Another Look at a Day in the Life of a Physician

22 May

Routines, routines, routines.

This chapter reprises chapter 8, “A Day in the Life of a Physician.” Now I show how to use the book’s lessons with most of the patients from that chapter. Exploring the patient’s story enhances the validity of the history and helps to define the issues. The doctor-patient relationship facilitates the whole process. Asking “What did I learn?” in the office, at the patient’s home, or the hospital bedside turns each encounter into a moment of en- hanced care and professional growth.

Besides the intellectual challenge and the opportunity to serve, this rou-tine keeps the physician stimulated and fulfilled. Good, careful, thorough physicians do all of this naturally. The time that it takes is crucial to good care. For patients, the consistent exercise of such a routine validates the physician’s commitment to them; they see it in the ways the doctor talks and takes action.

In the long term, such care depends on a good medical record. Together, the  “five steps,” the  problem-oriented record, and the  biopsychosocial model provide useful and reproducible frameworks for practice. The medi- cal record becomes a compendium of the physician’s insights, how our mind was working at the time we made a complex decision, and what works and what does not. Alone and together with records of other patients, it is a resource for self-teaching. A day’s worth of patients provides a year’s worth of lessons.

As I reprise the day, the dimensions of the human side of medicine stand out. I use the convention of preceding each with the symbol H.

THE HOSPITAL

Hospital patients tend to be complex and have many ongoing problems rather than  a single one. They often have many physicians and other health professionals involved in their care.

(Refer to the corresponding cases in chapter 8. Refer also to the com-mentaries  in  that  chapter  for an  explanation  of unfamiliar technical terms.)

Patient 1: A.B., Age 29

The Physician’s Note in the Chart

Abdominal pain and weight loss: Still no appetite. Tests, including proc- toscopy, barium enema, endoscopy of stomach, and CT scan of abdomen, show a small ovarian mass. Thyroid tests are normal.

Seizures: now and then.

Her abdominal pain and weight loss are very likely multidetermined— related to her antiseizure medication and the psychosocial issues in her life. Prior to discharge, we need to settle the medication issue and arrange for adequate psychiatric follow-up.

Additional Story, Additional History

For years she has had seizures, not well controlled despite use of various medications, and there is some question as to whether or not she is taking the medicines in the prescribed dose. During the last few months, she has lost 20 pounds, and has had some unexplained abdominal pain. Her life is in disarray. She has recently become engaged, and her fiancé is making un- reasonable sexual demands. She can no longer afford her apartment. She has no family or friends she can consistently turn to for moral support. Her medical care has become divided among a neurologist, an internist, a psy- chiatrist, a psychiatric social worker, and a social worker from the welfare department, and she does not know who is in charge.

The Issues

•  What is the cause of her weight loss? Does she have a malignancy or an overac- tive thyroid gland? Are her medications for seizures causing her to lose weight? H Is what is going on in her life contributing to her weight loss?

•  Does the ovarian mass discovered on her CT scan require further investigation to rule out an endocrine disorder or malignancy, or is it an incidental finding of no consequence?

•  H Who is in charge of her care—the neurologist looking after her seizures, the internist, the psychiatrist who has seen her previously and referred her to a day care program, or the patient herself? Is part of her illness related to her sense of panic that, in the face of her own inadequate system of support, no one seems to be overseeing her care?

The Doctor-Patient Relationship

•  I reassure her that she has no malignancy.

•  H I arrange for the neurologist to coordinate her care, to manage her seizure medications, and to be certain that she is getting adequate psychiatric follow-up.

•  H I call her to summarize these plans, and I arrange to see her in two weeks. I

tell her that I am available, even though I am not her primary physician.

What Did I Learn?

•  Some decisions are complex.

•  Single  problems (abdominal  pain,  weight  loss, loss of appetite)  can  be multidetermined.

•  H Weight loss has many causes, including organic ones and those having a psy- chological and social basis.

•  Resolution of some problems takes time.

•  H Psychosocial issues may intrude  upon a physical illness and prevent its timely resolution.

•  H Patients may panic when their medical care is so divided among various pro- fessionals that no one seems to be in charge. One person needs to coordinate care and present a consistent message.

Patient 2: C.D., Age 85.

The Note

Back pain: persists. X-ray shows osteoporosis of the lumbar spine and old compression fractures but no new ones. Her exam is unchanged. She rarely requires pain medication.

Additional Story, Additional History

Despite her failing memory over the last several years, she has managed to remain at home with help from a home-delivered meal program, peri- odic visits from a homemaker, and phone calls and visits from her brothers. Bladder cancer has been treated with chemotherapy. She also has aortic in- sufficiency, a heart valve defect. The recent onset of back pain has pushed her over the threshold of self-sufficiency; she can no longer get around or be alone.

The Issues

•  Has tumor spread caused her back pain? Are there other possible causes of her back pain?

•  H Where should she live? At home with live-in help or in a nursing home? The main dilemma is not her back pain, for acute fracture and tumor have been ruled out and pain is easily controlled by oral medication. But she is vulnerable and can no longer be alone.

The Doctor-Patient Relationship

•  H I recognize that she cannot be responsible for important decisions in her care because of her failing memory and impaired judgment. I define the issues for her brother, who is acting in her behalf.

•  H I recognize that the transition from home to a nursing home is a difficult and delicate one. I help provide her with not only a safe place but also enough time for thoughtful and adequate planning. I also provide moral support for the brother who feels guilty about moving her to the nursing home. “You’ve done all you possibly could for her,” I tell him. I involve the hospital social worker in these plans, and I assure the brother that he need not fear that his sister will be discharged from the hospital prematurely.

What Did I Learn?

•  Back pain has a number of possible causes, each of which has a different rem- edy.

•  H Part of the assessment of any patient is inquiring about what is going on in her life. For this patient, addressing only the issue of the back pain would not have solved her problem.

•  H The role of the physician is not only to provide diagnostic and thera- peutic support to the patient and her family but also moral and emotional support.

Patient 3: E.F., Age 85

The Note

Fever and lightheadedness: She’s no longer lightheaded. Fever has dis- appeared.

Potassium deficit: has been corrected.

Additional Story, Additional History

Unlike Patient C.D., who is exactly the same age, this lady has a sharp mind, is independent, lives alone, and conducts a very active life. What brought her to the hospital was an acute episode of dizziness associated with fever. For years she has had hypertension, treated with hydrochlorothiazide and a potassium supplement. Her hospitalization is a brief one, and while all the issues are not settled by the time of her hospital discharge, I feel that she and I can resolve them after she returns home.

The Issues

•  What is the cause of her fever? Does she have pneumonia, a bladder infection, the “flu,” or some other less obvious cause? Is she sufficiently ill to require an im- mediate extensive evaluation of the fever, or can I delay tests for a day or two and make further observations only if she gets worse?

•  What is the cause of her dizziness—dehydration, fever, the blood pressure drug, or all three? Is her illness multidetermined?

•  The blood potassium concentration  is low. Is she taking her medication cor- rectly?

The Doctor-Patient Relationship

•  H Because I have been her physician for ten years, she knows that she can call me at any time if she feels worse and I know that she is sufficiently reliable to fol- low up as I have suggested. We are both comfortable with her returning home before all the issues are settled.

What Did I Learn?

•  The presence of a problem, such as fever, may not require an immediate exten- sive evaluation.

•  H Age alone does not define how vigorous and self-sufficient a person is.

•  H Knowing a patient over a long period of time provides valuable insights for making difficult decisions.

Patient 4: G.H., Age 78

The Note

Fever: improving. No cough, no chills. Urinalysis is normal. Chest x-ray normal.

Diabetes mellitus: Blood sugars are in the 100–200 range on a mixture of

NPH and regular insulin.

Coronary heart disease: no breathlessness, no chest pain, no significant arrhythmia.

Thought disorder: He is still combative, and he won’t talk to me.

Exam: Alert,  does not  look acutely ill. Chest:  clear. Heart:  regular rhythm.

Etiology of the fever is still unclear, though he is improving on intrave-

nous antibiotic.

Additional Story, Additional History

This elderly man recently emigrated from the Soviet Union. In the last few months, he has been faced with an avalanche of illnesses, starting with complete heart block (a cardiac conduction disturbance), with associated congestive heart failure and respiratory failure, which required insertion of a cardiac pacemaker and use of a ventilator. Then he developed phlebitis in his leg, requiring anticoagulation. He has diabetes mellitus requiring insulin. In the nursing home, he had become suspicious of his physician and his nurses, ultimately refusing all of his medications. Hampered by the language barrier, a psychiatrist was unable to help decide if he was depressed, delusional, or confused. His new problem, unexplained fever, is superimposed upon all these other problems. His responsible family member, a daughter, is bewil- dered by the complexity of his illness and its related problems.

The Issues

•  What is the cause of his fever? Does he have pneumonia, an infection in his uri- nary tract, or a pulmonary embolus (a blood clot in his lungs)?

•  What therapeutic decisions need to be made for the diabetes mellitus, the coro- nary heart disease, and the fever of unknown origin? In the face of these uncer- tainties, can I begin treatment without knowing the definite diagnosis?

•  What is the cause of his combativeness? Of all the causes, some are not treat- able. Which ones are?

•  H What compromises need to be made regarding ideal management for this

“difficult” patient? What does it mean to be a difficult patient?

•  H Does the daughter or anyone else in the family need attention from the phy- sician?

The Doctor-Patient Relationship

•  H Faced with an uncooperative patient who is at high risk for progression of his illness, I alert the family members, recognize their own struggle, and help them make responsible decisions in their father’s behalf.

What Did I Learn?

•  I add to my practical list of possible causes of fever.

•  Beyond the technical tasks of managing each of this patient’s illnesses, named and yet to be named, is recognizing that his combativeness is itself a problem that needs to be more clearly defined.

•  Not every problem has a solution.

Patient 5: I.J., Age 68

The Note

Congestive heart failure: Overall he feels much better. Not breathless. Slept well. He has lost 10 pounds since admission, on varying doses of furosemide.

Exam: Pulse 60, irregular. Blood pressure 120/80. He weeps as he speaks of his illnesses. Neck veins flat at 30 degrees. Chest: clear. Heart: irregular rhythm,  variable S-1 as before. Liver: not  palpable. No  presacral or pretibial edema.

Gout: Erythema and pain in his hand have resolved. Pelvic tumor: no symptoms.

Additional Story, Additional History

He has been hospitalized because of a recurrence of congestive heart fail- ure, which began when he started taking indomethacin for an acute episode of gout and, on his own, had stopped taking a diuretic drug. Fifteen years previously, a rare type of pelvic cancer had been removed, and he had de- clined follow-up examinations. Eighteen months ago, the tumor recurred and required partial bladder resection. Around that time, he had his first ep- isode of congestive heart failure and a cardiac rhythm disturbance called atrial  fibrillation.The  electrocardiogram  showed a  myocardial infarct, though he could not recall any moment of severe chest pain. Again he de- clined medical follow-up and any tests to determine the state of his tumor.

The Issues

•  What is the cause of his congestive heart failure? Could any of the drug changes have precipitated the episode of congestive heart failure?

•  In the face of atrial fibrillation and congestive heart failure, is he at extra risk for blood clot formation? Does he need preventive treatment with anticoagulation medicine? Is the  presence  of tumor  a  contraindication   to  the  use of anticoagulation medicine?

•  What is the best management for his rare tumor—chemotherapy, irradiation, a combination of the two, or nothing at all? His tumor is so rare that there are in- sufficient data to support preference for any of these choices to answer this ques- tion.

•  H Why does he weep? Is he depressed? What are his fears? How does he inter- pret his condition?

•  H What ethical issues are raised if he declines recommended treatment?

•  H How does the physician integrate the patient’s values into making a decision about therapy?

The Doctor-Patient Relationship

•  H I explore his understanding of his illness and his feelings. I ask, “What’s this like for you?”

What Did I Learn?

•  Certain diagnoses, such as congestive heart failure, need to be further defined as to cause, for the treatment may depend on the cause.

•  Much illness is drug or treatment induced. When a new medicine or treatment is prescribed or stopped, we need to anticipate all the possible effects of the change. Indomethacin can precipitate congestive heart failure.

•  Certain tumors and other illnesses may have a tendency to bleed, and so they preclude use of anticoagulant drugs. Certain problems may preclude certain treatment of other problems. To be especially safe, physicians need to examine the interactions between problems and treatments.

•  H There is uncertainty in medicine. Sometimes the answers to difficult ques- tions, such as the prognosis and treatment of rare tumors, may yet be unavail- able.

•  H Physicians need to integrate the patient’s values into decisions.

•  H Hospitalized or not, a competent patient has the right to refuse care.

THE OFFICE

Office patients can have single, simple problems. Just as often, they may have multiple, complex ones, though they are generally not as acutely ill as

hospitalized patients. The first two cases, “annual physicals,” are an oppor- tunity to review the year and attend to all the medical and psychosocial is- sues in depth. Each of these encounters lasts forty-five to sixty minutes.

Patient 6: K.L., Age 45

The Note

A 45-year-old woman here for annual physical. Problems are as follows: Myxomatous mitral valve, post mitral valve replacement: on warfarin.

No chest pain. No breathlessness. No awareness of irregular heartbeat. EKG today shows sinus bradycardia, rate about 56, with frequent ventricu- lar extrasystoles and first-degree a-v block.

Thought disorder: ongoing.

Weight loss: a new problem. Weight 14 months ago was 150 and now is

138. She says she is struggling financially and often does not eat well. No special weather preference to suggest hyperthyroidism.

Medications: warfarin and some over-the-counter health-food prepara- tions.

Review of systems is otherwise essentially negative.

Psychosocial: Though she is struggling financially, she does not consis- tently turn to anyone for moral support. She knows that she can rely on her niece.

Impression: Weight loss, probably due to inadequate nutrition. Urged to eat better.

Arrhythmia, as noted above. Probably not clinically significant. With her permission, I will speak with her niece.

Return in 3 months.

Additional Story, Additional History

For many years, she had an abnormal heart valve, at first without symp- toms and then aggravated by an attacker’s stab wound to the chest, which required emergency open-heart  surgery. She later developed congestive heart failure and required a second heart surgery for insertion of an artificial mitral valve. Within a year, she developed endocarditis, a serious infection of the artificial valve, after a minor dental procedure. Her cardiac status is now stable. She takes warfarin to prevent blood clot formation around the valve.

Though she has a long-standing thought disorder, she is college edu- cated, and with her technical background, she has had steady employment, though now it is sporadic. Because of the psychiatric disorder, she is more vulnerable: She has made some unwise financial decisions that now par- tially explain her current financial bind. She has no living parents or sib- lings, though she relies on her niece and knows she could turn to her in an emergency.

The Issues

•  Is her cardiac status stable and satisfactory?

•  Is it a coincidence that the episode of endocarditis followed the minor dental procedure? Are there measures to prevent recurrence?

•  What is the cause of her weight loss? H Is it related to poor nutrition, and if so, is this a consequence of her unwise financial decisions and inadequate income?

•  H Is she able to make sound judgments? Is she a vulnerable adult? Do family members need to be involved? What are the ethical issues?

The Doctor-Patient Relationship

•  H My long-term relationship with the patient allows me to discuss some very personal questions: What are her financial resources? To whom can she turn for moral and financial support? Respecting her privacy, I ask her for permission to talk with her niece about her health and the financial issues.

What Did I Learn?

•  Though not all events are caused by preceding ones, the episode of endocarditis may have been caused by the dental work. For future dental procedures, she should take prophylactic antibiotic treatment.

•  H Ethical issues occur frequently in the course of medical practice.

Patient 7: M.N., Age 50

The Note

A 50-year-old woman here for annual physical. Problems are as follows: Diabetes mellitus: no weakness, numbness, or tingling of face, arms, or

legs, nausea, diarrhea, change in vision. She has periodic eye checkups by ophthalmologist and retinologist. No symptoms to suggest hypoglycemia. She is on this insulin regimen: regular insulin 12 to 18 units before break- fast, lunch, and supper, and NPH 30 units before supper. She does not regu- larly test her blood sugar but chooses the amount of insulin according to how active she is going to be. She has given up sweets and finds that there are fewer swings in her blood sugar when she does test.

Hypertension: no headaches or dizziness. On Vasotec, 5 mg daily.

Asthma: rare wheezing. She takes albuterol, 2 puffs, before she runs and as needed, and Theodur, 600 mg twice a day.

Caffeine excess: drinks about two cups of coffee a day and one or two cans of caffeinated cola a day.

Possible allergy to penicillin.

Ethanol, nicotine, and drug excess: none for many years. Rectal bleeding: none.

Epigastric burning: none

Impaired hearing: unchanged.

Review of systems is otherwise essentially negative.

Psychosocial: All in all, things are going well for her. She has taken on new work responsibilities, shares her feelings with her husband. She was of- fered a job in another city, the equivalent of a promotion, but chose to re- main here.

Impression: Diabetes mellitus: adequate control  for her. Check Hgb

A1C.

Hypertension: adequately controlled. Asthma: adequately controlled.

Plan: Continue current regimen. Call me in 4 days for test results and further discussion.

Additional Story, Additional History

She developed diabetes as a teenager, at which time I became her physi- cian. In the course of time, she admitted to abusing drugs and alcohol, and she also smoked. For many years, she struggled with these addictions and the associated disruptions in her life, while also having to deal with the reg- imentation of the diabetes treatment. Ultimately she conquered all of her addictions, has a successful and fulfilling career working in drug rehabilita- tion, and a good, honest, and open marriage. The management of her dia- betes  has  been  a  compromise, which  she  and  I  have  recognized, periodically revalidated, and renegotiated. Over the years, she has become more and more attentive to her diabetic care.

The Issues

•  H Beyond the  named illnesses—diabetes mellitus, asthma, and hyperten- sion—I need to attend to habits that may adversely affect the patient’s health, including nicotine, caffeine, alcohol, and drug consumption.

The Doctor-Patient Relationship

•  H I need to manage the diabetes in the context of what is going on in her life, know when to compromise, and be sufficiently honest enough to acknowledge

the compromise. A straightforward and open relationship facilitates such dis- cussions and also becomes a model to the patient for dealing with other dilem- mas in her life. While the control of her blood sugar level is not ideal, she is unable to discipline herself further, and I cannot ignore the other successes she has had in overcoming her addictions.

What Did I Learn?

•  H Sometimes important information, especially that of a sensitive nature such as substance abuse, may not be obtained on the first interview. The physician must always be open to readdressing the patient’s story.

•  H The story is never over. Her chaotic life, disrupted by addiction and diabe- tes, evolved into an ordered and productive one, with fulfilling relationships.

•  H That a person has diabetes mellitus (“is a diabetic”) does not define her. As physicians, we often define a person too narrowly and explain away all disrup- tions with the diagnosis of a chronic illness such as diabetes. (“Who wouldn’t be upset, angry, depressed, etc., if they had diabetes?”) Such a narrow view limits fruitful inquiry.

•  H In caring for patients and managing illness, we often compromise the ideal to fit with the individual patient’s life and capability for adjustment. Both the physician and the patient need to recognize the compromises and renegotiate them from time to time.

The next series of transactions include shorter office visits, up to fifteen minutes, and telephone  calls usually not exceeding five minutes. Even these briefer transactions have human dimensions. Throughout the day, the office staff and I exchange information and instructions.

Patient 8: I.J., Age 68 (Telephone—Son)

The Note

We talked about some of the issues involved in his father’s hospitaliza- tion (congestive heart failure, underlying heart disease, unusual tumor) and some of the uncertainties related to the illness.

Additional Story, Additional History

The caller is the son of Patient 5, I.J., who is currently hospitalized.

The Issues

•  H What are the best posthospital plans?

The Doctor-Patient Relationship

•  H The involved family helps to look after this man’s best interests. They are also suffering. My role is to help them with information, guidance in making posthospital arrangements, and moral support. At the same time, the family provides me with valuable information regarding the patient’s resources, and they help to validate decisions related to plans following discharge.

What Did I Learn?

•  H Illness is a family affair. Each family member has needs and can be a valuable source of information and an important part of the collaborative team.

Patient 9: O.P., Age 72 (Telephone)

The Note

Goiter: Repeat TSH is low. I spoke with my colleague, Dr. S, and also with Dr. M, the radiation therapist, about further evaluation and treat- ment. The nodule is “cold” on the 1989 radioactive scan, but thyroid aspi- ration was normal. To repeat the scan now to look for any changes. Further decisions about treatment will be made after the scan.

Additional Story, Additional History

The patient is a widow, and so she has to deal with each new crisis alone. She has had a prior encounter with malignancy, cancer of the breast, for which she had a radical mastectomy many years ago, and so she has dealt with many of the issues of malignancy:  uncertainty, loss, and the possibility of premature death. She has also dealt successfully with depression.

The Issues

•  Is the goiter, a swelling of the usually small thyroid gland, a sign of malignancy?

What is the best way to tell, short of surgical removal of the thyroid gland? Does the long-standing presence of the enlargement, unchanged over the years, ab- solutely rule out the presence of the malignancy? If malignancy is present, what is the best treatment for it?

•  H How will she handle the news of a possible new malignancy?

The Doctor-Patient Relationship

•  H I have been her physician for many years, and so I can raise the question of malignancy and offer her credible information and realistic reassurance. Even if the goiter is malignant and she requires consultation and treatment from a sur- geon and others, she knows that I will shepherd her through this new crisis, of- fering her advice and support along the way.

What Did I Learn?

•  The long-standing presence of a goiter may hide subtle subsequent changes of malignancy. (I had learned this when caring for another patient.)

•  Medicine is a collaborative profession. I consulted with an endocrinologist and a radiation therapist regarding her thyroid.

•  H We need not be reluctant to present potentially bad news.

Patient 10: Q.R., Age 78 (Telephone)

The Note

Tongue biopsy was negative for malignancy, she says. Call as needed.

Additional Story, Additional History

For a year, she has had unusual tongue pain and has seen many medical and dental specialists for it. None has been able to discover the cause, and various treatments for the pain have failed. Now she has had a biopsy to look for malignancy, and she called to bring me up to date.

The Issues

•  What are the causes of tongue pain in general?

•  What is the cause of her tongue pain?

The Doctor-Patient Relationship

•  H Despite the lack of a definable answer to her problem, she has not panicked.

From our long relationship, she knows that I am interested, that I continue to seek an answer, that I am committed to her comfort, and that she can call me at any time and I will respond. She calls only rarely.

•  H Because of the durability of our relationship, she is better able to tolerate the discomfort.

What Did I Learn?

•  H In the absence of an answer, sometimes the best course is to allow more time to elapse.

•  H In a trusting relationship, patients can better tolerate uncertainty.

•  H An important part of being a primary care physician is providing oversight.

It is important to have patients check back with information from other physi- cians, in order for the primary care physician to be certain that necessary tests have been completed and that the patient has had adequate explanation and an opportunity to address any unanswered questions.

Patient 11: S.T., Age 46

The Note

Abnormal liver tests: Gamma GT done 3 days ago was 67. The trend is certainly not getting worse and is better than last time.

Exam: BP 130/80. Does not look ill. Chest: clear. Heart: regular rhythm. Abdomen: soft. Liver: not palpable.

The liver test abnormality is probably of no clinical significance. No fur- ther follow-up seems warranted. Recheck in a year.

Wart: She has a wart on her finger for which she is using Compound W

and has some dry skin on her fingers for which she may use skin moistener.

Additional Story, Additional History

The liver test abnormality appeared on a blood chemistry examination done at the time of her recent physical examination. She has no symptoms to suggest hepatitis or gallstones, is on no medication, and does not abuse alcohol, all potential causes of this abnormality.

The Issues

•  What is the cause of the liver test abnormality? Is it of significance? Will a dis- ease, of which this may be an early sign, later appear in a full-blown state? In the absence of an answer, what is the  next step—liver biopsy, for instance,  or watchful waiting? How concerned should the physician be? How concerned should the patient be?

The Doctor-Patient Relationship

•  H I present the data, along with an interpretation and a context in which she can deal with the information. The relationship helps.

What Did I Learn?

•  Abnormal test results may not necessarily indicate disease. Even if a specific disease is present, it often improves without specific treatment.

•  Sometimes the physician sees a patient at the end of an illness, the major part of which caused few or no symptoms.

Patient 12: U.V.,  Age 58 (Telephone)

The Note

Elevated cholesterol: I spoke with her about her elevated cholesterol and will send her a diet. Recheck lipid profile in 3 months.

Nodules: She had the nodules excised and they were benign.

Additional Story, Additional History

In the past, she has had episodes of rapid heartbeat and now has the cho- lesterol problem. While she lives with her husband, they have been es- tranged for many years.

The Issues

•  Not all patients with blood cholesterol elevations require drug treatment. In light of her prior heart problem, how vigorously should I treat the cholesterol elevation, if at all?

The Doctor-Patient Relationship

•  H Because of her estrangement from her husband, I have a more important role in providing emotional and moral support.

•  H With regard to the nodules, part of our mutual responsibility is keeping each other informed, especially of outside consultation.

What Did I Learn?

•  H Problems that may seem trivial to the physician may be of major importance to the patient.

Patient 13: W.X., Age 58 (Telephone)

The Note

We reviewed the instructions of yesterday. May stop Lactinex if stools firm up.

Additional Story, Additional History

For years, the patient has had diabetes with many complications, includ- ing impaired circulation and an infected leg ulcer, for which I referred him to a surgeon. The antibiotic treatment for the leg ulcer caused the diarrhea, yet one more difficulty. He had been noncompliant with his diabetes treat- ment. He had a myocardial infarction years ago. He lives alone.

The Issues

•  How will the diarrhea affect the control of the diabetes? Will he need an adjust- ment in the insulin dose?

•  Are there other possible causes of the diarrhea? What are the best tests, and how urgent is it to determine that?

The Doctor-Patient Relationship

•  H We have a long-standing relationship, and so he feels comfortable with my advice that the best test now for the cause of the diarrhea is the test of time.

•  H Some time ago, we had recognized that his noncompliance with the diabe- tes treatment regimen was a compromise in his ideal care. It no longer intrudes in our transactions.

•  H Even though he does not know the surgeon to whom I had referred him, he is comfortable with that referral because he trusts my judgment.

What Did I Learn?

•  We need not do the definitive diagnostic tests for each new problem if we can make a valid educated guess, the likelihood of overlooking a disease that re- quires specific treatment is small, and the danger of delay in treatment, even if we have made an error, is small.

•  H Trust can be transferable—in this case, to a surgeon.

Patient 14: Y.Z., Age 72

The Note

Polymyalgia rheumatica: Muscle and joint aching persist. He feels as bad as when he entered the hospital in December. On prednisone 8 mg a day.

Exam: BP 140/80, P 80. Does not look acutely ill. He is cushingoid. Hemoglobin: 13.6. Sedimentation rate: 4. Electrolytes, renal function

tests OK.

Increase prednisone to 10 mg daily. Prescription for 5-mg tabs, #60, 2 each a.m. Call in 6 days.

Additional Story, Additional History

The story of his muscle and joint symptoms is complex. Superimposed upon a decade of pain from osteoarthritis, degeneration of his knee, ankle, and foot joints, was a sudden worsening of the symptoms, and the addi- tional diagnosis of polymyalgia rheumatica was made. He has hyperten- sion. He has been depressed for years, lives alone, and does not get along well with an ill older brother, to whom he feels an obligation to provide care.

The Issues

•  How do I decide on the correct dose of prednisone—by the level of pain and stiffness, by laboratory tests, or both?

•  To what extent will the prednisone adversely affect the blood pressure and the depression?

The Doctor-Patient Relationship

•  H As I alter the dose of prednisone from week to week, he tolerates the absence of immediate relief because he trusts my prediction of a good outcome.

•  H I provide him other emotional support that helps to avoid an exacerbation of the depression.

What Did I Learn?

Even though a patient’s symptoms may seem no different, sometimes a new illness with similar symptoms supervenes. We need to be aware of this phenomenon, to avoid overlooking an additional diagnosis.

Patient 18: D.E., Age 88 (Telephone–Nurse)

The Note

All in all, doing well after hernia surgery. Bladder catheter has been re- moved, and he is voiding adequately.

Additional Story, Additional History

The patient is intact intellectually and despite long-standing metastatic prostate cancer feels well in general. Whatever pain he has from the cancer is controlled with mild pain medicine. He lives at a nursing home, where he has found a community of other residents and staff.

The Issues

•  H Should decisions about his overall care be affected by the presence of the widespread cancer?

The Doctor-Patient Relationship

•  H If I had viewed him only as an elderly person with widespread cancer, I would have overlooked his intellectual competence and joy of living and dis- missed any new illnesses as not to be treated.

What Did I Learn?

Despite widespread cancer, some patients can live comfortable lives for a long time.

Patient 20: F.H., Age 67 (Telephone)

The Note

He has a cough, which is evolving into symptoms of upper respiratory in- fection. Observe. Call if no better.

Additional Story, Additional History

In addition to his respiratory infection, he has chronic ulcerative colitis, for which he had surgical removal of his colon, and hypertension, for which he takes medicine. Whenever he feels even mildly ill, he worries that it may turn into something serious.

The Issues

Is this simply a “cold,” which requires only symptomatic treatment, or does he have a bacterial infection requiring treatment with an antibiotic? How would the antibiotic affect his intestinal tract?

The Doctor-Patient Relationship

•  H I reassure him. Our relationship validates the reassurance.

What Did I Learn?

•  H Often, all patients need, rather than  a remedy, is reassurance that  their symptoms are not indicative of a serious illness.

Patient 21: G.I., Age 78

The Note

Abdominal pain, colitis: She is feeling much better. She is having three bowel movements a day and she says they are more formed than before. She will shortly stop vancomycin.

Exam: BP 130/80, P 92. Does not look acutely ill. Chest: clear. Heart:

regular rhythm. Abdomen: soft, nontender. Normal bowel sounds.

Continue azulfidine. She is to call in a week with progress. If no better, may consider specific antisalmonella treatment.

Additional Story, Additional History

She is frail and elderly and lives alone. Superimposed on Crohn’s dis- ease, a chronic inflammatory disorder of the small and large intestines, and following treatment with an antibiotic for bronchitis, she developed diar-rhea. The test for antibiotic-associated colitis from the Clostridium difficile

bacterium is positive.

The Issues

•  Was the diarrhea caused by the recent antibiotic  treatment  for bronchitis, tainted food, a worsening of her underlying bowel inflammation, or a combina- tion of one or more of these causes?

The Doctor-Patient Relationship

•  H I drew on the “trust account” of our long relationship as I proceeded stepwise over several days to address the diagnosis and oversee treatment.

What Did I Learn?

•  Diarrhea has many causes and may be multidetermined.

•  Sometimes the treatment for one disease makes another disease worse.

Patient 22: H.J., Age 74

The Note

Hypertension: no headaches. No dizziness. On Vasotec, 2.5 mg daily. Exam: BP 140/80. Does not look ill. Continue Vasotec, 2.5 mg daily. Abnormal prostate: He is anticipating prostate biopsy in a week and has

a number of questions about the implications should malignancy be found and about the approach of his urologist. We discussed all of these issues at length.

Constipation: in the last month. Likely of no clinical consequence. He had colonoscopy 3 months ago. Prune juice seems to help.

Return 3 months.

Additional Story, Additional History

Besides the above problems, he has had surgery for colon cancer.

The Issues

•  What is the cause of the abnormal prostate? In particular, is it malignant?

•  H What meaning does this have to him, particularly in light of his prior malig- nancy?

•  H What is all this like for his wife?

•  H The urologist is a new referral for him, and so he has yet to develop trust in his skills and advice.

The Doctor-Patient Relationship

•  H My relationship with him and my familiarity with the urologist with whom I have worked before allow me to encourage the patient’s confidence in the urol- ogist. I assure the patient that I will be involved in his hospital care and thereaf- ter. “We will do all we can to make things turn out well,” I tell him.

What Did I Learn?

•  H Even when the technical part of the care is in someone else’s hands, the pri- mary physician plays a substantial and crucial role in caring for the patient by overseeing his care, providing explanation, and, when necessary, endorsing the consultant’s recommendations.

Patient 23: I.K., Age 82 (Telephone–Nurse)

The Note

Toe ulcer: some purulent drainage. Stop the current topical application. Soak three times a day in warm water with soap. Start clindamycin, 300 mg three times a day for 10 days. Stop promptly if she has diarrhea. I will see her tomorrow.

Additional Story, Additional History

A nursing home resident, she has many complications of diabetes, which appeared during late adulthood, including impaired circulation. She already had one leg amputation that was preceded by a toe infection, and so she has reason to fear another one. She has been depressed.

The Issues

•  What  is the specific bacterial cause of her infection? That  determines the choice of antibiotic treatment.

•  What  are  the  potential  complications  of the  antibiotic  treatment  with clindamycin, a drug that may cause colitis?

•  At what point should I arrange surgical consultation?

•  H How will this new illness affect her depression?

•  H If a second amputation is warranted, would she accept it?

•  H Should hospitalization be considered, or should she be cared for at the nurs- ing home?

•  H Though she is competent, with whom in the family should I speak?

The Doctor-Patient Relationship

H I have a long relationship with her and her family, and I dealt with them on matters related to her late husband. Our relationship facilitates dealing with all the difficult decisions regarding her care.

What Did I Learn?

•  Though the diabetes appeared at a later age and the blood sugar level was never very elevated, she had many circulatory complications of the disease. Vascular complications can occur independently of the interval between the diagnosis and the present and independently of the level of blood sugar elevation.

•  H It helps to know about the life stories of nursing home patients. Whenever I assume the care of a patient whom I had not known previously, I arrange to meet with a family member to learn more of the patient’s story and establish a rela- tionship.

Patient 24: J.L., Age 61

The Note

Headaches and hypertension: They persist. In addition, he has nausea from time to time. All of these symptoms are long-standing. On his own, he continues to take an over-the-counter preparation.

Exam: BP 120/80, P 60. Does not look acutely ill. Some limitation of ro-tation of neck to the left. Tenderness at level of C4–5, left paravertebral area.

Continue atenolol 25 mg daily.

He wonders about referral to “neuropathologist” because of what he feels are “spasms of the blood vessels.”

Head and neck ache may be due to cervical osteoarthritis. Get cervical

spine x-rays. Add diazepam, 2 mg, #60, 1 four times a day. Return 2 weeks.

He has concerns about his wife, who has an ongoing sensation of “noise in her ears.” He asks for her referral to the Mayo Clinic, and I suggest that she first return to her local ear specialist.

Additional Story, Additional History

An immigrant from the former Soviet Union, he is remarkably facile with English and often helps his countrypeople by translating during physi- cian appointments. His wife is chronically ill.

The Issues

•  What is the cause of his headaches? Are they related to hypertension, vascular inflammation, tension, tumor, or some other cause?

•  What is the cause of his neck aches?

•  H What does he mean by “spasms of the blood vessels”?

•  H Is he inappropriately demanding? If he is, what does that mean?

•  H To what extent does his wife’s illness affect how he feels?

The Doctor-Patient Relationship

•  H The effectiveness of my care depends a great deal on my establishing a rela- tionship by attending to all of his questions.

What Did I Learn?

•  Many problems are common in a physician’s practice. Headache is one. Most often the underlying cause can be discovered through careful history and physi- cal examination. Only rarely are the more complex tests, such as a CT or MRI scan, needed to rule out a tumor or other serious cause.

•  H It is important to identify, acknowledge, and discuss the patient’s own view of his illness. Sometimes patients have fantasies about what is going on in their bodies.

•  H In the Soviet Union, people often had difficulty gaining access to adequate medical care, and so the patient had to be extremely aggressive in obtaining what he needed. Here, American doctors can misinterpret that sort of initiative as inappropriate and “demanding.” I need to understand that he has not yet es- tablished trust in the American system and in me. He is no different from any patient troubled by the uncertainty of his and his wife’s illness.

•  H It is important to have an appreciation of the cultural background of the pa- tient, even if the patient is not from a different country. Each patient is an indi- vidual.

Patient 25: K.M., Age 67

The Note

Hypertension: no headaches or dizziness. Feels better on Vasotec than on Calan SR and is not “tired.”

Exam: BP 160/70 sitting, 160/80 standing. P 80.

Increase Vasotec to 10 mg each a.m. Return in a month.

Diabetes: Blood sugar now is 257 at 2:50 p.m. Urged to lose weight.

Additional Story, Additional History

A long-standing patient, she is obese. She is widowed and has a single adult daughter who is intermittently  depressed.

The Issues

•  H The  severity and the  treatment  of diabetes and hypertension  are often weight dependent; the lighter, the better. How aggressive should I be in urging her to lose weight? At what point do she and I recognize that her lack of atten- tion to weight is a substantial compromise and remove it from discussion, lest it get in the way of dealing with other issues?

•  Diabetes and hypertension together are sometimes caused by Cushing’s syn- drome, adrenal gland overactivity. Does she need investigation for the presence of this illness?

The Doctor-Patient Relationship

•  H Our relationship allows us to address these issues of compromise as allies and to discuss them without her feeling defensive.

What Did I Learn?

•  There is a potential relationship between diabetes, hypertension, obesity, and Cushing’s syndrome, a disorder of the adrenal gland. I see many patients who have both diabetes and hypertension. This co-occurrence of diseases is far more common than Cushing’s syndrome, and so I need to learn simple ways to diag- nose the latter.

Patient 26: L.N., Age 72 (Telephone)

The Note

Constipation: We discussed her bowel problem. Milk of magnesia taken

4 days a week seems to help. On the fifth day, she has some diarrhea. Change to milk of magnesia, 15-30 cc at bedtime as needed.

Some dizziness. Change diazepam to 2 mg four times a day as needed, in- stead of regularly four times a day.

Additional Story, Additional History

This nursing home resident has had constipation for many years. She has had an extensive evaluation for underlying serious causes. She and I have worked together to devise a routine of medicine and diet to improve her bowel function. In addition, she has chronic back pain, coronary heart disease and coronary bypass surgery, hypertension, and chronic depression.

When she was 60, she had a stroke. She smokes. Many years ago, when I saw that she required frequent hospitalizations for undiagnosed abdominal and back pain and was no longer able to live alone, I suggested that she con- sider moving to a nursing home. She agreed, though she was one of the youngest residents at the time of her admission.

The Issues

•  H What is the reason for her call today? Is it to come up with a solution, or does she simply want me to listen?

The Doctor-Patient Relationship

•  H But for the continuity of our relationship and the perspective that it pro- vided, I would not have recognized years ago that she could not live alone, nor could I have convinced her of her need to live in the nursing home. Once there, I continued to care for her.

•  H Despite the absence of definitive answers to her questions, she appreciates that I simply listen and do not judge her adversely.

What Did I Learn?

•  H Sometimes all physicians need to do is listen. It was this patient who said

(chapter 4), “When I have a physician who listens, it’s magic.”

Patient 27: M.O., Age 49

The Note

Edema, left leg: persists and is somewhat more prominent  now, with some discomfort. He continues on anticoagulation.

Exam: BP 130/80, P 80. Does not look acutely ill. Gait is normal. Left leg: 2+ edema.

He has swelling that extends up into his thigh. No appreciable pelvic pain, but lymphatic obstruction needs to be considered.

Continue current regimen. Return 2 weeks.

Additional Story, Additional History

He emigrated from South America and is fluent in English and other languages. A knee injury at work severely disrupted his life. He was a reli- able worker and an effective father; after the injury, he could not work or be as much help to his teenage sons. His marriage is failing, and he is de- pressed. Before he saw me, he had been referred from doctor to doctor. No one seemed to be overseeing his care or attending to the psychosocial prob- lems.

The Issues

•  What is the cause of the leg swelling and the knee pain?

•  H How much of what is going on in his life is affecting how he feels and his re- covery?

•  H How is he handling all of this?

The Doctor-Patient Relationship

•  H Until now, he has had no physician say to him, “I will oversee your care and shepherd you through this process.” I offer to fill that role for him and also to look beyond the acute problems and consider the psychosocial ones. I have in- volved a psychologist in his care.

What Did I Learn?

•  H Especially when the patient does not seem to be improving as promptly as we would anticipate, we must look beyond the obvious problems and explore psychosocial issues.

END OF THE DAY

At the end of the office day, I return to the hospital to see one of my pa- tients for a second time. Then I go home to my family.

Patient 28: N.P., Age 45

The Note

In  the  evening,  I receive a telephone  call from the  husband  of a

40-year-old woman. He tells me, “She’s talking and she’s not making any sense.” On the way to their home, I begin thinking about what might be wrong with her. (See Case 2 in chapter 10 for a discussion of this patient.)

Like most of my practice days, this one was complex and fascinating. I started at 7:30 a.m., was home by 6 p.m., and the evening’s house call took an hour. During most of my practice years, I shared night and weekend call with three other internists. Because I had developed and refined a routine to what I do, a method of inquiry and interaction, and an efficient, repro- ducible way of looking at each problem and patient, I rarely felt rushed. I hope none of my patients did either. Practically every encounter was an op- portunity for me to learn.

Medical practice is complicated, but when we truly know how to do it, most of the tasks are easy. It is easy when we can analyze the problem, iden- tify its elements, understand how they relate to each other, come up with the best answer, work efficiently, and explain it in a way that is clear. It is tough when each decision is a struggle, as if we are dealing with it for the first time. It is easy when we learn from experience. It is easy to be a physi- cian when we like people and get along with them; it is tough for people al- ways getting into a scrape.

It is easy if we can organize the day, despite its inherent unpredictability; it is hard if every unscheduled demand throws us into disarray. When I worked as a busboy in a Catskill Mountains resort, my “teacher,” a dental student who had worked in the resorts for many years, advised me, “Don’t ever go into the kitchen empty-handed. If you’re going into the kitchen to pick up an order, take some dirty dishes with you, so you can save steps and save time.” Applied to daily medical practice, this means: Organize your day so that it runs efficiently. Return phone calls to patients throughout the day rather than leaving them until the end of the day. Dictate notes be- tween patients’ office visits when the information is fresh rather than at the end of the day when the memory of the transaction is more remote and the ability to concentrate wanes.

Many know this quintessential New York City story:

Tourist to native New Yorker: How do you get to Carnegie Hall? Native New Yorker: Practice, practice, practice.

How does one get through a day of a medical career? Routines, routines, routines. Routines for approaching patients’ symptoms, treating diabetes, addressing the  question, “What’s the  cause of the  patient’s abdominal pain?” making a referral to a difficult-to-reach specialist. Unless our rou- tines work—providing consistent ways of looking at illnesses, patients, and logistics—we will move through the day very slowly. The best routines in- clude time set aside to ask, after each patient  encounter,  “What did I learn?”

Much of medicine is routine, but even the routine parts are fascinating. There are also diagnostic “highs,” when we figure out an illness, the treat- ment for which is crucial, or one that occurs only rarely, or has been over- looked  by other  physicians, or  one  with  subtle  findings. There  are treatment highs when, but for the physician, the patient would have died or become severely disabled. Successfully treating acute pulmonary edema or overwhelming infection are such times. Though surgeons have more of these moments, much of their work is less dramatic. Vascular surgeons op-erate on patients with ruptured aneurysms, but they also see patients with varicose veins. Orthopedists may deliver traffic accident victims from di- saster by repairing their bones with complex emergency surgery, but they also see patients with chronic back pain.

There are “lows” also. Mistakes are a low, as I discussed in chapter 15. The death of a patient is always a loss, but not necessarily a low moment. More often it can be an especially enriching time for the physician and an opportunity to provide important support and comfort for survivors. Fa- tigue, from insufficient sleep or a succession of long days, is a low. The rem- edy is obvious—a good night’s sleep, a day off. Unappreciative and angry patients are a low, but they are rare; and to the real professional, they be- come a challenge to discover the cause of the anger.

Then there is the human side, not so dramatic—the events in everyday practice, regardless of the physician’s specialty or interests. Physicians en- counter many such profound moments: the opportunity to shepherd pa- tients and their families through a difficult illness, even one with a poor outcome, often over a period of years; the opportunity to help transform angry, isolated patients into more even-tempered people who can enter into fulfilling relationships; the opportunity to help heal broken marriages by getting husbands and wives speaking to each other meaningfully, . . .

And the opportunity to be part of so many dramas.

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