When the Wind Blows Hard

photo by Starla Smit

photo by Starla Smit

Let us not be surprised when we have to face difficulties.
When the wind blows hard on a tree,
the roots stretch and grow the stronger,
Let it be so with us.
Let us not be weaklings,
yielding to every wind that blows,
but strong in spirit to resist.
~Amy Carmichael

And so the government and its people are at an impasse–the winds of change are pummeling us all and everyone has entrenched more deeply in order to stay upright.

As a U.S. health care provider who has worked for over 30 years as a salaried physician, in non-fee-for-service health care settings providing patient care that meets the need when need arises without profit motive, I am flummoxed by this impasse.  Policy makers could not come up with a more simplistic solution than what is contained in 2000+ pages of complex regulations that are already creating bureaucratic havoc in all health care settings, distracting health care providers with electronic and telephone paperwork that pulls us away from the bedside. The patient and the provider no longer partner together without a dozen other entities dictating the choreography of their dance.

A potential solution to the problem of affordable access to all who need it already exists in the form of the Public Health Service Commissioned Corps with incentive scholarships for medical and nursing training in exchange for work in under-served areas.   An expansion of such a system, requiring funding at a much lower cost than the billions of dollars required by the current health care reform act,  would address the challenges of the uninsured and the uninsurable.

As a medical student in training, I  spent many months providing patient care in Seattle’s exemplary Public Health Hospital and its associated clinics.  Patients traveled hundreds of miles to see the specialists who worked there; the best and the brightest clinicians saw the poorest of the poor inside those walls, but there were a number of physicians and their families I knew who received their care there as well because they knew the people who worked there were devoted to the patient, not to profit.

When the Executive, Judicial and Legislative branches of government refuse themselves to participate in a health care system they have constructed for the people, then it is not created of the people, by the people, for the people for they are people who get sick and injured just like the rest of us.  What is best for them must be best for us all.

All citizens, and non-citizens inside our borders for whatever reason, should have easy access to affordable health care.   All health care providers should have opportunity to work off the costs of their training to keep the debt load from crushing them for decades to come.

I am grieved that health care has come to this impasse, with government now in a take-no-prisoners mode that clear-cuts us all down to the bare roots.
We need to lean in together for support and quit the fighting that only creates more injury.

We need look no farther than our own commissioned corps of health care officers.  It is an idea whose time has come.

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Palmed Off on the Unwary

blackcurrant

Nothing seems to please a fly so much as to be taken for a currant;
and if it can be baked in a cake and palmed off on the unwary, it dies happy.
~Mark Twain

Returning to clinic after time off for a summer break, I worry I’m like a fly hiding among the black currants hoping to eventually become part of the currant cake.  Just maybe no one will notice I don’t quite fit back in.

In thirty three years of practice, even after bearing three children and going through several surgeries, I’ve not been away from patients for more than twenty consecutive days at any one time.  This is primarily out of my fear that, even after a few weeks, I will have forgotten all that I’ve ever known and if I were to actually return to see patients again, I would be masquerading as a physician rather than be the real thing.   A mere fly among the currants palmed off on the unwary.

Those who spend their professional lives taking care of others also share this concern if they are truly honest: if a patient only knew how much we don’t know and will never know, despite everything we DO know, there would really be no need for us at all, especially in this day and age of accurate (and some terribly inaccurate) medical information at everyone’s fingertips.  Who needs a physician when there are so many other options to seek health care advice, even when there are a few flies mixed in?

As I walk back into an exam room to sit with my first patient after my time away, I recall over thirty years of clinical experience has given me an eye and an ear for subtlety of signs and symptoms that no googled website or internet doc-in-the-box can discern.  The avoidance of eye contact, the tremble of the lip as they speak, the barely palpable rash, the fullness over an ovary, the slight squeak in a lung base.  These are things I am privileged to see and hear and make decisions about together with my patients.  This is no masquerade; I am not appearing to be someone I am not.  This is what I’m trained to do and have done for thousands of days of my life.   No need for the unwary to fear.

The hidden fly in the currant bush of health care may be disguised enough to be part of the cake that an unwary patient might gobble down to their ultimate detriment — but not this doctor.  I know I’m the real thing, perhaps a bit on the tart side, but offering up just enough tang to be what is needed.

And I will die happy doing this.

 

 

What’s Beneath the “Chief Complaint”

Any primary care clinic has a schedule that lists the appointments of the day in incremental time slots.   There is a column for the name of the patient, the patient’s age, and always there is a place for the reason for the visit–the “chief complaint” according to medical parlance.

A quick review of the “chief complaints” for the day gives the physician a sense of how clinic will flow.   There are the seemingly “quick” concerns, like a blood pressure check, sore throat or ankle sprain, and then there are those that will predictably take longer such as fatigue, trouble sleeping, back pain, or headache.

All health care providers are aware that the chief complaint may not be what the patient really wants to talk about.   Finding out the real concern can be part of the detective work the physician must do.  Sometimes it doesn’t actually reveal itself until the physician’s hand is on the door knob, ready to say goodbye and move on to the next patient.

So I can’t depend on a seemingly routine and straight forward chief complaint to be what it appears on the daily schedule.   When I knock on the exam room door, I need to expect the unexpected.  Otherwise,  I’ll have failed my patient and not done what I’m trained to do–look for what is “beneath” the chief complaint.

Examples:

“itching” – a patient who reports 2-3 months of daily itching, worse at night, with no other symptoms and no apparent rash.  Treatment for scabies showed no benefit, there has been no significant relief from antihistamines or topical corticosteroids.   Examination is unremarkable with no skin findings other than the excoriations from scratching.  Lab work reveals mildly elevated liver function tests.  Additional labs reveal no acute or chronic infectious hepatitis but further work up confirms primary sclerosing cholangitis.

“back pain” in a patient who had been seen with similar low back pain six months previously, but it has been intermittent up until a week prior to this visit when the patient’s legs feel heavy when going up stairs.  Exam reveals an abnormally “stiff” gait but no leg swelling or neurologic abnormality.  Sed rate is elevated and subsequent MRI scan shows bilateral iliac thrombosis due to a congenitally absent inferior vena cava.

“memory lapses” in a patient who notes two weeks of feeling that it was a struggle to remember something that had happened only a few moments before.  Significant recent stress with fatigue but mental status exam and physical exam appears entirely normal.  Screening lab work reveals a significantly elevated calcium, with subsequent testing showing hyperparathyroidism.  Surgery to remove the offending parathyroid gland reveals incidental papillary thyroid cancer as well.

“constipation” in a patient who has noticed bloating in her lower abdomen for several weeks.  She has had normal cycles on birth control pills, has a negative pregnancy test, and a rock hard 18 week size mass in the pelvis.  Subsequent surgery reveals a rare non-metastasized ovarian malignancy requiring aggressive chemotherapy.

“fatigue” in a patient who is puzzled about having slept for almost 20 hours straight.   General disheveled malnourished appearance and smell suggests issues with being able to do basic self care and an examination reveals needle tracks on both arms.  Admits to daily heroin use but doesn’t think it is connected to the excessive sleep need since drug use has not changed over several years.

“fever” with headache, myalgias, and nausea for two days in a patient whose rapid strep and influenza screen is negative, lab showing normal white count with a left shift.  Blood cultures eventually grow strep viridans from subacute bacterial endocarditis on a previously undiagnosed bicuspid aortic valve, presumably from a dental cleaning a few weeks before.

“rib pain” in the left lower anterolateral chest wall of a patient with a week of dry cough, congestion, and low grade fevers.  Vital signs and pulse oximeter readings are normal, as well as a plain chest xray, a urinalysis shows some red blood cells. Scan of the abdomen rules out kidney stone but suggests a subtle infiltrate in the left lower lobe.  D-dimer is mildly elevated and scan of the chest shows multiple infarcts most likely related to use of combination oral contraceptives.

Any of these routine “chief complaints” could have led me to conclude an every day diagnosis, forming a treatment plan based on standardized clinical guidelines with prediction of an uncomplicated recovery.   But complacency in a primary care setting would be disastrous.

My job is to peel down through the layers and find what lies beneath the symptom that was the patient’s reason for seeking help.   It is that every day mystery that keeps me coming back, day after day, wanting to know what will happen next when I open the exam room door.