Archive for the 'Progress Notes' Category

“I Just Want an X-ray”

People often want to order their own test. Or, rather, they call and want us to order the test they think they need. I usually decline such requests. Not because I’m mean spirited or money hungry, but because I am a conscientious doctor.

I don’t make any more money by making the patient come in so I can examine them and be sure to order the right test for their symptoms. I’m on salary. But I know anatomy and physiology better than most patients, and I know which test is better for what.

The self-directed imaging request is not a one step process. Whether the test is positive or negative, there are usually followup questions that require medical advice, which takes time and creates liability.

A sparained ankle can be as disabling as a broken one. What (free) advice do I give a patient I didn’t examine?

I, personally, would hate to be asked by a malpractice lawyer why I settled for ordering a plain X-ray of Mr. Barnes severely bruised leg at his request, over the phone, when it was swollen and tender and he in fact turned out to have a deep vein thrombosis that caused his near-fatal pulmonary embolus.

The other day a nurse called and asked me to order a shoulder X-ray of her husband with shoulder pain. When I saw him in the office, he had an A-C separation, a condition better evaluated with X-rays of the acromioclavicular joint – sometimes both of them, carrying weights.

It is important to listen to our patients’ accounts of their symptoms and their fears and concerns about worst-case scenarios. Some people need more and earlier imaging than others: Their past medical history (of cancer, for example) or nuances in their symptoms can make all the difference in the world.

I believe in, and very much encourage, self care for common illnesses and injuries. But when medical tests are called for, a medical person needs to order them and interpret their significance.

A Back Door to Treatment

I had a medical dream last night. I was in a clinic of some sort and the nurses pointed me in the direction of a talkative woman and a silent man in her company. They weren’t in an exam room, more like a pergola of some sort. I was given a tray with syringes and other medical paraphernalia. There was neither a paper chart nor any kind of computer medical record.

The woman spoke about having Graves’ disease but also a host of symptoms that she connected with it that I knew were likely unrelated and instead signs of florid psychosis. She had seen many doctors before and none of them had understood her or offered to help her. She had her own expectations of what that treatment would look like and it was all endocrionological, but made little sense to me.

The man in her company was deferential, soft spoken, as if afraid to upset her. I couldn’t tell what their relationship was. At one point, I think I heard her refer to him as her driver.

With no medical record and a tray of museum-like medical equipment I felt a little helpless. This woman needed an antipsychotic, that was clear, but I didn’t know where we were, what was available or how to reach her in her delusional state.

I told her I thought that not only did she have Graves’ disease, but she was also suffering from exhaustion trying to figure all her symptoms out on her own. I said that I wanted to help her, even though I didn’t really know how and with what.

I started to become aware that this was probably a dream, but I hesitated rising to full consciousness. It was as if I didn’t want to give up on my patient, my improbable clinical challenge.

The dogs’ rhythmic breathing, the cool morning air through the window and the sputtering noise from the coffee maker in the kitchen drew me away from my imaginary duty and into my Saturday morning reality.

How familiar, I thought to myself. A sort of parallel to the experience I had in the psychiatric ER in late 1980 back in Norrköping.

That time, I admitted a psychotic patient for observation. He was the only one who knew that very soon, earth was going to switch places with another planet and our lives would be switched, too. I got him to accept a sedative so he could get a few winks of sleep while things were still quiet, to gain strength and prepare for the next day; a back door to a first dose of treatment.

I had spent great effort aligning myself with his suffering, not challenging his delusion, but instead focusing on his distress. It didn’t work badly.

A few hours later, he tried to escape through a skylight.

Ever since then, I have used the same non-confrontational, low key frame of mind to try to form a therapeutic alliance for very small or incremental goals when treating patients – psychotic, disbelieving, hostile or otherwise unreachable.

But that time my overnight clinical experience provoked a dream after my shift where his powerful delusion suddenly played out in my own mind. All of a sudden I became him and in my dream I was convinced the planets were actually going to switch places.

Switching Places


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”.

BOOKS BY HANS DUVEFELT, MD

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