Commentary

The patient who changed the way I practice family medicine


 

Over the ensuing years, Alice taught me how to talk doctors out of narcotics, how to game pharmacists, and how to play the system. (I almost convinced her to counsel our residents on her techniques, but agoraphobia created too high a wall.) In turn, I catered to her health care needs, and there were many. I treated her pain and I treated her in a manner to which she was not accustomed to being treated by doctors.

Alice taught me how to talk doctors out of narcotics, how to game pharmacists, and how to play the system.Addiction is nearly as heritable as pervasive mental illness. For a time, I cared for Alice’s daughter, Erika—a similar phenotype of chronic pain, addiction, “bipolar disorder,” bad teeth. I cared for her son-in-law as well. After too many episodes, too many violations, I let Erika go … another in a string of outcasts. She circled awhile, found a new provider, died of an overdose. I suspected something more ominous perpetrated by her husband. No proof. He moved on and away.

In my dealing with Alice and Erika and the myriad of their ilk that populates my practice, a song—from the soundtrack to The Hunchback of Notre Dame—often imposes itself. Written by composer Alan Menken and lyricist Stephen Schwartz, “God Help the Outcasts” reminds us of a shared journey:
Winds of misfortune
Have blown them about
You made the outcasts
Don’t cast them out
The poor and unlucky
The weak and the odd
I thought we all were
The children of God.

Alice continued to see me. I did what I could to help her cope. Missed appointments were more a consequence of her fears and quirks than maliciousness or irresponsibility. When she did come in, she shuffled down the hall, humped over a cane, and later, a walker, appearing as a hag making an unwelcome appearance among mortals.

Alice ultimately died of sepsis emerging from delayed presentation of cholecystitis. It was not a pleasant death, spelled out on the wards of our teaching hospital, of tubes and lines and bright lights; an affront to her guarded soul. She had not wanted to come in. By the time she called, it was already too late.

One of my last visits with Alice was in August, a few months before her death. My note recorded “critters under… skin.” On prior occasions, she had been concerned with lice, scabies—the usual players; sometimes real and sometimes imagined. She did have dermatitis and tended to be a scratcher and a picker. This time was different.

Sealed in one of her medication pouches—the kind the pharmacy prepared for her—were things she said she had extracted from the skin of her left forearm. The cellophane bag held a housefly, an earwig, a click beetle, and a toad (the diminutive amphibian smashed pancake flat). Being a naturalist and biologist long before a physician, I was intrigued. I readily identified all 4 species and explained, in no uncertain terms, that these confederates do not burrow or otherwise get under the skin. Alice was adamant. “What can you do to take care of this?”

Recognizing defeat, I ordered clotrimazole and betamethasone dipropionate cream. I explained to her how to use the cream. “Two to 3 times a day for a week should take care of all the vermin,” I added.

My action was repaid with a broken smile and the deep, twinkling dark eyes. “I knew you’d do the right thing,” she beamed.

I am haunted by her eyes.

[Second-Place Winner]

"I just know there's something wrong with me!"

Luis Perez, DO
Firelands Physician Group
Sandusky, OH

It had been a long day at the resident clinic, where we provided free care to uninsured and underinsured patients in exchange for valuable opportunities to learn clinical medicine with “real” patients under close preceptor supervision. It was 5 PM Friday, and I was looking forward to finishing the day and enjoying the weekend. I glanced at my schedule and groaned. My last patient of the day was 27-year-old “Natalie,” a frequent visitor to our clinic.

It was Natalie’s third visit to our clinic that week, all for the same issue: cough and shortness of breath with “wheezing.” I tried to stifle my judgment before entering the exam room. I looked at her chart; in her 2 previous visits she had been diagnosed with a viral upper respiratory infection and then bronchitis, and had been prescribed albuterol and antibiotics.

I don't know why, but I decided to have here wear her pulse oximeter and walk around the clinic. Her oxygenation plummeted.Natalie appeared comfortable and her physical exam was completely unremarkable, including a complete absence of wheezing on auscultation. With a bit of exasperation, I advised her to continue the previously prescribed treatments and to just give it some more time. Not satisfied, Natalie begged me to “do something” for her because she was still short of breath. “I just know there’s something wrong with me!”

Next Article: