. “I’m sorry, Sandy,” he said, “but I somehow got two doctor’s appointments scheduled at the same time. The other is with my orthopedist, and since my elbow’s hurting me right now, I think that’s the one I should keep.”

“I charge $50 to patients who cancel within 24 hours of their physicals,” I told him, listing my reasons.

“Hey, remember the time I fixed your pump and didn’t charge you for the service call?” he asked.

I confessed that I didn’t, but I took his word for it and told him he could reschedule; I would waive the fee. Still, it didn’t feel right.

That evening Carlos called me at home to apologize. “I was out of line today,” he said. “Charge me the fifty bucks, and I’ll pay it.”

“That’s all right,” I said. “I appreciate the apology. Next time, you can give me some pro bono plumbing work.”

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