Monthly Archives: April 2009

The past five weeks of my Family Medicine rotation has been a true crash course in primary care. I have been very lucky to have an excellent preceptor who both teaches constantly from his broad base of knowledge and facilitates opportunities to allow me to be more independent. In some respects, this rotation feels like a sub-internship for me: prior to seeking his guidance, I am expected to workup acute health problems and chronic issues for new patients and previously seen patients, hone in on the best diagnosis, obtain any tests available in the clinic (from EKGs to blood glucose checks to urinalyses to microscopy to Wood’s lamp examinations), counsel the patient, and prepare the paperwork to complete the visit and and the outpatient lab and imaging forms for the next visit. This is unlike any other rotation I have done previously where decisions to treat or pursue diagnostic studies are discussed as a team (often at length for teaching purposes).

However, my world view of medicine and health care has also been constantly challenged by my experiences in the world of outpatient medicine. Here are some lessons I have learned:

1. People lie. – While I wouldn’t go so far as to endorse Dr. House’s mantra that “Everybody lies,” I have been surprised how often patients or their family members will selectively forget or outright lie to evade blame or guilt. Sometimes my preceptor or I will hand the patient a lab order form and give her specific instructions on how to obtain them, and then at the next visit three weeks later she’ll say, “You never gave me one.” Or a patient’s family member will deny feeding a disabled parent food prior to a blood glucose reading, only to later admit to it after being asked the same question three different ways. Perhaps I was too naive to see it, but I don’t remember having to try as hard to uncover the truth when interviewing patients in the inpatient hospital setting: my assumption is that most patients that are sick enough to be hospitalized have crossed a threshold where it is not in their best interest to be dishonest. But in the clinic, there sometimes seems to be a constant struggle between the physician (who is trying to take care of the patient’s medical needs based on as accurate information as possible) and the patient (who has different goals, often unrelated or only peripherally related to the best maintenance of health).

2. Everyone wants the physician to be responsible for their problems. – The number of forms that patients bring to the physician to have signed is mind-boggling. My preceptor has alerted me to the notion that this is often an effort to deflect responsibility onto the physician. For example, a form might be provided that indicates the the physician has educated an assisted living caretaker about the usage, dosage, and adverse effects of a list of medications. However, there may be a blank space where the caretaker’s name should be. Essentially, a physician signing this paper would be “writing a blank check”: any name could be filled in, even though the physician may not have spoken with that caretaker. If the caretaker does something wrong, the blame eventually tracks back to the physician (and his or her malpractice insurance). This has made me very skeptical about any paperwork that patients bring in that “just need a signature.”

3. Sometimes you have to work the system. – Although I am generally skeptical about the intentions of pharmaceutical companies on the marketing side of the equation, I have a lot of respect for my preceptor’s method of handling them. His clinic is usually frequented by 4-10 pharmaceutical representatives each day, and he will usually give them a couple of minutes to speak while he signs for the medication samples they provide. Usually, he asks one question: “Is your drug on the formulary of the insurance companies (e.g. Medicare HMOs, Medicaid) for my patients?” While the time spent with pharmaceutical reps delays patient appointments or takes away from time with patients, that time also allows for a steady supply of free medications. Some argue that those free medications simply get patient’s “hooked” on expensive, brand name medications, but my preceptor balances the issues of drug cost and the patient’s ability to pay well. One example was with a patient taking 8-10 medications who came with a blood pressure of 180/84 and a fasting blood glucose of 159. He was on two medications for both blood pressure and glycemic control, but he was only taking one of each because of the cost. In an effort to restore some ability to treat the patient’s conditions with the appropriate medications, my preceptor gave the patient samples of the (expensive) medications he was obtaining so that he could pay for the other two medications he had chosen not to take.

I have felt that primary care is an area of great importance for our country’s medical reform efforts, and I definitely believe it even more so now: primary care physicians need as much help as they can get, and we need more of them.

Somehow, I imagined that the physician training process would help me gain greater familiarity with the road to death. In dealing with life and death issues on a routine basis, I believed that I would become comfortable with the most common dilemmas, the many pathways that the mind of a grieving loved one would take, and the right words and means of solace to offer at the right times. However, I realize now that I have focused most of my attention on the experience of the patient: the one who is dying, the one with a biological explanation for suffering and sickness. Like some physicians, I find it easier and truer to my calling to take the hand of a dying man or woman to help ease their suffering and dispel feelings of solitude in the final steps of life. The suffering of a loved one is a trickier and less straightforward matter: he is not the patient, and thus, a physician might not see him as a responsibility (when there’s always another patient to see).

And yet, there is much suffering there to be addressed, to be confronted, to be shared. The pain of a loved one – that which we call “bereavement” in medicine – is commonplace in the mind of the physician. It is so common that we may forget to confront it routinely: it requires no medicine, no surgical intervention, and no billing code. But it is not ordinary in the lives of most people who have just lost a loved one. It is the crushing realization that you will never again hear a person’s voice, see her smile, or share a moment in time with her. It is the moment that makes even the hardest cynic want to believe that there is a better place after this life. It is a place where the emotional turbulence twists and grows more intense, trapped in every memory and reminder of that person, making you want to scream or cry or bang your fist against the table because there doesn’t seem to be any other method of release.

If you truly want to help ease this suffering, there is no formula or set method. It’s true that a single expression of sorrow is unlikely to shorten the time that a person grieves, but it might help lessen the suffering. Everyone grieves differently, and it is always hard to find the right words and the right time to say them or offer a hand or an embrace. However, the important thing, the greatest imperative, is to say something, say anything. Just as you accompanied your patient on the road to some better place, please let her loved ones know they are not alone.

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