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A Tale of Two Patients

Monday, August 4, 2014 // Uncategorized

I was struck by this when I read it 10 years ago.  Unfortunately, it is as topical now as it was then.  From The Annals of Internal Medicine.  At the end of the issue they have a section called “On Being a Doctor”.  I think of it as my reward for having weighed through the journal.  I am always humbled by the writing skills of some of my colleagues.

On Being a Doctor | 1 June 2004

A Tale of Two Patients

Faith T. Fitzgerald, MD

Ann Intern Med. 2004;140(11):929-930. doi:10.7326/0003-4819-140-11-200406010-00017
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Requests for Single Reprints: Faith T. Fitzgerald, MD, University of California, Davis, 4150 V Street, Suite 1100, Sacramento, CA 95817.

Late last year, my 87-year-old mother developed diarrhea. I phoned her doctor’s clinic and was answered by a recorded voice that periodically told me, “All of our representatives are busy helping other clients. We appreciate your patience. Your call is important to us. Please hold for our next available representative.” Synthetic music alternated with synthetic messages for 28 minutes before I lost my appreciated patience and hung up. I phoned again later; after a 15-minute hold, in the midst of “Your call is important …,” I was disconnected. I got through on the third try: The first possible appointment was in 2 weeks. I took it. I would cancel my own workday afternoon to take my mother to see her doctor.

The receptionist ignored us when we came into the office at 3 p.m. I stood by her desk, Mom beside me in a wheelchair, while she chatted and joked with the clerk next to her for several minutes. I coughed. Nothing. I coughed more loudly. She glanced in my direction, so I quickly told her we were there for a 3:30 appointment. “Name?” she said. Then, “Registration card?” and “Insurance card?” She stamped a bunch of sheets of paper, then shoved a clipboard covered with a sheaf of documents to be signed toward me. We were directed to sit in the crowded waiting room. When we were settled there, I started to read the forms to Mom, but they were dense and in microprint, and largely unintelligible, so she finally just signed them unread. I carried them back to the clerk, who took them without a word. We waited some more. At 4 p.m. I went back to the desk. I stood in line behind more recently arrived patients and gradually worked my way to the front: “When will my mother be seen?” I asked the clerk.

“Name?” she asked. I told her. “Registration card? Insurance …?”

“We’ve done all that already,” I said.

“Oh!” She shuffled though a pile of stamped papers, found Mom’s, then put them back in the pile.

“Doctor is running behind. He’ll see her as soon as he can,” she said.

“Does he know we’re here?”

“He’ll see her as soon as he can,” she repeated. She sounded annoyed.

“She feels miserable and tired,” I said.

Even as I spoke, the receptionist picked up the ringing telephone and began to talk to the caller, turning her eyes away from me. I stood firm in my spot.

“Hey!” I said. She ignored me. “Hello! I’m still here.”

“Excuse me,” she said to the caller, putting her hand over the receiver. Then to me she said: “I’m on the phone!”

“I know that,” I said. “When will my mother be seen?” It was now 4:15 p.m.

“Doctor will see her as soon as he can,” she said, and resumed her telephone conversation.

I didn’t move. When she hung up the phone, she looked around me to the next person in line behind me. “Name?” she asked him. “Registration card?”

I went back to my mother, who was sitting in her wheelchair holding her head in her hands. “Is the doctor going to see me soon?”

“He’s running behind,” I said.

“Does he know we’re here?”

“I don’t know.”

“I’m really tired,” she said.

“I know.”

“What time is it?”

“4:20.”

“Wasn’t the appointment for 3:30?”

“Yes.”

“Where is he?”

“Busy.”

“I’m really tired,” she said. “And I have to go to the bathroom.”

“I’ll take you.”

“No. The doctor might come and not find us.”

“I’ll tell the receptionist where we are.”

“No. I’m afraid we’ll miss him.”

“Do you want to go home? I can make another appointment.”

“No. I’ll wait.”

She looked up expectantly as each new movement occurred in the waiting room. Periodically, a nurse would come out of the inner office with a sheet of paper and call out a first name. “Bill?” she’d say, and a distinguished elderly man would get up. Then, 15 minutes later, “Harriet?” A woman stirred from her corner. Each time, my mother’s hopes visibly rose with the nurse’s appearance, then fell again, and she slumped back into her wheelchair when the name called was not hers. Finally “Irene?”

I pushed my mother’s wheelchair to the door; I said to the nurse. “My mother is 86 years old and from a time and place that equates respect with titles. Please don’t call her by her first name.”

“Okay,” she said, startled. “What shall I call her, then?”

We were put into a cubicle. Mom’s blood pressure, pulse, and temperature were taken. She was weighed, with great difficulty because of her immobility (I held her up on the small platform of the standing scales), and her body mass index was calculated from a wall chart. We were directed to an examination room that barely accommodated her wheelchair. It was cold. I asked the nurse for a blanket for Mom. She gave me a sheet. “We don’t have any blankets,” she said.

It was 5:30. “Is the doctor coming soon?” my mother asked the nurse.

“He’s running behind,” she said. “He’ll be here as soon as he can.”

“I have to go to the bathroom,” Mom said.

“The doctor may want a urine sample,” she said. “Can you wait?”

“I can wait,” she answered.

“I’ll take you,” I said, and, over her protests, did. On the way to the bathroom, we passed a conference room full of laughing staff. They were having chips, coffee, cake … a party of some sort. We took a long time in the bathroom to get done. Maneuvering Mom in and out of the wheelchair onto the toilet isn’t easy. When we came back to the room, she was frantic. “Did he come? Did we miss him?” Just then, the harried doctor came in. He was apologetic, pleasant, polite, attentive, and thorough. He took a careful history and did a directed physical examination. “Her examination is normal,” he told me, then more loudly to her, “Your exam looks okay, but we should get some tests.”

“Now?” she asked.

“No,” he said. “It’s too late. The clinic lab is closed.”

“When?” she asked.

“We can draw the blood tests tomorrow.”

“What do we do now?” she wanted to know.

“You go home and eat a liquid diet until we know what’s going on.”

“No medicine?” she asked.

“Not until we know what’s going on,” he said.

He turned to me. “I’ll give you a stool cup and urine specimen cup. You can bring them to the lab when you bring her for the blood draw.” It was clear that, though he knew I was a medical school professor and had a clinical, administrative, and teaching schedule of my own, this was quite secondary to the system’s constraints. If we wanted this done, it had to be done this way.

We went home, arriving well after 7 p.m., both exhausted. The next day, after my early morning hospital rounds and rescheduling my non–patient care appointments, I took her to the lab, where a single, haggard phlebotomist faced about 20 patients.

Her diarrhea continued until the study results came back negative, then gradually stopped. “Probably something she ate,” her doctor said when I phoned him with the news.

The bill, when it came 3 months later, was for over $600, mostly paid by Medicare.

Late last year, my 10-year-old boy developed diarrhea. I phoned his doctor’s office, and the receptionist answered within 2 rings of the telephone. I explained the problem, and she said, in a voice of concern: “Oh, goodness. You’d better bring him in. Can you come in about an hour?”

“Sorry,” I said. “I have appointments myself until this afternoon.”

“Well, how about early this evening? Five o’clock? Five-thirty? Or we could see him this weekend.”

“Five-thirty today is good. I’ll get a chance to swing by home and pick him up.”

“See you then. Call if you can’t make it.”

It was a squeeze, but I managed to get away early from work and arrived at the doctor’s office only 10 minutes late. The receptionist looked happy to see me, greeting me by title and last name, and was similarly welcoming to the patient. He was glum and anxious, but she was sympathetic. Within 3 minutes of our arrival, he had been weighed (markedly obese, as before), and we were led into a cheery, warm examination room. Four minutes after that, the doctor came in.

She spoke first to him; “How are you doing?” she asked. Then, as he turned away from her, “You poor guy. You don’t feel well at all, do you?” She ran her hand gently through his hair.

He didn’t answer.

“What’s the problem?” she asked me and smiled sweetly at him. “It seems he’s not up to talking.”

I explained. She quickly, but thoroughly, examined him. He squirmed, uncooperative. She didn’t seem to mind. A stool sample obtained by rectal exam was sent immediately for microscopy. “We’d better check a few labs,” she said. The blood was drawn there and then. By the time she’d finished, the stool report was ready. “No white cells, no blood, no ova or parasites,” she said. “His abdominal exam is normal, but we can get an abdominal radiograph to check for partial obstruction or volvulus if you like.”

“Okay.”

She took him to the radiography suite down the hall and returned in 10 minutes without him, but with his film in hand, showing it to me on the view box: “Negative,” she said. “Perfectly normal. We’re getting a urine sample now,” she said. “Sometimes a urinary tract infection can do this.”

The urine and just-drawn complete blood count results accompanied his return to the examination room 5 minutes later. All was normal. The liver and renal chemistries would take a little longer, and the doctor promised to call me with them in the morning.

By this time, he looked better. I noticed that they had cut his nails, which had been a little long, while he’d been in the radiography suite. I was given dietary instructions by his physician. “No further therapy was warranted,” the doctor said, and we left. The visit, exam, labs, radiograph, pedicure, and advice had taken 30 minutes and cost $175. He was hungry again that night, and his doctor phoned me first thing next morning to ask how he was doing and to give me his lab results—all normal.

“Probably something he ate,” the veterinarian said. “You know how dogs are, and Igor is particularly dedicated to eating anything he can get his muzzle around.” She laughed. “But if it happens again, just call us.”

Faith T. Fitzgerald, MD

University of California, Davis; Sacramento, CA 95817

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