Change my story

A few months ago, a new patient walked into my clinic at four o'clock on a Friday afternoon. She was a fiftyish woman who had recently moved to the area from a different state. On the plane ride up, she had developed a fever and cough, and the day after arrival, had been admitted to the hospital with a huge, cavitating pneumonia. She was seeing me in follow up to her hospital stay.

Her hospital discharge, which I had skimmed earlier in the day, detailed an extensive past medical history including sarcoid disease and drug abuse. That afternoon, when I walked into the room where she waited for me, I thought I'd read the wrong document: she was young, and she looked relatively healthy.

Our visit felt like a hailstorm. She hurled her medical problems at me, resisting interruption, without any sequence or logic. The names of studies and procedures and heavy duty, immune-system-modifying medications poured out of her. At one point, she burst into tears. After the visit, as I pointed her toward the checkout, she put her arms around me. "This lady is my new best friend," she crowed to a bored-looking nurse at the nurse's station. I got a bad vibe.

Often, with new, complicated patients, things begin to sort themselves out after a few visits. Old records start flowing in from other doctors, patterns of symptoms become clear, and as a relationship builds, it gets easier to identify and treat both the acute and chronic issues at the same time.

With this patient, things were different: as I got to know her over the following two weeks, her problems became more complicated, and the course of her illnesses more tortuous. There was more to her story than I had in front of me, but all I could do was wait for her old records to come in from her many previous doctors, and order some simple blood tests to establish new baselines. Meanwhile, she came in at least twice a week with demands: she wanted referrals to specialists; she wanted home nursing; and of course, she wanted narcotics. I held off. I needed more information, I said, and wasn't going to refer her to a new specialist until I saw the records from the old specialist.

One afternoon, I got a message from her while I was out of clinic. A specialist had told her I should prescribe her narcotics, and she was calling me to get them. I called the specialist, a fellow (subspecialty trainee) who is known to be a bit of a pill. In her way, Dr. Dick explained that she felt sarcoid disease--for which the patient had been treated in the past--was the root cause of her problems, including her chronic pain. Blood tests to confirm active disease were pending, I said, but my hunch was that the pain was less disease and more psychiatric overlay.

Dr. Dick scoffed. "What the fuck is overlay?" she said. "You've got to treat her pain. I basically told her you should give her Vicodin." Also, she said, I should've referred her to a sarcoid specialist earlier. "She's been treated for it before--why wait?"

To openly disagree with a patient's other provider in front of a patient--even more so, the patient's primary care provider--is poor form. To advocate prescription of an addiction-forming medication in a patient with a history of drug abuse is also poor form. But the poor form isn't the point. Now, several weeks later, I have more data: a group of new tests and an old workup more or less ruling out sarcoid as an active problem, and an old medical record detailing a narcotic addiction. And the point is, I saw this coming.

When I was an intern, a senior resident once cautioned me that "crazy people get real disease, too." In reality, it is just that simple, but it can be much more complicated in practice: a patient's disorganized or angry affect makes some doctors not believe a word they're saying, and sends others running to do their every bidding. What this kind of affect should do is cause doubt, and demand inquiry. This woman has real disease--it's just not the kind she thinks she has.

My second year of residency has been harder than I expected it to be, but with the difficulty has come growth, and with the growth has come instinct. And that instinct can change my story. Normally, I'm uncomfortable directly addressing triumph as part of practice. But as I wrote an email to this specialist asking for a revised opinion, I all but licked my chops. And as the crazy patients stream in the door, I'm more comfortable trusting myself to know when to act, and when to wait.