Sound and Fury

Family and Community Medicine

Latravia Kell was my favorite patient. I can’t think of one bad hand that life hadn’t dealt her but she was unfailingly cheerful, polite, and compliant with all of her treatments. I met her on my first day of family medicine clinic and saw her at least every month afterwards. I didn’t do too much for her. She had a small platoon of specialists following her various medical conditions. Rheumatology had dominion over her SLE, Orthopedics claimed her osteopenia, Infectious Disease had suzerainty over her HIV and OB/Gyn was following her for various pelvic irregularities. In fact she seemed to have all of her bets covered and I was not sure what she needed from me.

“I’m here for my Depot shot,” she said on her first visit, “All you have to do is sign the form and the nurse will give it to me.”

“Well hell, we can do that,” I said, a little relieved because she seemed a monstrously complicated patient to inflict on an intern. “Is there anything else I can do?”

“No, not really. I’m good.”

Although we later became friends and she hugged me and cried on my last day at Duke, on her first visit I think even my brief physical exam annoyed her.

Later I had to dictate our standard clinic note hitting all of the high points of the chief complaint, history of present illness, and review of systems even though these were completely incidental to the purpose of her visit. I suppose this was to give the illusion that we were actually doing something besides routing her to the shot nurse but it seemed like a lot of sound and fury for nothing. My assessment and plan was basically a list of who was following her for what condition.

But that’s family medicine, at least at a big academic medical center.

I had other regular patients. It’s not as much fun as they make it out to be and occasionally you look at your panel for the day and hope that particular patients decide to skip their appointments.

Like Mrs. Ribitz. I knew that she was old and sickly. I was aware that her bones were fragile sticks and that she had recently fallen and broken her hip and her arm. I knew that ortho had pinned and casted her and that she was in a lot of pain. Hell, she looked terrible. And she smelled like the crappy nursing home where she lived which is not a nice smell as it is basically the smell of stale urine and dried food stains.

But my God could that woman complain. About everything and everyone. After the obligatory “What can I do for you today” she would stare at me malignantly for a few seconds and then launch into a tale of pain and suffering that would have made stones weep if it was anybody but Mrs. Ribitz telling it.

And then she would cough, gasp for air, and take a rest while sucking air through her nasal cannula. Her emphysema didn’t deter her from smoking and my eyes watered in the small examination room from the fumes that permeated her clothing.

“Well, Mrs. Ribitz,” I began while her coughs subsided, “I’m sorry to hear that things aren’t going well but if you had to pick one problem to address today, what would it be?”

“My feet are swelling,” she said curtly, “And my back hurts.”

I took off her slippers and urine-stained socks to examine her feet which were indeed swollen and pulseless, an alarming finding except they has been like that since I started seeing her and no combination of medications or therapies had been able to make a dent in the problem. I threw the Doppler on her and was able to hear the faint, plaintive sound of her tired blood struggling to supply her foot with blood. It was all peripheral vascular disease and poor medical compliance (which sounds nicer on the note than saying, “Patient is an idiot.”) She had already lost three toes to gangrene and I noted that most of the rest were heading that way. There was nothing to do as Mrs. Ribitz was the poster-girl for poor surgical candidates. I confirmed her next appointment with vascular surgery but that was the extent of what I could do for her.

“Tell me about your back pain,” I said with profound regret.

The floodgates opened and I heard, for the tenth time, the story of her chronic pain (from vertebral compression fractures) which was untouched by enough narcotics to drop a small herd of elephants, after which we both looked warily at each other. A physical exam to assess her pain was out of the question. She would probably have a heart attack from the exertion of standing up, which she couldn’t do anyways because of her hip.

“I’m out of Percocet.” A statement. “I need another prescription.”

At one time Mrs. Ribitz had a pain contract but I believe by the time she had exhausted two residents the clinic surrendered and just gave her what she wanted.

“I’ll just write you a prescription and you can be on your way.”

Mrs. Ribitz grunted in satisfaction. I verified the dates of her next appointment with ortho, checked her vitals and stood up to let the nurse wheel her out.

“And don’t even start about my smoking,” she snarled.

“Ma’am. You’re 85. I’m not your father. I’m not going to lecture you but if you want to quit I’m ready to help you.”

Surprisingly, on my last appointment Mrs. Ribitz sobbed uncontrollably and told me I was her only Doctor who wasn’t a pain in the ass and that she would miss me. I guess I kind of grew to like her myself, once I realized that her visits were primarily social calls. She had the usual cadre of specialists addressing her medical problems. All I ever did for her was write for the occasional narcotic and listen to her complaints.

Not every patient was so complicated.

“I’ve got a drip,” said Mr. Ryan nervously after the nurse closed the door.

“I guess we’re not taking post-nasal, right?” I had seen Mr. Ryan several times before.

“Naw, it’s down there.” He gestured down there. “And it hurts when I whiz.”

“Sexually active?”

“Yeah. Do you think it’s the clap?”

“Could be,” I said, “Let’s take a look…yup…certainly looks like it. Tell you what, I’ll send these swabs for cultures and we’ll treat you in the meantime.”

“Hey Doc, don’t tell my wife, Okay?”

“Maybe you need to tell her. I think she needs to know.” This is one of those moral dilemmas they’re always talking about. His wife is also one of my patients.

I had seen his wife just a week before for unusual vaginal bleeding. Of course we ended up referring her to OB/Gyn, just to be safe.

The latest fad in family medicine is identifying “barriers to care.” Naturally, some of these barriers were intuitively easy to identify. Being poor and unable to afford a doctor visit comes to mind, as does being unable because of a disability to travel to the clinic. But some of the barriers are a stretch. Being angry and deciding to express this anger by not taking one’s free prescription medications seemed kind of weak to me but this was exactly the kind of barrier I was supposed to take seriously.

One of our initial clinical assignments was to visit a patient at their home and identify their “barriers to care. My patient was an obese, pleasant, single mother of two with the usual comorbidities, all complicated by medical non-compliance. We weren’t actually supposed to say “non-compliant,” instead substituting the more optimistic and non-judgmental phrase “pre-compliant.’

Having lost her Section 8 housing because of some fraudulent activity which involved subletting her subsidized apartment while she lived with her mother, she lived in a small but adequate house, the rent for which ate up most of her meager income from the public treasury. The first thing she complained about was the poor upkeep of the house and asked me what she was expected to do about it. The social worker who accompanied me nodded empathetically as if to say, “Here, you newly minted doctor and representative of ‘The Man,’ here is a barrier to care. How will you help her over it?”

In my written report I suggested that this was a matter far beyond our scope of practice, something best worked out between the tenant and landlord either amicably or in the City small claims court. Besides, this in no way effected her access to our clinic as her visits cost her exactly nothing and a broken window and leaky faucet are not exactly homeowner’s emergencies.

My wife and I managed a housing project years ago (before my wife quit after discovering a dead tenant which is another story) and we used to get calls at 3AM demanding that we drive across town to unclog a toilet. The helplessness of the dependency class does not admit to any effort, no matter how small, to take responsibility for anything in life. The typical response to the natural question, “Do you have a plunger?” was, “I’m not sticking my hand in the toilet.”

I once got a frantic call from a tenant’s whose apartment was on fire.

“Did you call 911?” I asked.

“No. Do I need to?”

“Not unless you think I’m going to get in my private fire engine and drive over there.”

But I digress.

I also pointed out in my report that despite her claims of poverty, the patient must have had other income. She had furniture, the babies were fed, there was a large (but not extravagant) entertainment center in the living room, and I saw no signs of deprivation of any kind. The children also looked clean and well-cared for. She even had a working automobile.

Apparently her mother helped out.

Lack of daycare was another barrier to care, as it prevented her from coming to clinic even though my wife sometimes has to drag all four of my kids to her doctor’s appointments. I discovered however that while the baby-daddy’s mother, the baby-granny, wanted to take an active role in caring for the children, my patient had refused her access to her grand-children until she bought them expensive clothes as a propitiatory gift. My patient bragged about this. Apparently greed and arrogance were also legitimate barriers to care.

It turned out that she was angry. Yes angry. Angry that when she came to clinic no one listened to her concerns and nobody explained her treatment regimen in a manner which she could understand. Nor did we respect her sensibilities as an independent, intelligent African-American woman.

“I just don’t feel like you take me seriously,” was her explanation as to why she didn’t take her insulin as directed. The social worker soothed her ruffled feathers and I held my tongue. I was not kind to her in my written report. She was a stupid, lazy, selfish woman all of which characteristics are personal problems, not medical issues or barriers to care.

Her anger, I wrote, was a form of transference. Impotent and ineffectual in every other aspect of life, she gave herself the illusion of control by making her social worker and the physicians at the clinic jerk like puppets to her whimsy. The clinic, after all, was probably the only place in the world where she was taken seriously. In every other venue she was just a fat, dumb, single mother without the sense to take advantage of the help she has been given by the State.

Tragic, perhaps. A crying shame and a waste of her potential, no doubt. But not a medical problem.

This report was not received well by the program chairwoman. As if I was a third-grader, I was asked to rewrite my homework, not once but twice, in order to please the sensitivities of the program. And the second rewrite wasn’t good enough either. I was asked to write it again but decided to blow it of and never heard about it again.

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