A Patient in the Lobby Refuses to Leave: Medical Emergency, Unhappy Customer or Active Shooter?

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

A Country Doctor Reads: July 12, 2019

Basch Unbound—The House of God and Fiction as Resistance at 40 | Humanities | JAMA | JAMA Network

The 1978 novel The House of God is a fictional account based on the internship experience of Samuel Shem (Stephen Bergman) at Beth Israel Hospital in 1973-1974.

I am more appalled now than in 1973 by our national politics, by the way house staff are forced to spend much of their time at computers, by the fact that patients have no idea that electronic health records are designed to optimize billing and insurance payments rather than their care, and by the way nonphysician executives at the top of hospital systems, having never been trained in patient care, dictate the terms of the profession.

Chekhov described the best of writers as those who convey “life as it should be in addition to life as it is.”3 The impulse to resist, reform, and create a view of life as it should be still inspires my writing and has carried me through everything I’ve done. I’m trying to hand that fight over now to the younger generation, in my teaching at NYU Med, in public speaking, and in a forthcoming new sequel to House called Man’s 4th Best Hospital.4 I talk to anyone who will listen about the electronic health record and the takeover of medicine by money and the opportunities that exist to resist it.

“We doctors are the workers, I tell them. Without us, there’s no health care.

We have power and can shape the fate of medicine.

My generation is almost gone, we’re out the door, so this is your fight now, your life.

What will you do with it?”

— Read on https://jamanetwork.com/journals/jama/fullarticle/2738069

The Stages of a Man’s Life

Moving always involves pondering book titles as you pack and relocate your library. This weekend I did my last walk-in Saturday in Bucksport and back in Caribou sixteen hours after starting out I randomly opened a box that contained my prized Osler biography, signed by Cushing, and came across the 80-some page monograph “He” by Jungian psychologist Robert A. Johnson. I wrote about this book here six years ago.

I have a couple of copies of this little book and I keep coming back to it. First published in 1989, just before I started a four and a half year stint at Cutler Health Center at the University of Maine during my first exile from Bucksport, it describes the archetypical journey most men must undertake as they move through the stages of life, referencing literary names like the Fisher King, Parcifal, Don Quixote, Garamond, King Arthur and the knights around his table, the Holy Grail and the Grail Castle.

The essence of Johnson’s book is that males during adolescence have a profound (Holy) Grail experience, too powerful for them to remain in but then spend the bulk of their manhood hoping to find again. They finally learn that they were never that far from it; it is just a short way down the road and to the left, and this time, if they have learned their life lessons, they can enter the castle and remain there.

Central to the legend is that a simple man, a fool, needs to ask the simple question “whom does the Grail serve” in order for the wounded Fisher King to be healed. But Parsifal, who is such a person, heeded his mother’s advise “don’t ask too many questions” and missed his opportunity.

As I reread the book this time, a sunny Sunday morning over several mugs of coffee, I reflected on how much I have changed in the thirty years since I first read it.

One of the themes throughout the book, woven through the Grail legends, which exist in several cultures and languages, is man’s relationship to his inner feminine, one of the strong elements of Jungian psychology.

Johnson lists six basic relationships a man shares with the female world. All are useful, but they must not be confused with each other: His human mother, his mother complex, his mother archetype, his fair maiden (Jungian speak for inspiration), his flesh and blood wife or partner and Sofia, the goddess of wisdom.

Johnson explains the difference between mood and feeling. Feeling is the ability to value and mood is being overtaken or possessed by a man’s inner feminine.

I am still working on reigning in my tendency for moodiness on some levels, and I am working on letting go of my Americanized idea of “the pursuit of happiness”.

Johnson, as many other thinkers says that happiness is, linguistically and philosophically, living in the present, with “what happens”.

He references Alexis de Tocqueville:

“One cannot pursue happiness; if he does he obscures it. If he will proceed with the human task of life, the relocation of the center of gravity of the personality to something greater outside itself, happiness will be the outcome.”

Here I am, unpacking boxes, mending fences, cleaning stalls, reorganizing closets and cupboards; life is happening in a humble red farmhouse with peeling paint and a sagging front porch. It feels a lot like moving out to camp every summer when I was a young boy, before I started to think I had to be a knight and a dragon slayer…

To quote James Taylor, not for the first time:

“The secret of life is enjoying the passage of time. Any fool can do it. There ain’t nothing to it.”

A Country Doctor Reads: July 6, 2019

Time and the Choice to Listen

This week, again, I ran into a couple of articles about the inordinate amount of time doctors spend on charting and reading chart notes. Each of my reads made the point that it is better to listen to the patient.

When you find yourself in a position of rendering a second opinion, do you read through old notes and test reports or do you put all that aside and listen to the patient tell their story from the beginning?

Osler himself said “Listen to your patient, he is telling you the diagnosis”.

Raphael Rush, MD, has a thoughtful essay in The New England Journal of Medicine, titled “Taking Note”:

I turned my chair away from the computer and angled toward her. My stethoscope weighed on my neck and I removed it, along with my smudged glasses, which forced me to lean in. I picked up a pen and some paper, ready to transcribe whatever she said.

After a moment, she took off her jacket and settled into her chair, resting her coffee cup down on my desk. She seemed to relax. I confirmed her name and date of birth, and then we began.

“I have a lot of records from your other doctors,” I said. “We’ll review those together in a bit. But I want to hear your story again, in your own words, if that’s OK. From the beginning.”

http://www.nejm.org/doi/full/10.1056/NEJMp1816537

JAMA Network Open featured a piece this spring by Pieterse and colleagues titled “Shared Decision Making and the Importance of Time”

Clinical encounters, although uncommon in the lives of many patients, offer a place and time for clinicians to gather insight into what matters to each patient and for patients and clinicians to co-create care that fits each patient’s situation. Time during encounters is usually set by the schedule, which is the result of algorithms that prioritize meeting the demand for access to available clinicians over offering enough time for unhurried consultations. The completion of recommended tasks and of clinical and administrative documentation further taxes the time in consultations. Clinicians often feel hurried and interrupt the conversation with a patient, on average, within 11 seconds.4 When lacking time, clinicians may present information with a complexity or tempo that may easily overwhelm the attention of patients who are ill and worried. Information is then lost on patients, and time is wasted. Clinicians may not allow for a silent pause and miss key patient disclosures or questions.

Conversely, wresting unhurried visits from a system that overbooks clinicians occurs by accident, such as, for example, when a patient does not show up for a visit, or requires a conspiracy between patients and clinicians to lengthen the visit and spend the necessary time together. The resulting delay may offend other patients who are waiting and frustrate the staff who will have to stay late at work.

https://jamanetwork.com/journals/jama/fullarticle/2731737

And in my own archives I have a piece from 2017, titled “Did You Read My Chart?” about a woman with a chronic problem I saw one busy Saturday (No, I did not read it):

https://acountrydoctorwrites.blog/2017/02/28/did-you-read-my-chart/

Medicare PSA Screening Reversal: Yesterday’s Quality Measure is Today’s Rejected Claim

(So much for “The Conversation”)

There are two versions of “The Conversation” we have with men: One is for teenage boys and it is about wet dreams, sexually transmitted disease, unwanted pregnancy and at one point also about testicular self-examinations. Those have now been edited out of the script, which makes sense to me since I have seen only three cases of that in forty years of practice, all but a couple of them diligently preaching that particular gospel.

The other one is with men of the age I now am, explaining, a few years ago, the benefits of blood tests (and, remember the rubber glove exam?) for prostate cancer screening and more lately the confusing intricacies of PSA blood tests.

For several years I’ve been spending a lot of time during physicals and wellness visits talking about the pros and cons of prostate cancer screening. I tell people you have to treat maybe 36 patients with prostate cancer to save one life. I tell patients that a recent long term study of men with early prostate cancer showed that 10 years into it only half of them had needed to do anything about the cancer. Still, many people want to be screened and I just encourage them not to panic if the result is abnormal.

A few weeks ago I got my first rejection of a Medicare PSA test for cancer screening purposes (ICD-10 diagnosis Z12.5, screening for prostate cancer).

My first, primitive, reaction was “here I have to spend all this time soft pedaling the news that PSA testing, which men (and doctors) were brainwashed into performing, is a general waste of time” and Medicare simply stops paying for it overnight without even telling me to save my breath.

Medicare will now only pay for PSA testing if you have the dribbles or something like that, not for screening for prostate cancer. On my iPhone I get notifications of all kinds of stupid things that don’t bother me a whole lot. Why couldn’t somebody tell me that Medicare no longer covers PSA for screening? Or maybe there’s an App or social network I’m not on?

Medical Quality is a fickle mistress, reminding me of the mythical Swedish “älva” (fairy), or is she just one of those random formations in the foggy mist I drove through on my way up from Bucksport to Caribou last night?

I Wish My Clinical Hunches Were Wrong More Often

He did a double take as we passed on our small town sidewalk the other day.

“Hey Doc, I didn’t recognize you dressed like that, without your…”, he gestured to where my tie or stethoscope would have been. I was wearing a cafe-au-lait colored T-shirt and faded Levis.

“Did you hear about the appointment with the cardiologist yet”, I asked.

“It’s in two weeks”, he answered. “Tell me, Doc, how serious is this murmur?”

“Right now, not very, but you could end up needing a valve job some day, so you’ll need to have another echo done through your esophagus so they can get a better look at that noisy valve and then regular follow-ups”, noting silently to myself and I’ll never know how you make out now that I’m handing over your care to one of my partners.

He started thanking me for being his doctor for so many years, through so many illnesses, both life threatening final diagnoses and mere scares we had worked our way through.

Two years ago, almost to the day, I had a hunch that he might have a malignant kidney tumor, based on some nonspecific symptoms and an extremely elevated sedimentation rate.

In the end, he had something a bit less serious, and I was more relieved at him not having cancer than embarrassed about my inaccurate clinical hunch.

This time, he had been in for a routine checkup and as I listened to his heart I heard something new. He had a distinct early diastolic murmur. Soft systolic murmurs, between the first and second heart sound, are dime-a-dozen, but diastolic ones are fairly rare and his was fairly loud – what I ballparked as a 2-3/6 (more than a third of the maximum volume imaginable).

Systolic murmurs sound like Bipzzzt-Bip; diastolic ones sound like Bip-Bipzzzt. The diastolic murmur I knew the most about but haven’t diagnosed very often is mitral stenosis, usually caused by rheumatic fever. My patient had never had that as far as I knew and he had no symptoms of heart failure. I sent him for an echo and I got a call from the cardiologist who read it, praising me for my “excellent pick-up” of the murmur, which on the transthoracic echo indeed looked like at least a moderate if not severe mitral stenosis.

Being praised for my auscultation skills was nice, but I wasn’t pleased that my patient could be facing heart surgery in just a few years.

Early in our careers, doctors have a tendency to triumph over serious or rare diagnoses we make as we marvel over our newfound skills and the logical complexity of the human body.

At this stage of mine, I often feel sadness when a patient I care for, and care about, develops a symptom that signals the possibility of a serious disease.

If the diagnosis I think they might have is easily treatable with a good prognosis, I can triumph over my clinical hunches and diagnostic acumen. But if it is not, how can I feel proud about my skill at recognizing the distant footsteps of the grim reaper?

My New Life

We all have 168 hours a week to spend.

For some time now, I have been working well over 60 hours a week and spending 15 hours in the car traveling the more than 200 miles between my two homes and clinics.

As of this July, the month of my 66th birthday, I am staking out a new life for myself. I’ll be spending 30 hours a week in my Van Buren clinic, only 3 hours commuting, 30 on horse related things and 30 on my writing. Add the 63 hours I figure I need just to survive, and I will still have 12 hours to do something else. I admit some of that time, probably 5 hours a week on average, will be remote chart work, which can be done while looking out at the horse pasture. That still leaves an hour a day on average to do something new.

I’m calling this a semiretirement although it is really just slowing down to a more normal pace.

That means I’m giving up the medical directorship and work in my other clinic. But it also means I’ll be a more well balanced human being, I hope, as I consolidate my life in northern Maine, in a Swedish looking little red farmhouse not far from the village of New Sweden.

Aerial view of SOLTORP, which means “Sunny Little Farm” in Swedish

I have written about this before: During my internship in Sweden, I read an article in a Stockholm newspaper about the Swedish colony near Caribou. I was in the process of applying for my Family Practice residency in Maine, so I wrote to one of the people featured in the article. He forwarded my letter to the presidents of both the Caribou and Presque Isle hospitals and they both invited me to come and take a look. The rest is part of my career history and apparent ultimate destiny.

First trip to New Sweden, 1983

As I now reach what the American Social Security Administration calls my full retirement age, I hope to be able to continue the work I love for many more years, but at a pace that allows me to smell the roses along the way. I look forward to having more horse time and more time for my writing.

Another change, sadly, is that I have exchanged my wedding ring for a newly purchased caduceus signet ring. Not that my dedication to medicine and long hours caused this to come about, but this change certainly did make me think hard about how I want to spend whatever time I have left on this planet.

Raking the roof at Soltorp

Look for much more writing in the future, at least after I get settled into my new routine.

Thanks for listening (I mean, reading).

Hans


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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