A couple of weeks ago I wrote a post titled “Never Assume” about a handful of patients, whose case histories took an unexpected turn.
Well, as it happened, a few more twists and turns unfolded since then:
Peter Bartley, the man with upper abdominal pain and black stool, not just from the Pepto-Bismol he had taken, had his upper endoscopy. It only showed some mild gastritis without bleeding. Fortunately, the surgeon also did a colonoscopy, which showed an actively bleeding polyp almost the size of a clementine in his transverse colon.
Black stool is generally thought to be from the stomach or duodenum, located above the ligament of Treitz. It has been said that it takes the digestive juices 14 hours to change the color of our hemoglobin into black melena. Peter’s intestinal transit time must have been slower than most people’s for this to happen with a bleeding polyp in his colon.
Norma Daigle, who had received another patient’s trazodone and Lexapro, called the other day and told Autumn she wanted some trazodone of her own, because it had made her sleep so well.
Beatrice Nash, whose hip pain seemed to come from a mass in her left pelvis, had her CT scan. It showed a very large probable lipoma, a harmless fatty tumor. She has seen the surgeon, who wrote in his not that she described the pain as sharp and coming directly from the hip, and not at all from somewhere higher up than that. He didn’t think the lipoma had anything to do with the hip pain, and recommended she see an orthopedic surgeon.
As it happened, a few days later she had a follow up visit with her orthopedist for a cortisone shot to her arthritic knee. I eagerly read through his note to see if he thought her pain was from the hip joint or not, but there was no mention at all of her hip pain!
Diane Fehrer, who never seemed to remember to take her thyroid medication, accepted the pharmacy’s offer to put her pills in monthly calendar bubble packs. I am keeping my fingers crossed that she will remember to look at the bubble pack every day, and I keep wondering: If she does take her levothyroxine every day, will my prescribed dose be too high and cause her tremors, palpitations or even atrial fibrillation?
Finally, Matt Wikert, the physical therapist with high blood pressure and chest pains, showed up at the hospital for his stress test as planned. Earlier that morning he had a 45 minute episode of chest pain. His EKG showed some subtle changes from the one I had done, so the stress test was cancelled and he was admitted for observation. He ruled out for myocardial infarction and was discharged with plans for a rescheduled stress test. We still don’t have a date for it.
Every day, just like that day a few weeks ago, I see patients whose stories don’t quite fit the expected pattern. In the words of Sir William Osler:
“Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”
A Country Doctor Writes: 
Your 3/28 and 4/10 posts re “Never Assume” so beautifully open up the stories of patients and PCPs who struggle with the unknown. I applaud your skill in capturing the uncertainty of a bleeding polyp, of what an orthopedist chooses to document in the consultation note for a patient with hip pain, of the appropriate levothyroxine dose for a non-adherent patient, and of atypical chest pain in the physical therapist who ruled out for MI. Sitting with these dilemmas and making expert decisions in the face of them is what the primary care physician is counted upon to do. Regardless how many members of the team are placed on board (e.g., care coordinators, health coaches, ‘primary care technicians’), it will remain the PCP’s task to make sense out of “stories that don’t quite fit the expected pattern” and the PCP’s role to accompany and guide patients as they will respond in their unique ways to illness and disease. Over the years, I’ve had the privilege of working with many expert physician generalists and in large part to honor and support them, along with my colleagues, I have written about the challenges of the work you so beautifully describe in “Clinical Uncertainty in Primary Care: The challenge of collaborative engagement.” Our book can be accessed for free if your medical library has the Springer platform. Once connected to your library, put: http://www.springer.com/medicine/book/978-1-4614-6811-0 into the browser and follow the prompts to free download. (The book should be published in softcover this summer at an affordable price!) The book’s fundamental message? Primary care clinicians need to seek out each other in their workplace settings to collaborate in addressing the challenges their patients present and, in the process, build a supportive learning community.
Lucia S. Sommers, MSS, DrPH
Director of the Practice Inquiry CME Program
Department of Family & Community Medicine
University of California, San Francisco