MRI's demanded

Seeing Kimberly’s name on the schedule brings tightness to my chest.  I know it’s going to be a confrontational, tense appointment.  Kimberly just called two days ago.  She has pain in 7 different body areas, and she wants MRI’s ordered on all of them.  She does not see why she should have to come in for this, as she is too busy, and frankly the co-pay is not worth it.  My message through the nurse: you must come in if you want to be evaluated for these problems.

 

I open the door.  Kimberly is smartly dressed, all business.  She has a page long list of her symptoms, and further questions.  She has pain in her shoulder, back, neck, abdomen, left side of her head, knee and wrists.  When asked to focus in on the main, or most pressing problem, she states, “All of them are equally important”.   When asked to go through the history of the complaints, she rolls her eyes, as if to say, “Here we go with this game again.”  I spend about 15 minutes going through her history.  In addition I notice that her blood pressure is quite high.  “Are you taking your blood pressure medication?” I ask.  Yes, but she changed it back to an old medication, and she really doesn’t believe it is that high.

 

Getting back to her physical exam, I examine each of the areas she is concerned about.  Although she has 10 – 15 minutes scheduled, I know there is no way this is going to take less than 30 minutes.  It’s better to put the time in now, I say to myself.  Her physical exam is really rather unremarkable.  It would be hard to list a single significant physical finding.   Once again I share with her my impression from my physical exam.  As I do so, I see her body language of defiance.   I ask her, “Do you believe anything I am telling you?”  “No,” is her reply.

 

Now is when I am going to have to be very direct and lay it on the line.  “Kimberly,  I believe that there can be a physician-patient relationship unless there is trust, and unless you are willing to follow my recommendations, or at least to discuss and manage our areas of disagreement.  But we have none of those.   There is no trust here and I am not willing to order tests just because you demand them.  I am not willing to continue as your doctor.   “That’s fine”, she responds, “ I was going to switch to another doctor if you did not order those tests.”  

 

I am relieved that I have been able to deal directly with Kimberly’s demands  and have been able to tell her what I am willing to do, and, in her case, not willing to do.  It is so easy for physicians to become burned out when they do not tell their truth about unreasonable expectations or demands.  In my early years of practice, I could not have dealt with Kimberly as directly, and I would carry around the stress, feel guilt and anger that would seep out on other innocent people.

A woman with headaches

Jackie is the epitome of youth -- young, beautiful, black and smart. She moved here to start her first job as a social worker. But tonight she complains of a daily headache for about 2 months. The headaches start behind her right eye, pound, and cause her to have to go to bed when she returns home. She had never had headaches before coming to Grand Rapids, and they are not present in her family. I asked some probing questions, caffeine? alcohol? cheese? medications?... all met negative response. Finally I asked, " do you eat or drink anything with artificial sweetenters?" "Well, yes, since I started my job, I have been drinking Crystal Light most of the day," she replied. Ah, this is the clue, I remarked to myself. Crystal Light contains aspartame, and a continuous intake of this could precipitate the new onset of migraine headaches. After a neurological exam, I prescribe Jackie some medication in case she continues to have headaches, but most importantly, she will stop drinking Crystal Light. Hopefully, her headaches will resolve without need for an extensive evaluation and multiple medications.

A wall of smoke

Joyce is 58, and as I walk in for her annual physical I am confronted by a wall of stale smoke as I enter the room. She doesn't have to tell me, she's started smoking again. It was just 2 months ago that she had completely stopped smoking. I had tried all the medications plus counseling, and now the new medication, Chantix. Chantix works by blocking the receptors in the brain that give people the pleasure from smoking. It's worked better than other devices or drugs I've used in the past. I thought we had finally won a 40 year battle with an addiction. But my heart sinks now, knowing that we have lost. Joyce tries to put a positive spin on the situation, "I haven't quit quitting", she says. But honestly, looking at her across the chasm that divides us, I see a 100# overweight woman with grey coarse skin, bags under her eyes, and stained with nicotine. I am struggling to maintain hope for Joyce. "You were right," she says, "it did make the cigarettes taste like cardboard. But it reminded me of those cigarettes from the late 60's, 'Lark' I think, that also tasted like that, and I really wanted one." I proceeded with Joyce's physical, ordered her mammogram and blood tests, and asked her to attend a free smoking cessation class. I don't believe she is ever going to stop, but I have to try. Sometimes I am surprised by who finds hope to break free from an addiction.

A resilient child

Simpson Claude Rodriguez seemed a peculiar name, as I picked up the chart for an immigration physical and flipped through the documentation. I opened the door and a smiling blonde woman and two boys awaited me. Both boys are very dark with African features. As I went through the documentation for immunization and tests, I asked the boy, "so how are you so lucky to have one English name, one French name, and one Spanish name?" He shrugged. His mother told the story. Simpson is Haitian. When he was four, he was being brought to the US to have an operation on his face by a missionary group. But before the group could get to the US, they were kidnapped by an armed gang in Haiti, and before Simpson could escape, he was shot. Fortunately the party escaped and was able to get to the US. After arriving here, the blonde woman and her husband decided to adopt Simpson, so now he is applying for residency. Simpson shows no signs of post-traumatic stress. He is calm, not fearful and plays like any other kid. His mother confirmed that he shows no signs of the trauma he survived before. I am always struck by how resilient children can be, given a stable and loving home.

Dry wells restored

I was dragging in the office today. All the children are back in school. It's the difficult chronic medical problems that seem to have no solution that confront me, and my energy is lacking. Taking a brief nap at lunch helps a little.

I pick up the first chart after lunch... a middle aged Asian woman, Mrs. Q. As I walk in, she looks puffy, and runny, but there is an intensity and a liveliness in her eyes too. "Thank you for saving my husband's life," -- it jumps out as if she had been holding it in for a long time. I did not expect that. Yes, I did work her husband in at the end of a Friday when the couple drove 3 hours back to Grand Rapids from the Upper Peninsula, him with chest pain, and instead of going to an emergency room like most people, they wanted to see me. His EKG showed an arrhythmia and possible ischemia(critical lack of oxygen that carries the threat of heart attack), but not a heart attack. I was able to get my good friend and cardiologist, Dr. M, to see him yet that afternoon. Within a couple of days in the hospital the mystery had been solved, a pacemaker inserted, heart attack averted, life normalized. "I was very pleased to help your husband, and I am glad he is better". I am thankful that there are still people for whom the relationship with their doctor is more important than an MRI. But mostly, I am thankful that my dry well is filled today by the celebration of a success and for life restored. It becomes energy that I can draw on for the rest of the day.

Why is brown ugly?

Maria says she is here today because of pain over her heart. It is like a rock on her chest, and it gets worse when she thinks about the pain in her life. She says, "Mis hijos me odian, " my children hate me because I abandoned them in Mexico. I have no one. I work hard but my body is failing as I work. I don't ask her to tell me why she abandoned them. I know. It was her husband who told her to come to the US, and he's not there anymore. Maybe he died, maybe he found another woman. Maybe he's an alcoholic. "I was left in a garbage dump by my parents," she goes on to report. "Another family found me when I was a few hours old. They never told me until one day I was yelling at Blanca she shouldn't be hitting that child, and she fumed back, 'you are not really a part of our family, so don't tell me what to do with my children. Your parents left you because you were ugly. Your eyes are brown and their eyes were colored'". "Why are brown eyes are ugly", I inquired? She said its just the way things are, but she said, " sometimes I dresses up and can look nice. I'm not really ugly, I don't think."
Maria's EKG is normal and I am going to have her get a stress test. I am suspicious it will not divulge the source of her pain.

Salvadoran lunch

My morning at the free clinic ended on time this morning, giving me time to actually stop for lunch. I had heard about a new Salvadoran restaurant in the neighborhood, and ever since then I have had a hankering for that Central American food that is so simple tasty and a bit too greasy. I bounded over the snow drifts, looking down the street. Right next to the sign advertising "Deep massages -- American girls" was a little blue and white sign Salvadoran Restaurant. Despite the grungy facade with neighboring store fronts falling in on themselves, I was greeted by an impeccably clean, newly painted restaurant. The tables and floor were glistening. On the wall was a 20 foot long mural of a busy Salvadoran market. Juan Carlos bounded over to my table. "Don't I know you?" he asked me in Spanish?" It's possible I've been your doctor at some time I admitted, playing the odds. Oh, yes I had treated him in the past. I submitted the order and soon I had a plate of steaming pupusas, tamales, fried banana and yucca in front of me. Pupusas are made of masa, like the corn meal that is used for corn tortillas, but thick, moist and with a cheese and bean filling. They melt in your mouth. New immigrants bring some problems, but no one seems to recognize their hopeful, entrepreneurial spirit that brings new life to neighborhoods long ago abandoned to drugs and decay by Americans who have long ago fled to the suburbs and beyond.

Reality show?

Marta came in for her physical today at the free clinic. She left her children with their grandparents 8 years ago in order to come to the US to try to make enough money to support them. Since then she has been working in our town in a factory and sending a chunk of her income back every month. "Have you seen your children since then?," I asked. No, she's afraid she would not make it back in the country without any documents. But she does talk with them every few days. She's also been stressed because she finally decided to leave her abusive alcoholic husband. She's on her own now and feels stronger. She's happy that her children will have enough to make it. I can not imagine leaving one's children in order to help them. It's a calculation that the benefits will outweigh the anger and resentment those children feel of being left behind. But it's a calculus that is worked out every day by desperate parents who can not make it where they are. I don't expect to see a reality show about this very soon.

Toxic waste

Dinh, a Vietnamese father of 2 was in for vomiting and diarrhea. He was already improving after about 1 day of symptoms. I was nearly knocked over, though, when I entered the room. It was the strongest ripest diaper smell possible. My nurses usually impressed with my fortitude of ignoring unpleasant smells, but this was over the top. I looked around the room at the 2 and 3 year olds toddling around the room, and asked, "Does someone have a poopy diaper?" The man, barely functional in English, finally got the message. He looked into the diaper of little Tran. Oh, I guess she needs a change. "I have a stuffy nose so I couldn't smell anything, he explained." He changed the diaper in the bathroom and left the diaper in the trash there. Nursing drew straws for a toxic emergency swat team to remove the offending trash bag to the outdoor dumpster. After a few sprays of air freshener, and a laugh, we were back to normal operations. Several women I know have wondered out loud whether the 'Y' chromosome confers an ability to ignore all needs of the house and children. Now I can understand their comment!

Bipolar is more than a label

23-year old Jennifer was in today with husband Todd and step-daughter. Despondent, she had just just dropped all of her college courses and has not slept for 2 weeks. I thought we were making progress only 3 weeks ago when we found the proper combination of medications to clear her migraine headaches...even figuring out that her perfume was a trigger. But now she has not slept, her weight is slipping away and her anorexic patterns are returning. She finally admits to her depressed feelings, though it goes completely against her religious faith and her attempts to generate the gratitude and joyfulness that her cognitive brain understands to be true. Because of her lack of sleep I am suspicious of bipolar depression, and if I put her on a typical SSRI antidepressant such as Prozac or Zoloft, I could trigger a manic episode. I downloaded the Goldberg Screen for Bipolar Depression from the internet and administered the screening questions. She is positive for 11 out of 12 questions. I think she is bipolar, presently depressed, and in danger of serious anorexia. I will get her in to a psychiatrist as soon as possible. Unfortunately, the health care system is broken in that I can not refer her directly to someone. The psychiatrist will only accept an appointment made by the patient, so tomorrow I will need to call to make sure she has an appointment.