A Country Doctor Writes:

The past two weeks have been unusually hectic. My clinic schedule has been overbooked and poor Autumn, my sleep deprived nurse-and-mother-of-an-insomniac-three-year-old, seemed to be drowning in triage telephone calls.

Priscilla Pye, a longtime patient, called our clinic six times one day. It was clear that we were not meeting her needs, and yet with every call she made, our therapeutic relationship deteriorated exponentially.

It started a few weeks ago.

Priscilla Pye is normally a very bright, articulate and self-assured woman, who has made quite a name for herself in the art world. She owns two galleries, and recently started another business promoting local craftspeople to a bigger audience.

Priscilla, over the years, has been both a fan and a critic. She has often lamented the fact that I seem so much busier now than twenty years ago. She also hasn’t had much sympathy for my choice to eliminate some more complex and high-risk procedures from my clinical repertoire; when I first came to town there were fewer specialists in the nearby cities, and primary care doctors in general did more procedures than they do now.

This spring Priscilla developed back trouble and this summer she fractured her ankle. She didn’t do well physically or emotionally, ended up firing her back specialist and usually would double check with me everything her orthopedist told her about her ankle.

Her pain medication made her constipated and she started to have attacks of abdominal pain. Then her legs started to swell and she put on weight. One day two weeks ago her asthma seemed to be bothering her more than ever before, and when she called with such a constellation of serious symptoms, we gave her a 30-minute appointment.

She arrived twenty minutes after her scheduled appointment time, which in a practice that runs on time is a major problem. From my hurried history and physical exam it was clear that Priscilla needed further testing of her heart as well as lots of laboratory testing and CT scans to make sure she didn’t have malignant lymph nodes or tumors compressing the veins in her chest and abdomen. I also started her on fluid pills and stool softeners.

Priscilla’s appointment had been mid-day Friday. The way my day was going there was no way I would get her chart note dictated and the necessary forms over to the outside appointment scheduling staff before the end of the day.

Priscilla was frantic. Her symptoms didn’t justify an acute hospitalization and she didn’t seem to have much sympathy for the fact that I had fifteen more appointments that day after hers, and all of them expected my undivided attention and punctuality. She called twice that afternoon to check on the status of her referrals. Autumn could not calm her down. Pressed for time, I grabbed the telephone receiver and told her: 

“I’m working as fast as I can!”

At 5:30, with our staff gone, and more than an hour’s worth of paperwork left to do, I called the scheduling center of one of the hospitals we use. Miraculously, I was able to get all her tests scheduled for the following Monday.

I called Priscilla to tell her about all the appointments I had made for her; she seemed calm, perhaps even a bit touched that I went through this trouble for her. I warned her that I wouldn’t have any results until a day or two later.

The day after her tests she called first with a request for results, which were not in, then with a concern that she was having dizzy spells. She demanded I order a STAT MRI because she was sure she was dying from a stroke. At that point in time our clinic was like a labor room during a full moon. Autumn appropriately told her that ordering an MRI without evaluating her was bad medicine, and if she really thought she was dying and/or having a stroke, she needed to be evaluated at the hospital emergency room. Priscilla was unimpressed, and her next several calls that day were to the clinic administration.

All the tests I had ordered on Priscilla were negative. She called a few more times, lamenting to Autumn how little I must care about her. Autumn was so disturbed by the tone of these calls that she forgot to ask how the fluid pills were working.

This Friday, we had a cancellation of a 30-minute slot, so I asked Autumn to call Priscilla and offer the time slot to her. Autumn’s look made it clear what she thought of that idea. Priscilla was very nice on the phone and thanked Autumn for thinking of her.

So it came to be that my last appointment Friday was The Dreaded Visit with Priscilla Pye. I expected that her dissatisfaction with my busy schedule and my decreased appetite for medical heroics and risk-taking would get me a raking-over-the-coals, maybe get me fired from her case, or she might even have succeeded in getting me into trouble with the clinic administration. I fantasized about walking into the room and telling her that I was already doing the best I could, and if that wasn’t good enough, she could take her business elsewhere.

As usual, I walked into the room, greeted the tired and fearful looking patient, sat down and recapped what had transpired from a medical point of view. I told her I wasn’t smart enough to know yet exactly what was going on.

She interrupted me by saying she thought I was the smartest doctor around, and the only one she trusted, because I had common sense. She said:

“I’m a businesswoman – I know you don’t have the administrative support you need. You need your own secretary and more nursing support, and…”

We reviewed what needed to be done next, including another blood test to check what the powerful diuretics had done to her potassium level. I opened the door to the hallway and as I left the room, Autumn’s eyes met mine as if to ask:
“How bad was it?”

I revealed nothing. Then Priscilla emerged from the room and said:

“Autumn, I brought something for you and your little boy…”