I receive a message about you can't make me saying that I am not giving a solution and why just be depressing?
I do not mean it to be depressing. This is my reality as a Family Practice Physician. I think part of my job is to pay attention to all the stupid stuff people are doing and ask if they are ready to do something else.
You can't get the elephant out of the room if everyone denies its' existence.
Name the elephant. Alcoholism, addicted to sex, addicted to Easter Chocolate. I have a woman complaining about her back hurting. Turns out she sneaks downstairs at night to sleep on the couch cushions on the floor with her dogs. She is in her 70s. I offer to write a prescription saying "Mrs. Smith may sleep with her dogs." At that point Mrs. Smith says she doesn't need a prescription, she just needs to tell her son and daughter in law.
I have been with doctors who steadfastly ignore the elephant. A woman grieving talking about the death of her husband while the orthopedist replies ignoring the grief and death and only speaks of the knee replacement. I could hardly stand it. I wanted to hug her and say "I am so sorry." I stayed back because I want to know, does he ever acknowledge it? No. He didn't. A doctor videotape where the patient is talking about bugs crawling all over her skin. The young doctor is trying to get a sexual history and NEVER acknowledges how AWFUL the patient is feeling. I could hardly stand that one either. In retrospect, that patient was probably withdrawing from methampheamines or alcohol, but I didn't know much about meth in residency. And our addiction training was frankly dismal and inadequate. I wondered why I was different and really, it was because I had read all those books on alcoholism in college and then about families with addiction and about enabling. I extrapolated from alcohol to illegal drugs and benzodiazepines and opioids. Seemed pretty obvious to me, but in fairness, most doctors my age had very poor training. I had experiential training since birth, though I can't recommend that.
My daughter saw an orthopedist last week in Denver. She has a foot problem which then has messed up knee and hip. She said that the knee was doing better with PT and the foot needed the MRI. The ortho person said that they didn't do ankles, they only did knees and hips. She was rescheduled with an ankle person. I think that is frankly ridiculous and dangerous. What if she didn't have me to say to the original orthopedist here, "She says she can't fully flex her foot and the pain started there, not the knee." He said, oh, and looked at the ankle, after saying the knee was fine. He said the ankle is not fine and he did a floroscopy right then. She has now had the MRI but results have not trickled through. Something fairly rare and congenital that I'd never heard of was the first orthopedists diagnosis, to be confirmed by MRI. But without me in the room, he would have ignored the ankle and dismissed her with a clean bill of knee health and the problem would escalate and get worse. Thank the Beloved I am a generalist and interested in everything. I read everything. I can't learn it all but I learn new things every day and from specialists and from patients. A patient with high platelets comes back from the Hematologist Oncologist. "I have a rare genetic disorder that they treat with iron tablets and another pill, both of which are cheap. I feel better than I have in thirty years. Thank you for sending me to him." I just noticed that his platelets where really high twice and I couldn't tell why. I talk to the Oncologist who is all excited about this new genetic thing that they can test for and treat and that the treatment is easy and cheap. Within 4 years I have three patients who have been diagnosed. The fourth high platelet one has a different rare genetic thing....wow.
We desperately need generalists like me. Only 30% of primary care are willing to go rural and only 30% of the Family Practice Doctors are willing to do obstetrics in a rural place. The internists and the pediatricians don't deliver babies. The Obstetricians mostly are not willing to be in such a small area where they are on call 100% of the time. So now that I am on oxygen, it doesn't look likely that I will get off, and I am too at risk for a fifth pneumonia to work with patients, well.... I will start contacting medical schools and residencies. I went to a very rural area and did Family Medicine with OB starting in 1996, so I have 25 years rural, 15 of those doing obstetrics. I would have kept doing obstetrics because I was excellent at it, but the local hospital system got rid of me and I opened my own clinic. I served as many people as my health allowed. And I loved that, too.
A generalist primary care doctor has to be open to possibility. Yes, rare things are rare, but in 25 years, I have seen some spectacularly rare things. Two people, one with Guillan Barre and one with the even rarer relapsing remitting version. The person who is the index case of a genetic disorder and appears in a photograph of the most used Pediatrics Tome. She can tell the page number. Her photograph at age 8 is still in the latest edition and she is over 50 and probably in her 70s.
The solution is that I cannot change people. They come to me for their health. I am thorough on new patient visits. I don't care if they are only there for their ankle. I still ask about alcohol, tobacco, marijuana and drugs, past medical history, social history, what do they do for work, retired from what, what branch of the military and what years and where I asked personally, myself. What that does is tell the patient that I am interested in all of those things. I am fast fast fast entering these things by now. I print the note at the end of the visit and tell the patient to please read it over and tell me if they forgot to tell me something or if I got anything wrong. I fix it at the next visit, addendum since it's already signed off, and explain about addendums.
Some patients say, "Wow. You got all that?" They feel listened to, and they have the proof in their hands.
And some of them will come back, to say, I need help with methamphetamines. I was afraid to tell you. Domestic violence. Their child is on drugs.
How can we help if we don't listen and if we don't look at the person as a whole?
Listening and being thorough, those are my solutions.