Better in their words…

PW is a 35-year-old man with chronic, primary insomnia. During our first visit, we discussed sleep hygiene and planned a trial of sleep-restriction therapy. At our second visit, we discussed pharmacologic therapy, and I started a medication. During our third visit we adjusted the medical regimen.

About a month after that visit, PW left a message on my voicemail. He let me know that we had made no progress. I called him right back. I suggested that he might have to learn to live with insomnia.

We never had a fourth visit.

Patients leave doctors’ practices all the time. Thirty years in, it might be that more people have left my practice than remain. Most patients depart because of the realities of life: a move, loss or change of insurance, death. Some people joined my practice with no intention of staying. They were healthy and needed to deal with a single issue or felt like it was time for a “check-up.” Most of these departures are silent. I wrote about my “ghost patient panel” in the past – that panel of patients who were my patients, no longer are my patients, and whose departure went unnoticed.

Then there are the patients who left my practice because they were not satisfied with the care I delivered, or with me as a doctor. They fired me.

These people decided they needed another doctor and, in one way or another, left me aware of their decision. Revisiting these relationships is unpleasant.[i] I have a pretty good sense why our relationships ended. Sometimes the cause was a “rookie mistake”, one that I would not make today. Others were errors that I’m pretty sure I’d still make. Then there were the relationships that were just wrong. Not every doctor is right for every patient.

 

AR was an older man referred to me by a close friend of his. His friend had been my patient for well over a decade. AR was a health professional and came into the relationship pleased to see me. I had come recommended by someone he trusted and he was, in his own memorable words, “impressed by my pedigree.”

AR was a deeply religious man, a fact he made known in even the most casual conversations. In our first two visits, he sought out my religious beliefs in indirect ways. I deflected these inquiries. There is a literature about how physicians deal with religion in the doctor/patient relationship.[ii] Like many doctors, I express respect for people’s beliefs and encourage them to leverage their faith to benefit their well-being. Also like many of my colleagues, I keep my own beliefs to myself.

AR arrived at our third visit seemingly having decided that it was important that he had a doctor who shared his faith. He would no longer accept my circumlocution. He told me a story meant to highlight the importance of his church in his life. After finishing, he asked me if I worshiped regularly.

“I do not,” I answered.

“I am truly sorry to hear that. It is unfortunate for me but more so for you.”

He left without making a follow up appointment and I never saw him again.

= = =

When I think back on PW and our interactions around his insomnia, I end up shaking my head. What have I learned about my “rookie mistakes?”

First, if a call is going to be difficult, stop and think. Sure, there are calls that need to be made immediately. Mostly, however, things can wait. I am amazed how results or situations that seem perplexing are always less so a day later.

Second, I have come to think that my job is to always have something to offer. This doesn’t mean snake oil and unnecessary tests and referrals. It might mean providing the time and counseling so that a person comes to terms with their illness. It might mean a referral to a doctor who has more to offer or might be better equipped to get a patient to the place of acceptance. “I think you’ll have to learn to live with this” might be true, but better if expressed by the patient: “I realize I am probably going to have to live with this.”

Third, lifelong learning is not something we just pitch to medical students because we can’t teach them everything and because half of what we do teach them is wrong. I know so much more about treating insomnia and about the resources available now than I did then.

Last, having now lived through my own bout of insomnia, I have empathy I could not have imagined a decade ago.

==

RP was a physician, about my age, whose philosophy of care could not have been more different from my own. Where I am an avowed minimalist, a medical conservative, she was a maximalist with a faith that medicine could prevent or cure anything. She answered my “less is more” counseling with “more is more” desires. After our third disagreement over her wanting preventative medications and screening tests far out of line with guidelines — and my own comfort – she decided she’d be better served by another physician.

In my early teens I worked in my family’s store — a grocery, butcher shop, and restaurant supply business. The business was founded by my grandfather. At the time I worked there it was run by my father’s cousins whom I referred to as my uncles.

I must have been 13 or 14 when a woman walked in and ordered a wedge of taleggio. I asked her how much she wanted, cut her an appropriately sized slice, wrapped it, taped it, weighed it, and wrote the price on a receipt. I asked if there was anything else I could get her.

“Did you wipe the knife on your apron before cutting the cheese?” She asked. (I may very well have but, in my defense, the apron was fresh from the cleaners.)

I did not have time to respond before she marched out the door with enough drama for everyone to notice. I was apoplectic and verging on tears. I was sure I was in for a talking-to. Instead, my uncles Jimmy and Mike stood on either side of me.

“What that person wants, we don’t sell,” said Uncle Jimmy.

“I hope the door didn’t hit her on the way out,” said Uncle Mike.[iii]

This is how I should have thought about RP’s departure from my practice. Years later, however, her departure still stings.

==

TA was a 40-year-old-woman who, for a time, was the patient I spoke with the most. She was healthy, apart from well-controlled hypertension. She also had pretty severe health related anxiety that, despite my best efforts, was not well controlled. I scheduled her to see me in the office every three months but that did little to assuage her concerns. I frequently saw her in between these visits for urgent concerns which always turned out to be nothing. Symptoms had either resolved by the time she came in, or the “debilitating respiratory infection” was just a sniffle.

We also spoke on the phone about every two weeks. There was usually an ache or a pain that she was worried about; a medication side effect she thought she was having; interest in a new diagnostic test or advertised supplement. Although she never expressed dissatisfaction with my care, I never felt she was happy with me. I was frustrated that the time and energy I put in was having no effect on her health (or was even being acknowledged).

Predictably, the wolf arrives, and the cries are ignored.

About five years into our relationship, TA began to have joint pain. As I look back at the record today, there were two visits and two phone calls over four months about these symptoms. I can’t remember what I thought was going on, but other than documenting the concern, it does not seem like I really addressed it, diagnostically or therapeutically. Then came the visit I remember. At this visit there were inflamed joints and obvious synovitis. Laboratory tests revealed elevated CRP, ESR, anemia, positive rheumatoid factor, and anti-cyclic citrullinated peptide antibodies: obvious rheumatoid arthritis.

I called her to discuss the results, initiate therapy, and schedule her with a rheumatologist. The phone call didn’t end there.

She asked. “Was rheumatoid arthritis the cause of my symptoms over the last 6 months?”

I responded, “I’m pretty sure that it was.”

“Did you miss the diagnosis?”

“I probably could have made the diagnosis earlier. I wish I had made it sooner, but in the long run, I am sure the prognosis is good and that the ultimate outcome won’t be different.”

“Why did you ignore my symptoms?”

“I really did not ignore them. Sometimes it takes time for symptoms to become specific enough to suggest a diagnosis.”

“Can you refer me to a new primary care doctor?”

==

To keep this reflection under 2000 words, I leave out the stories of two other patients. I am also not sure I could have tolerated writing more. These patients did the right thing leaving my care. We were wrong for each other, or I had given what I had to offer (at the time) and it was not enough. That does not lessen the feeling that I failed.

[i] The unpleasantness probably explains why it took me until “Friday Reflection #35” to get to this topic.

[ii] I really like this piece. It includes a terrific reference list.

[iii] We spread the cheese on bread for lunch.

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