Bioethics Discussion Blog: "The Doctor's Office"

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Wednesday, November 29, 2006

"The Doctor's Office"

I found this story "The Doctor's Office" written by a medical student and it struck me that this story was very appropriate for my blog. I wonder if any of my visitors here find the experience of Ms. Clemens in the story familiar.

Thanks to Synaesthesia Literary Magazine, University of Southern California Keck School of Medicine for allowing me to post this story here. ..Maurice.

"Synaesthsia was created in the Spring of 2004 by a group of students and faculty at the Keck School of Medicine with the hope of providing USC's health sciences community with a forum for creative expression."

The Doctor's Office
by Soames Boyle
(Soames is a member of the Class of 2007)

I was reading an article entitled "The twelve secrets to making this Thanksgiving the best ever" when a woman called my name. I got up and walked into the Nurses' Station. It was April, but that article was the finest offered in the waiting room.

An overweight woman in red, white, and blue scrubs verified my name.

"Maureen Clemens?"

"That's me."

"OK dear. Take off your shoes and get on the scale." I was here to ask the doctor about the problems I was having with my high blood pressure medication. My weight as changed from two months ago didn't seem germane to my current medical concerns. And I didn't like being called "dear" by a woman twenty years younger than myself in coral hued lipliner.

"Really? Do I have to?" I heard myself whining. She nodded by way of answer and turned away to write something. Her body language indicated she too believed me to be whining. I dutifully got on the scale. I had gained 10lbs since my last visit. Braced for a reprimand or advice such as 'you should try drinking more water', I was a little surprised the nurse said nothing at all. She ushered me into a room and told me to undress below the waist. For high blood pressure medication? Again, for what earthly purpose? The nurse left.

Someone rapped quickly and a young girl walked in. A couple of pimples, a stethoscope around her neck, a little food in the corner of her mouth. Please God, don't let this be the doctor.

"Hi My name is Student Dr. Steamed I am a medical student working with Dr. Kares I am going to ask you some questions and then he is going to come in." This was said in one fluid seamless sentence without pause or room for interruption. She had either rehearsed her introduction or had anticipated my surprise and wanted to head off any concern that she was the doctor I would be consulting.

"Can you tell me why you are here?"

"My blood pressure medication is making me sick. And I am having problems sleeping at night. I lay in bed for -"

"What do you mean 'sick'?" She interrupted. "have you been vomiting? Nauseated? Changes in bowel habits? Fever, chills, abdominal pain, sinusitis? Orthostatic hypotension? Or do you mean the hypertensive medication is preventing you from falling asleep?" she inhaled "or do you mean you wake up at night and your heart is beating really fast?" She shook her left hand over her left chest quickly, gesticulating a palpating heart I imagine. "No." I paused and she opened her mouth to continue, but I cut her off - "I have two independent problems. My medication and sleeping problems."

"OK. Tell me what's going on." Now we were getting somewhere.

"My blood pressure medication is giving me a cold. I have a sore throat and a cough that hasn't gone away since I started the medication two months ago. And I can't sleep at night, which has been going on since my husband died last year."

"I am sorry to hear that." She pursed her lips and gave a little nod in condolence. "Do you live alone? Or with someone? What have you been doing to get yourself through this time?" The concern seemed genuine, but the questions forced and obligatory. I didn't want to overwhelm the poor girl. She wasn't old enough to have experienced the loss, abandonment, disappointment that haunts old age. She didn't want to hear about our martial problems, the fights, the frustration of cancer and his constant needs, my guilt now that he was gone.

"I live alone. My children are grown. I have tried the mild sleeping pills, some herbal medications, a glass of wine with dinner. Nothing helps."

"How much wine are you drinking?"

"A glass or two" I repeated myself.

"So like 15 drinks a week would you say?" Quick mental arithmetic indicated she was grossly overestimating my intake.

"No. Not that much."

"Have you tried to cut back?"

"Haven't seen the need."

"Have you ever been annoyed by criticism of your drinking?"

"Huh?

"Have you ever felt guilty about your drinking?"

"I just said I don't drink that much."

She looked apologetic. "Sorry, I have to ask those questions of everybody. Please don't be offended. Have you ever needed a drink in the morning to get you going?" The last question seemed reflexive and she didn't wait for an answer before asking "What can you tell me about your cough?" At least we weren't talking about alcohol anymore.

"It hurts. It's dry and-"

"That could be caused by your anti-hypertensive medication, the ACE inhibitor."

"The what?" Was she insane? Was I insane? "But I feel sick."

"This is very common side effect of this medication. I am going to talk to Dr. Kares and we will return in a few minutes." She left.

I sat there and waited. I studied a framed poster of four little girls in sundresses eating ice cream cones.

Dr. Kares and the medical student returned. "Hello." He looked down at his paper and added "Mrs. Clemens. Can you tell me why you are here today?" Again? I looked to the medical student, but she was looking at her paper.

"I am here because my medication is making me sick and I am having problems sleeping." And in anticipation of similar confusion I added "I don't think they are related."

"Have you been exercising?" What? Given the succession of unrelated and unprompted questions, I wouldn't be surprised if he next asked me was who I thought would win the Superbowl this year.

"No." Did I want to tell him my knees had been hurting lately? Not if it would set off another three ring circus of free-for-all Q and A sessions.

"Well you should. It would be highly beneficial in the management of your blood pressure and surely efficacious towards your insomnia. I am changing your medication to another similar drug in this class. I want you to start a walking routine three times a week. Do you have someone to walk with?" I didn't. I nodded a confirmation.

"But I don't want the drug. It made me sick. I have had a cold since I started it."

"You have had a cough, which is caused by the medication." He took my silence to be agreement. But I was just confused. He looked at me again and reconsidered my understanding. "Does that make sense? You shouldn't have the same problem with this new medication." He was trying and I appreciated it.

He wrote me a prescription. Get it filled. Something about the pharmacy.

"Is there anything else I can do for you today?"

"I am having problems sleeping. I just can't fall asleep at night."

"Do you want some medication for that?" Not really, but again, he was trying to help.And that is what I was here for. Some help.

"Sure, that would be fine."

6 Comments:

At Friday, December 01, 2006 3:31:00 AM, Anonymous Eric said...

This is a wonderfully powerful story. I hope that it gets the readers that it deserves. Unfortunately this is an experience that is all too common.

 
At Sunday, December 03, 2006 5:26:00 PM, Blogger Maurice Bernstein, M.D. said...

I think it is powerful enough to use as a tool for medical students learning about student/physician/office professionals developing a relationship and interacting with a patient, that yesterday I requested my first and second year medical students to read this story and write a brief commentary regarding the office visit process and behavior of the participants. We will then discuss their commentaries and the issues involved in the upcoming week. ..Maurice.

 
At Monday, December 04, 2006 7:51:00 AM, Anonymous bob koepp said...

Maurice - I'd appreciate it if you would provide a summary/report on what your medical students make of this story.

To me, it nicely illustrates how a medical interview can very quickly come to be dominated by a "script" rather than being driven by the concerns that prompted the patient to schedule the appointment in the first place.

 
At Wednesday, December 06, 2006 12:53:00 PM, Blogger Maurice Bernstein, M.D. said...

Bob, as one first year medical student summarized the visit as “abysmal”, there was unanimous agreement amongst the students about the poor quality of the visit and poor professional behavior. One of my medical students presented this analysis of the story:

Dear Dr. B; I am glad I had the opportunity to read this article because it did a very good job of illustrating what NOT to do. Here is a list of problems I recognized.

1. The nurse should not have asked the patient to get undressed without explaining to her the reason why. She should have also offered her a gown.

2. The medical student should have:
a. Asked the patient permission before asking questions. She also should stop interrupting the patient.
b. Asked questions in an organized, logical train of thought manner. She was jumping around too much.
c. Talked more to the patient about her husband' s death, especially since it could be the cause of her insomnia.
d. Not have led the patient to believe that she could have an alcohol abuse problem. She did ask some leading questions.

3. The physician should have:
a. Done a patient interview / examination before recommending treatment.
b. Determined whether the patient suffers from clinical insomnia before recommending treatment.
c. Listen to the patient speaking. Even the attending physician was interrupting her.

Finally, it would be nice to have good reading material in the waiting room.

 
At Tuesday, December 12, 2006 2:52:00 PM, Anonymous Anonymous said...

True. So true.

 
At Saturday, December 30, 2006 1:31:00 PM, Anonymous Moof said...

The chain of unanswerable questions is all too familiar ... and is one reason that I would rather be ill, at home alone, than see a doctor.

You walk out feeling traumatized, you still have the problem you went there for, and perhaps an additional one - or more - from medication which isn't treating what you actually do have, and which you probably don't need.

Students are not the only ones guilty of these practices.

Enough similar experiences, and you get the feeling that it's easier to just be sick ...

The medical student you quoted in your last comment summarized things very well.

 

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