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.
But I guess the reason we practice medicine is that we never succeed in being fully accomplished physicians, no matter how many years we spend at it. We keep learning. We keep developing. We keep practicing the art and the science, hoping to improve our skills, our intuitions, our empathy, our expertise.
One of the enemies of good medical practice is stereotyping. I fell victim to this problem not long ago and and want to share my story. It shows I still need more practice in my practice.
The story begins when I looked down at the single piece of paper provided me for an urgent care visit one morning. The medical assistant had written down Mr. Robinson’s chief complaint: “Back pain. Wants Rx.” I had never seen Mr. Robinson before, but I noted he was 38 years old. My hackles rose a bit as I sat at my desk, taking a last sip of Peet’s before going in to practice medicine on Mr. Robinson. Probably wants his Vicodin, I thought. The French roast steadies me as I leave the sanctuary of my office.
I walked into the room to find an enormous man, easily six foot five, 290 pounds, largely muscle it seemed, trying to perch on the exam table. Oscar Robinson had a scowl on his face and grunted more than said hello when I stuck out my hand to introduce myself.
“My back hurts!” he commanded me. His words carried the authority of his body habitus, and left little room for doubt. He was proclaiming his diagnosis and setting the stage for the therapy he will demand. I had been in these situations before and could already anticipate that he would explain to me, “Motrin doesn’t work. I need something stronger.”
“OK,” I said, “but I need to get a little more history and then examine you, so we can find out what’s causing your back to hurt and decide the best therapy.”
“You can forget that,” said Mr. Robinson. “I already know why my back hurts.”
Right, I was thinking. This is a classic case. I was already anticipating coming into conflict with what he wanted and what I thought would be most helpful. “So, tell me why your back hurts.”
“Gunshot wound.”
“Gunshot wound?”
“That’s what I said. I got shot in the back three years ago. It hurts. Especially if I have to do heavy lifting. And I have to do a lot of heavy lifting on my job. That’s why my back hurts.”
Great, I told myself. Not only would I have to decide whether to accommodate Mr. Robinson’s request for narcotics, but he was probably angling for disability. I knew his type. Why me? Why couldn’t this guy have had a personal doctor I could have punted this to?
“How did you get shot?” I asked.
“Folsom Prison. The guards set up a fight in the exercise yard between the whites and the blacks so they could shoot people. I got caught in the middle. I wasn’t involved, but I got shot by a guard anyway.”
Hmmm, I thought. Well, this wasn’t your usual back pain story. It should be possible to see if he’s telling the truth. Mr. Robinson readily showed me his bullet wound scar, a pretty sizable dent over his right lumbar area. OK, so he had scar tissue there, but was the work angle on this? I knew he was searching for at least an off-work note.
“Where do you work?” I asked.
“At the Oakland Zoo,” he answered.
At this point, I started getting a bit intrigued.
Mr. Robinson continued, “We’re building a fancy new pen for the lions. The managers say this new pen will fool the lions. It will look so much like Africa they won’t know they’re in a zoo. Hell, those managers don’t know what they’re talking about. Those lions will still know they’re in a zoo. Trust me. I know. I’ve been there.”
I found I was actually warming a bit to Mr. Robinson. It was not that often one heard a story like this. An ex-prisoner, shot by his guards, now helping build a prison, but he did so with no illusions. Though he worked for the zookeepers, his sympathies lay squarely with the lions.
After a quick and somewhat cursory exam, I asked, “So, you want some Vicodin, I presume?”
“No way,” said Mr. Robinson. “I wouldn’t touch that stuff. I just want my Motrin. It works good for me. And doc, could you make it the 800 milligrams? I’m kind of a big guy.”
“Do you need a work slip?” I then asked.
“No, because if I keep working, I work through the pain. Besides, I like my job. I like watching the lions. I’m heading down to work this afternoon.”
I was back to my office in 15 minutes, having learned another lesson. Health professionals shouldn’t prejudge people. We have to take each case as it come, evaluate each one individually. We can never tell what’s behind the next exam room door. I guess that’s why it’s called the practice of medicine, from our first day as a physician until our last. Even on one’s final day of practice, a doctor is still practicing medicine. Perhaps it is on the first day of retirement that we will finally have it down pat. Oh happy day.
(April 2000)