My second patient of the night was an elderly woman who presented
with left-sided
numbness of her face, arms, and legs. Symptoms had
started the day before, and though they had not worsened, they had not
resolved, either. She was particularly concerned that adult-onset
diabetes,
heart disease, and a blood-clotting
disorder (Leiden Factor 5 deficiency)
increased her risk for stroke. She had seen her primary care physician in
his office earlier that day; upon detecting dizziness and upper extremity
weakness, he had sent her to the emergency department for evaluation.
A check of the patient’s vital signs and my neurological exam of her
yielded completely normal results. Her CT head scan was unremarkable.
Had she experienced a TIA? Why did her numbness and tingling
persist? I asked her how she had been sleeping and eating and if she had
been under an unusual amount of stress. After an uneasy silence, she
furrowed her brow and hoisted herself up on her elbows. She explained
that she and her husband have one son, who lives out of state. His job
often takes him away from home, and their daughter-in-
law
has, in effect,
raised their children. Finances are tight, and the patient and her
husband have drawn on their retirement savings to help support their
son’s family. Their daughter-in-
law
had called last week, unbeknownst
to her husband, and insisted on talking to my patient’s husband. He
was told that his grandson had gotten into trouble at school. When the
boy’s father (the patient’s son) had reacted by confiscating his phone, the
boy had threatened to kill him with a knife. Meanwhile, the patient had
heard nothing more from her son or daughter-in-
law.
She could not say
anything to her son, because he did not know that she knew about the
incident. As the patient was talking, I watched as the reading on the self-inflating
blood pressure cuff climbed to 190/110. Her voice was now quivArrival
127
ering, her fingers were trembling, and she nodded meekly when I asked if
the tingling had returned.
In medicine, it is easy to travel far down the road of assumptions
before stopping to ask how or where we have traveled. We do what we
are trained to do; we follow a well-worn
clinical agenda. We press ahead
with our blinders and prejudices, too busy or proud to ask for directions.
Increasingly, we ask computers and assistants to enforce our protocols,
because, frankly, we know they will do a better job. We become distracted,
tired, rushed, and annoyed. We are lured by prior experiences and
competing loyalties. But it takes a generalist physician—in
touch with
one’s instincts and emotional intelligence—to
recognize a clinical dead
end or ill-fitting
puzzle. It takes time—time
that no one has—to
start
over, engage in conversation, reestablish trust, and offer hope that a solution
is still possible.
What should patients expect from their doctor? To have their diagnosis
set aside until someone with the time, training, and desire has
heard every concern, even those you are unwilling or unable to express.
This is the challenge and privilege of primary care. It permeates primary
caregivers’ field of action and rules of engagement:
Patients present with an undifferentiated problem.
The time frame for action is open-ended,
not critical or urgent.
Illness has upset the patient’s routine.
Change is required in order to return to the norm.
Change begins only after the patient accepts personal responsibility;
it is mediated through the patient’s social network.
The doctor-patient
relationship is a starter kit for acceptance and
change.
with left-sided
numbness of her face, arms, and legs. Symptoms had
started the day before, and though they had not worsened, they had not
resolved, either. She was particularly concerned that adult-onset
diabetes,
heart disease, and a blood-clotting
disorder (Leiden Factor 5 deficiency)
increased her risk for stroke. She had seen her primary care physician in
his office earlier that day; upon detecting dizziness and upper extremity
weakness, he had sent her to the emergency department for evaluation.
A check of the patient’s vital signs and my neurological exam of her
yielded completely normal results. Her CT head scan was unremarkable.
Had she experienced a TIA? Why did her numbness and tingling
persist? I asked her how she had been sleeping and eating and if she had
been under an unusual amount of stress. After an uneasy silence, she
furrowed her brow and hoisted herself up on her elbows. She explained
that she and her husband have one son, who lives out of state. His job
often takes him away from home, and their daughter-in-
law
has, in effect,
raised their children. Finances are tight, and the patient and her
husband have drawn on their retirement savings to help support their
son’s family. Their daughter-in-
law
had called last week, unbeknownst
to her husband, and insisted on talking to my patient’s husband. He
was told that his grandson had gotten into trouble at school. When the
boy’s father (the patient’s son) had reacted by confiscating his phone, the
boy had threatened to kill him with a knife. Meanwhile, the patient had
heard nothing more from her son or daughter-in-
law.
She could not say
anything to her son, because he did not know that she knew about the
incident. As the patient was talking, I watched as the reading on the self-inflating
blood pressure cuff climbed to 190/110. Her voice was now quivArrival
127
ering, her fingers were trembling, and she nodded meekly when I asked if
the tingling had returned.
In medicine, it is easy to travel far down the road of assumptions
before stopping to ask how or where we have traveled. We do what we
are trained to do; we follow a well-worn
clinical agenda. We press ahead
with our blinders and prejudices, too busy or proud to ask for directions.
Increasingly, we ask computers and assistants to enforce our protocols,
because, frankly, we know they will do a better job. We become distracted,
tired, rushed, and annoyed. We are lured by prior experiences and
competing loyalties. But it takes a generalist physician—in
touch with
one’s instincts and emotional intelligence—to
recognize a clinical dead
end or ill-fitting
puzzle. It takes time—time
that no one has—to
start
over, engage in conversation, reestablish trust, and offer hope that a solution
is still possible.
What should patients expect from their doctor? To have their diagnosis
set aside until someone with the time, training, and desire has
heard every concern, even those you are unwilling or unable to express.
This is the challenge and privilege of primary care. It permeates primary
caregivers’ field of action and rules of engagement:
Patients present with an undifferentiated problem.
The time frame for action is open-ended,
not critical or urgent.
Illness has upset the patient’s routine.
Change is required in order to return to the norm.
Change begins only after the patient accepts personal responsibility;
it is mediated through the patient’s social network.
The doctor-patient
relationship is a starter kit for acceptance and
change.
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