I logged in to the computer and found my patient panel. I was scheduled to see patients in thirty-minute increments from 1:00 P.M. until 4:30 P.M. Opening the medical record of my first patient, I felt a small thrill as I prepared to jot down notes about him, a fifty-three-year-old man who had been coming to the clinic for several years. I opened the last note from the previous primary care provider. But as I read, my eyes almost instantly went crossed. The note began:
Problem List
1. HTN
2. CKD
3. CAD
4. TIA
5. COPD
6. GERD
7. PVD
8. Migraines
9. ED
10. DM2
11. BPH
12. Active tobacco use
13. Depression
14. HLD
15. OSA on BiPAP
16. Afib on Coumadin
17. Glaucoma?
18. HCM: needs c-scope
What kind of patient had eighteen different problems to deal with? It seemed like I’d need a team of specialists in the room with me just to provide primary care. Sifting through the befuddling acronyms, I felt my stomach turn. I recognized some of the letter combinations, but every unknown acronym felt like a small knife in my side. Were they using a different set of abbreviations at Columbia? I suddenly missed the immediacy of surgery, of just fixing something right then and there, showing Axel, and moving on. I reread the note from the beginning and began Googling the various combinations of letters that weren’t immediately recognizable.
My palms broke into a light sweat as I typed. What if this patient had other problems—problems that weren’t on this list? Patients were more likely to focus on things they could feel, like a sore knee, than on things they couldn’t, like diabetes or high blood pressure. How could I possibly address old issues and new ones in one short clinic visit? While the computer performed the search, my thoughts drifted back to Carl Gladstone, as they had every time I found myself with a moment of free time. Was he going to be okay?
I had to say something.
After twenty distracted minutes I was only a third of the way through the patient’s medical record, but sitting behind the large desk I did feel somewhat like a real doctor, at least more than I did in the cardiac care unit. Feeling a moment of modest inspiration, I hopped up from my swivel chair and decided to test out the blood pressure cuff. In medical school I’d always found the contraption cumbersome and knew from experience that fumbling with it would be a dead giveaway that I was new in town. Once satisfied that I could hold the stethoscope in place with one hand while pumping up the cuff with the other, I returned to the medical record. After fifteen more minutes of referencing and cross-referencing, I had to shut my eyes.
Was it really possible to memorize and retain all of this knowledge? And more important—was it necessary? Or did real physicians retain a core of crucial information and simply look the rest up on the fly? Baio seemed like he’d seen it all before, drawing on experience to guide his decision making. As I dug deeper into the chart and all hope of diagnostic parsimony appeared lost, there was a knock at the door. I sprang up from my chair and opened the door.
“Dr. McCarthy,” the receptionist said, “your one P.M. is here.”
“Okay,” I said. “Great.”
“Do you want to see him?” she asked.
As I glanced at my notebook, I momentarily wondered whether any answer besides yes would be acceptable. In truth, I thought I’d need another hour before feeling prepared to see the patient.
“Well,” I said, folding my arms, “I suppose I should—”
“It’s one forty-seven P.M.,” she said. “He was almost an hour late and your one-thirty P.M. just arrived.”
“He seems kinda sick,” I said. “Maybe we could do a shorter visit or—”
“I’ll send him in,” she said and closed the door.
A moment later, a stocky bearded man in a faded barn jacket entered the room and extended a callused hand.
“Sam,” he said firmly.
“Matt. Mr. McC——Dr. McCarthy. Please have a seat.”
I waved my hand across my desk like I’d just performed a magic trick. “You actually gave me some time to familiarize myself with your chart.”
The fact that Sam was even upright and walking into my office under his own power came as a small surprise. After reading the long list of conditions in his chart, I was expecting a borderline invalid, but Sam looked rather well. He was husky, with shaggy gray hair that drooped into his eyes, and if Heather saw him on the street she might whisper to me that he looked like a sheepdog. “Terribly sorry I’m late,” he said. “Didn’t know you guys still used charts.”
His smile revealed crowded, champagne-colored teeth. “It’s mostly computerized,” I conceded, “but yes, some records are still on paper.”
In medical school they often filmed us interviewing an actor who was pretending to be a patient, to get a better sense of our bedside manner. I’d routinely been given the feedback that my somber demeanor was depressing to patients. I flashed a large smile and cracked my knuckles.
“There’s a lot here,” I said as I pointed at the monitor. “Seems like you’ve been through a lot. So…how are you?”
It had been drilled into my head to lead with an open-ended question.
“I’m good,” he replied. “Real good. Feel great.”
We sat in silence and I began counting in my head. I’d recently been reminded that most doctors interrupt their patients eighteen seconds into the interview. I nodded and opened my eyes wide, encouraging him to speak.
“You?” he asked flatly.
I finished counting to twenty and said, “Me?”
“Yeah, you good?”
“Yes.”
I nodded and he nodded. There were many nods.
“So, let’s get down to it,” I said. “Now, I went through your chart and counted more than fifteen medical conditions. Since we’re new to each other, I’d like to go through each one with you.”
“Fifteen? That can’t be right. I’m just here for a checkup.”
“I agree it’s a lot. It might be easiest for me to just go down the list. First on here is high blood pressure.”
I was using an old improv technique to prolong conversation: avoid negatives; agree and add on. I glanced at the blood pressure cuff.
“Huh. Blood pressure is always normal. I wouldn’t say I have high blood pressure.”
“You take a medicine for it, yes?”
“Yes.”
“Otherwise it would be high, no?”
He shrugged his shoulders. “I don’t know. Maybe we should try.”
“Try what?”
“Try not taking the medicine. Maybe my blood pressure wouldn’t be high.”
“No, it would.”
So much for improv.
“Okay, next on here is kidney disease.”
He shook his head. “No one has ever mentioned that I have kidney disease.”
That seemed impossible. If the previous physician had put it in the note, why wouldn’t he tell Sam about it? Or was there something about Sam I was missing—he wasn’t responding to me in the way I had seen patients respond to primary care doctors at Harvard. Perhaps I needed to switch tactics—to change gears entirely—but how? In time I’d learn to ask wide-ranging questions—is that growth on your face new? Is your diarrhea frothy?—but for now, sitting in front of Sam, I was stumped.
A voice from outside the door announced, “Your two P.M. is here. One-thirty is still waiting.”
My pulse quickened. “Okay, let’s hustle through these conditions.”
“Hustle away.”
After twenty more minutes of stilted interrogation that produced little useful information, I stood up. Sam was clearly more confused now than when he’d arrived. “I’ll be right back. Just need to discuss your case with someone. I’ll be just—”
“Aren’t you going to examine me?
”
I looked down at the stethoscope that was resting comfortably on my desk. “Yes, of course.”
The idea, undoubtedly, was that I would eventually find my way, stumbling upon a bedside manner through trial and error. But how long would that take? In orientation, the expectation of primary care clinic had been clearly laid out: residents would concoct a plan of action for each patient and the PIC would critique that plan, ensuring that the patient received quality care as we learned. I had supervision, but it was in another room, a room that at the moment seemed very far away. Every patient was trouble, the comatose ones who needed to be kept alive, the seeming healthy ones who might be dying, all of them my responsibility. Getting the adrenaline going was the only thing that momentarily relieved the pressure, but in the low-key setting of the clinic, my anxiety expanded to fill the room. And I suspected Sam could tell.
“Take a deep breath,” I said, pressing my stethoscope against Sam’s back. “And again.” I took a few deep breaths, too, hoping it would calm my nerves.
As I searched in vain to find Sam’s thyroid gland, which was supposed to feel like a bow tie, I missed Baio’s silent hand gently pointing me in the right direction.
10
A few minutes later, as Sam waited, I walked down the hall to an office labeled PIC. Inside the room, a fifty-something man with a page-boy haircut was reading the latest issue of The Journal of the American Medical Association.
“Hello,” I said softly, “I’m one of the new interns.”
He put down the journal and looked up at me, beaming. “Welcome!” he said. “Please take a seat.” The PIC, whose name was Moranis, was wearing khakis and a blue Ralph Lauren button-down with a red tie, the unofficial uniform of an academic physician.
“I want to apologize for running late. My first patient is a bit complicated.”
Moranis shook his head. “Never begin any presentation with an apology. It’s your first day in primary care,” he said, quickly blinking his sea-green eyes, “and they’re all complicated.”
I took out my notebook. “Where should I begin?”
“You tell me. I’m just here for guidance.”
I gazed down at the sun-faded notebook—a tempest of composition—and felt unsteady. “Well, I made a problem list.”
“Good way to start. What’s at the top of the list?” It was clear he’d been coaching young physicians for years, and I felt a bit more at ease. But that might’ve been just because I was no longer dealing face-to-face with a patient.
“Top of the list is high blood pressure,” I said. “His blood pressure is a bit elevated today.”
“Is he on a diuretic?”
I scanned the medication list looking for Lasix—the only diuretic I could think of. A day earlier, I’d mentioned on rounds that Lasix gets its name from its duration—“(la)sts (six) hours.” Baio had one-upped me, detailing the way Lasix found its way into horseracing after it was noted to prevent horses from bleeding through the nostrils during races. Hence the term “piss like a racehorse.”
“No Lasix,” I said. “But he is on a bunch of other medications.”
“Is he on hydrochlorothiazide? And do you know why I ask?”
“No. And no.”
“Several years ago a large trial called ALLHAT showed that patients with high blood pressure should be started on a thiazide diuretic if single therapy is being initiated and another medication is not indicated.”
“Gotcha.” I quickly wrote down ALLHAT.
“However, you said this patient is complicated, so a different medication may be indicated. Perhaps Lisinopril if he has kidney…”
I tried to transcribe his thoughts but couldn’t keep up.
“…However, if he has heart disease a beta-blocker may be indicated.”
How would I ever remember all of this? Did I have to go back and explain it to Sam? Maybe this was why the previous physician hadn’t told Sam he had kidney disease—because it was just too complicated to explain.
As the waiting room continued to fill up, Moranis went through each of the issues on the problem list and explained the rationale behind each diagnosis and treatment. Despite the boyish haircut, he had the unmistakable patina of age and authority, and he spoke with a kind of joyfulness as he turned over each piece of information to examine the possibilities as they related to Sam. I tried to absorb it all but caught myself zoning out, watching his lips move while wondering if a lifetime spent memorizing journal articles and acronyms would turn me into someone like him. Someone who seemed to know more about my patient than I did without ever having examined him. Or would I become a creature so consumed by minutiae that I’d be incapable of interacting with patients on even the most basic level? Would it all just become a tangled skein of factoids?
“Let’s go see your guy,” he said finally, rising to his feet. “The best part.”
When Moranis stood up, I realized that I could rest my chin on his head. This man whom I found so intellectually imposing was nearly a foot shorter than I was. As we walked back down the hall, I noticed that his eyes sparkled a bit the way Baio’s did. I was with yet another doctor who felt squarely in his element. Would I really ever get to the point where any of this might seem pleasurable?
“This is my boss,” I said to Sam as we reentered my office, “the physician-in-charge.”
“Sam,” he said, extending his right hand. “Your liege was just telling me all the things that are wrong with me.”
Moranis turned his head toward me and frowned. “I understand you two covered a lot of ground.”
“Dr. McCarthy mentioned that I have more than fifteen problems. Never thought of myself like that, but I guess it’s good to be aware of it all.”
“Let me offer an alternate hypothesis,” Moranis said, holding up an index finger like his kid-shrinking namesake, as if about to introduce a tween-condensing laser beam. “You were told you had high blood pressure at a young age.”
Sam wrinkled his brow, and Moranis nodded gently.
“Perhaps. That sounds right,” he said.
“And I’ll bet you were offered a medication for it.”
“I don’t remember, honestly.”
“And you didn’t take that medicine.”
Sam flashed a mirthless grin. “You’re right about that. I didn’t take anything until I turned fifty. And then it apparently all went to shit.”
“Your untreated high blood pressure led to kidney disease, which further exacerbated your hypertension. This, in turn led to heart disease.” Moranis glanced at his belt and silenced his pager. “The heart disease,” he continued, “led to liver disease, which in turn contributed to your erectile dysfunction. And the erectile dysfunction contributed to your insomnia.”
“Great,” Sam said, “so what’s the answer? Treat the blood pressure and it’ll all go away?”
Moranis held his finger up to his lips so he could listen to Sam’s heart and lungs with his stethoscope.
“It’s not that simple,” I said, eager to contribute. “These are all chronic conditions that will likely need to be managed, not cured.”
My pager went off, and Sam covered his eyes with his right hand. “You know it seems like I see a different doctor every time I’m here. Every few months I start from scratch with someone. Can you be my permanent doctor?”
We had made a small connection. “Of course I can be your permanent doctor. I’m here for the next—”
“No,” Sam said, motioning toward Moranis, “him.”
Moranis removed the stethoscope from his ears and moved toward the door. “We’re a team here. You’re in good hands. It was a pleasure to meet you.”
—
“There’s one other thing I didn’t mention to your boss,” Sam said meekly once we were alone. “I guess I was embarrassed. But I ran out of Viagra a few weeks ago and was wondering if I could get a refill.”
The Viagra commercial popped in my head—an attractive baby boomer sailing on a lake—with
the voice-over “Do not take Viagra if you take nitrates for chest pain.”
“Do you take nitrates for chest pain?” I asked.
“You tell me, Doc.”
I scanned his medication list. “No.” I imagined Sam trying in vain to get an erection. “Of course, I can get you a refill.”
We wrapped up our session a few minutes later. On my way to give paperwork to the receptionist, I stuck my head into Moranis’s office.
“Thank you,” I said, “for that. All of it.”
“It’s why I’m here.”
“Well, thank you.”
“Meant to ask,” Moranis said, putting down his journal. “Did you notice that he’d been incarcerated?”
I was shocked. “Uh, can’t say that I did. I suppose I got caught up in—”
“Quick tip. You can’t just go through the most recent notes to understand your new patients.” Moranis must’ve combed through the older notes while I was examining Sam. But there were dozens of notes in the chart. How did he know which ones to read?
I considered Sam, the adorable sheepdog. “Did you ask him why he was in jail? Did I miss that?”
A smile crept onto Moranis’s face. “Why do you think?”
“I guess I’d be curious.”
“Why?”
“I don’t know—if he was a pedophile or serial killer or something?”
“Why?”
“You’re asking me why it would matter if he’s a sex offender? Or a wife beater?”
“Sure. Would that change anything about the way you treated him?”
—
The question sent my mind back to Boston three years before, to a seminar I once took at Harvard. One afternoon per week, a small group of students would get together to discuss prejudices in and out of medicine in a course called Emerging a Culturally Competent Physician. At the end of the seminar, we were asked to divulge one prejudice to the group.
“I think fat people are lazy, sometimes,” a young woman said.
“When I hear a Southern accent, I kinda think the person might not be too bright,” said another.
We continued in this manner until we reached Ben, an aspiring trauma surgeon like Axel, who was gently shaking his head.
The Real Doctor Will See You Shortly Page 6
