Notes From The Practice

Mothers are wonderful. They never stop. Their stores of wisdom, guidance, kindness, and love are infinite. Their willingness to provide these benefits to their children is timeless. A mother’s child can never be anything other the child of that mother.

One of the blessings of working in health care is that we get to witness, on an intimate and frequent basis, the small miracles that unfold in our patients’ lives. Susan Swanson came to see me recently for her annual checkup. She is quite healthy other than mild hypertension. She is one of the few patients I especially love to see. She has few complaints, her meds are easy to refill, her labs can be ordered quickly, her data entry needs are minimal, and she usually brings in no agenda to her office visits other than her health.

There is something to be said for having practiced medicine for 19 years. After tens of thousands of patients, I — like many doctors in the same situation — feel I can size things up pretty darn quickly. Not that I am never stumped, mind you. But doctors develop a gut-level resonance with people such that, within a minute of walking into a room and encountering an unfamiliar patient, you know quite a bit about them. You can tell if they are really sick, or not so sick. You can sense if they’re under stress. You can tell if they smoke cigarettes even before asking. If unspoken issues underlie the chief complaint, you can usually tell, even if you don’t yet know what these specific issues are. You know what I mean. You’ve been there, done that.

Let’s face it. Seeing one patient after another after another, day after day after day, month after month after month, can be grueling, boring, and stressful. Especially in the field of adult primary care medicine, the litany of unresolvable complaints is unending.

At the end of some days, I wonder why my patient satisfaction ratings aren’t negative 50. With every appointment, my patients are losing ground. Why don’t they finally wise up and realize that each time they see me, they move one step closer to the grave? That is why I have taken to calling these encounters “disappointments” — as in, “I’ve got 13 disappointments this morning, but only 12 disappointments in the afternoon.”

Despite twenty years of medical practice in Vallejo, California, I won’t tell you I have seen it all. But I can tell you I have met Mildred and Thomas. After you hear their story, you may want to meet them too.

Through thick and thin. In sickness and in health. These are the grand concepts. The notion that two people can be soulmates and destined to be together forever has immense appeal. But why is it such a rarity? Why does the myth so often fracture during the long years trying to sustain intimacy and friendship? Till death do us part, you say? One is more likely to encounter a fogless summer in San Francisco. It is that rare?

No, I am not talking about estate planning. Rather, I want to ruminate for a few hundred words on the awesome magic of the trust that society in general, and our individual patients in particular, place on physicians in general, and each of us in particular.

Sometimes I am blown away by the deeply personal and intimate secrets that patients tell me. My days are regularly sprinkled with stories of betrayal, selfishness, individual failure and turpitude. Often these stories involve matters so deeply personal they have never been revealed to the person’s spouse or best friend. And sometimes the stories come from people I have know for all of 60 seconds, the time it takes to introduce myself, exchange some perfunctory pleasantries, and inquire how I can help today.

After close to 20 years of practicing internal medicine, I have a reasonably sound knowledge of the work done by internists and family medicine physicians. I am also very aware that practicing medicine is not a solo activity, but a team event requiring the expertise of many disciplines. As the years go by, I grow ever more impressed with the unique and interdependent contributions made be all members of the team.

Professionalism, n. The status, methods, character, and standards of a professional.

We physicians are all members of the medical profession. We are not members of a medical club, a medical special interest group, or a medical fraternal order. As members of a profession, we are expected by society — not to mention each other — to act like professionals. This expectation is simultaneously a burden and a badge of honor and grace. To comport ourselves as professionals, we live by a code of conduct loftier than that which governs many other honorable fields of work. For clinicians in the medical arts and sciences, this is our blessing and our curse.

When my final patient of the week came in on a Friday afternoon in May, I was exhausted. It had been a long week with too many patients who were much too sick. It did not help that spring had not yet arrived in Vallejo, California. Clouds and fog clung to the land with gritty determination.

It came down to one last patient, Kenneth, a 43-year-old intellectually disabled man who lived with his mother. I had taken care of Kenneth for 10 years. He was massive, 6 foot 3, and he carried his 300 pounds close to the earth. Despite an intimidating appearance, he was a gentle man of few words. During a decade of taking care of him, I had never heard him say more than an occasional “yes,” “no,” or “fine.”

One of the most important, yet most difficult and most mysterious tasks we face as physicians is helping patients and their families approach an impending death. No matter how much practice I have had carrying out this role, it still takes every ounce of emotional and professional reserve I possess. And it is never routine, never the same, from one patient and family to the next. Unlike the management of hypertension or diabetes, here is no practice guideline to follow. For the physician, it takes equal measures of empathy, sympathy, and objectivity, leavened with ample doses of wisdom and intuition.

It was a Wednesday, early afternoon, and I was running 25 minutes behind. Actually I shouldn’t call it running behind. More accurately, I was creeping along, 25 minutes behind. I just could not keep up. Every patient had more things on his or her list than any human doctor could possibly deal with in the time allotted. The tide of patient messages coming in from the Call Center was rising steadily, green message sheets washing over my desk. In addition, walk-up patients flowed in all day, a stream of people unable to get through on the phone, people so desperate to connect with their personal physician they were willing to risk a long wait in the waiting room.