A Country Doctor Writes:

Last month I saw a woman with a few weeks’ history of pain and swelling around her left ankle. She hadn’t injured it and she had no history of gout or arthritis. It was swollen and tender but not red or warm. Moving it hurt her and she walked with a limp. I ordered an X-ray, which was negative, and some bloodwork. Her inflammatory markers were high, uric acid level was normal and antinuclear antibodies and rheumatoid factor were negative. I prescribed a nonsteroidal and referred her to orthopedics.

Almost a month later I got a call. It was the orthopedist:

“Your Mrs. Patterson – she’s got lymphedema up to her thigh. There’s nothing wrong with her ankle. I’m sending her back to you for a lymphedema workup.”

I gulped.

“She only had swelling at the ankle when I saw her a month ago, so this has changed a lot”, I said as our conversation ended.

I made sure to see Mrs. Patterson the very next day.

“That orthopedic doctor didn’t think much of your diagnostic skills”, she said. “But I told him all this other swelling happened after I saw you.”

Being the first contact in a new disease process always involves the risk of missing diagnoses and looking stupid. The last person to see a patient has all the advantages: more time for the disease to evolve and more previous tests and treatment failures to take into consideration.

Emergency room doctors, hospitalists and specialist consultants need to be honest when they disagree with the primary care physician. But they have a choice whether to assume all the diagnostic clues were there when we saw the patient or not. They also have a choice whether to be graceful or degrading if we were indeed on the wrong track when we saw the patient.

We strive for perfection, but none of us are perfect. That is the scary part about being a doctor in this litigious society. But we are in fact not held to the standard of always being right. We are only required to do what a reasonable clinician would do under the same circumstances.

No insurance company would cover a lymphedema workup for modest ankle swelling. Ordering that would have been inappropriate, wasteful and excessive.

But, as I think back on this particular case, I have once again formulated a resolution. Since I am practicing in an area where it often takes a long time for patients to get an appointment with a specialist, I need to be even clearer than I have been in telling my patients:

“If things get worse before the consultation, I absolutely need to hear about it.”

I have known doctors that cultivated a dependence among their patients by suggesting their health and safety depended on regularly scheduled visits and laboratory testing for what seemed to me stable, chronic conditions. People would come in every three months, year after year, to review cholesterol numbers, potassium levels and glucose or blood pressure logs and have a more or less complete physical exam every time. Patients would also get scheduled for rechecks of ear infections and other simple conditions I always thought patients can assess themselves.

Compare the effort on the part of the physician with that type of practice versus seeing stable patients less often, doing more urgent care, and being more available for new patients. The first approach seems comfortable, possibly complacent, and the second more demanding, but also more satisfying, at least to me. My goal is always to make my patients as independent and self sufficient as they can be. I don’t want them to be dependent on me in an unhealthy way.

It is a matter of temperament, but it is also a matter of stewardship and resource management if we see ourselves as serving the populations and communities around us.

Maybe it is because of my Swedish upbringing and education, but I would feel guilty if sick patients or even relatively healthy people don’t even have access to a personal physician if I were to spend my days over-monitoring stable conditions.

In this medically underserved state, don’t we have a responsibility to consider whether we are getting too comfortable in our chronic care routines? Patients check their own blood pressures and glucose levels. They could get in touch if their numbers worsen. Do we really need to bring them in to make sure they don’t stray when there are people in our communities without access to care?

I sometimes actually use the phrase “I don’t babysit”. I don’t necessarily use the word “empower”, but that is what I always try to do with my patients.

I admit that it doesn’t always work when I ask a patient to let me know if their home blood pressure drifts above 140 or their weight goes up by 5 lbs. But this is where I think we all, providers, clinics and healthcare organizations, can utilize support staff. Someone other than the physician could reach out to patients for followup information instead of hauling them in just to establish they’re on track. We obviously need to do that with complex or very ill patients, but it is inefficient and sometimes unhealthy to do that with every patient taking medications for relatively benign conditions.

It is easy to feel responsible for our patients if our prescriptions cause harm or even carry great risk, but this is (still) a (mostly) free country and every patient has choices to make every day that we have no control over. We can’t be there, watching their every move. We know people don’t always take their medications or follow our advice. We might make them more compliant by seeing them more and more often or by instilling fear in them or insisting they let us assume all responsibility for their disease.

But that amounts to an unhealthy doctor-patient relationship, undeserving of a civilized and free society.