The Heart Beat

Why do you come to my office to see me?

At least once a week I see someone who comes to me for my opinion about what’s wrong with them and what to do about it. We always have a discussion before that person leaves the office about what I think is wrong, why I think that, and what I think should be done. Sometimes, like many health care providers, I’m not absolutely sure what’s going on, but I’ve got a differential in my head. This is a list of possibilities about what’s wrong, prioritized from most likely to least likely.

If I’m a little torn, I may think out loud to them, and say, “I think it’s this, but here’s why I’m not 100% sure. We’re going to do X, Y, and Z, and then I’m going to see you again in a very short time to see if this has helped. If you’re better, we’ll keep up this plan. If you’re not as well as I would expect at that point, we’ll reassess and make another plan.” People are Ok with that. They know you’re being thoughtful in your approach, they know you’re not throwing them to the dogs, and they know that you care enough to check on them again.

Egos aside, I don’t honestly think that anyone expects me to be 100% right, 100% of the time, the first time I evaluate a problem. Before they leave, I always say to them, “I’ve given you a lot of information; do you have any questions for me?” We talk about any questions or concerns that the individual has and I send them on their way, with a plan for when the person is to come back. They leave knowing when and why I want to see them again, and they have stated that they agree to follow that plan.

At least two or three times a month I see one of those people back for the follow-up. Sometimes it is for the scheduled visit that is supposed to occur from the visit described above, but often it goes like this…

Me: “So, when I saw you last you were having symptoms ‘A,B,C’ and we made a plan for you to do ‘X,Y,Z’ and come back in two weeks to see how you were doing. Here it is three months later and you’re back with the same symptoms, only now it seems as though they may be worse. Tell me what happened.”

The Patient: “Well, I started to feel better, and by the time I finished up the medicine that you gave me I felt so good that I thought I didn’t need to come back.”

Me: “Do you remember me saying that this medicine would take a few weeks/months to completely heal your problem?”

The Patient: “Well, yeah, but since I felt better, I thought maybe I just healed more quickly than you thought.”

Here’s another one:

Me: “So, I see that last year at this time you were here for an infection and we noticed that you had very high blood pressure. We talked about how you might lose some weight and get a little more exercise. When I saw you the next time a couple of months later you had not had much luck with losing weight or getting out to walk. We talked about how it was pretty tough at that time for you to meet those goals. I recall that we agreed that you would take medicine until you were actually able to exercise and lose some weight. We were both worried because you didn’t want to have a stroke like your dad did. Is that about how you remember it?”

The Patient: “Yeah, well I took that medicine for awhile, but I didn’t like the way it made me feel.”

Me: “Well what brings you in today?”

The Patient: “I’ve been feeling really tired, and having a lot of headaches, so I thought I better get that checked out.”

Me: “How long has it been since you took any blood pressure medicine?”

The Patient: “A couple of months now.”

Me: “Well your blood pressure’s pretty high today, 240 over 136. I think if we get that under control you’ll feel a whole lot better. But we need to do some blood work today, because I’m concerned about what your high blood pressure may have done to your kidneys.” (Because I see that he really hasn’t had a medication refill in 8 months, and I know that we found his hypertension when he was in for a sick visit, so at a minimum he’s been a year with high blood pressure, probably more). “So tell me about how that medicine made you feel, and I’ll see what I can do to pick one that won’t give you those side effects.”

Which brings me back to the question, “Why do you come?” If you think medicine is a one-way street, where you don’t have to let me know that something isn’t working for you, think again. You’re an adult. Take some responsibility for your health. There are a lot of medicines out there, lots of other options if you don’t feel well on the first choice prescribed for you. When I tell you that I need you to come back, I’m serious. Even if you feel better, it doesn’t mean you’re cured. You might actually need several months of medicine, or you might think you’re better, and not actually BE better. When you get your license to practice medicine you can decide that. Until then, I’d appreciate it if you’d follow my advice regarding medication and treatments and come back to see me when I ask you to. Either that or don’t bring your problems to me for my advice.

Laurie

Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.

Thomas Szasz, The Second Sin (1973) “Science and Scientism”

Related Topics: WebMD Survey: The Lies We Tell Our Doctors, Managing Hypertension

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