Primary Care for Christmas: Anything and Everything
*All names and potentially identifying information (including some physical descriptions and case details) have been altered to comply with HIPAA regulations, as well as to be nice and ethical.
I’m a primary care doctor and a new mom. I was on call for Christmas week this year, meaning I covered the pager after-hours answering calls, did any admissions, and rounded on all our inpatients every morning, in addition to seeing my scheduled outpatients in the afternoon, from Christmas eve at 8 a.m. through New Year’s Eve at 8 a.m. In my warm and fuzzy practice, the Call Week only comes up about once every 3 months or so, and holidays are well-dispersed. In comparison with other practices, it’s cake. Still, it’s exhausting, and kind of a bummer, as this was my Babyboy’s first Christmas. But everyone has to do Christmas Call once in a blue moon, and better to take it when Baby didn’t even know that it was Christmas, and so there I was.
The exact thing that keeps primary care fresh and fulfilling is exactly what kills me during Call Week: I can (and do) see anything and everything, from life-threatening emergencies to commonplace annoyances. The week had had its rash of pathetically typical narcotics-seeking pages (“I don’t know what I did with that prescription for Percocet! I just need a few days’ worth to get me through until my regular doctor is back!”), miserable but also run-of-the-mill upper respiratory infections, plus many random emergencies (the lady who fell down her stairs and hit her head and lost consciousness… 10 hours before she called me) and logistical urgencies (prescription refills, transfers, lab and x-ray results to check up on). The pager wasn’t too too crazy, but there were several of those midnight-to-4-a.m. pages; that combined with consistently Hungry Baby at 6 a.m. and long, full days made it a long, full, tired, week.
I had two inpatients: Julia Grosgrove*, a lovely older woman with many, many serious medical problems who was now dying of cancer; and Elizabeth Knipper*, a fragile but feisty 90-year-old lady with failure to thrive. Ms. Gosgrove was the matriarch of a proud, religious family; they and she were just coming to terms with the fact that she may not live the week. It was an emotionally wracking time for them; Thank Goodness that their own primary care doctor and one of my mentors also took the time and trouble to come in, even on her days off, to be with them and guide them through. Ms. Knipper was being fed and followed by nutrition, but she also possibly had cancer and we were running the least invasive tests possible to figure that out.
That was the week I had fielded a call from Lacey Lovely*, a middle-aged obese woman with chest pain, as well as numbness and tingling in her left arm, after shoveling snow. I asked her all the appropriate questions, and then mulled over the possibilities.
“Could this be a heart attack… or a stroke?” She had asked me, in a near-whisper.
“Yes,” I said, “it could be…but you sound so good, that I think it also could be a muscle strain in your chest and a pinched nerve in your elbow area.”
“Well, what do we do?” She asked, a bit alarmed.
It was a Sunday morning, and a major blizzard was expected by midday.
“The safest thing,” I said, “is to make sure it’s not a heart attack or a stroke. You need to be seen in the emergency room.”
She was not too excited to be going to the ER on the day of a huge snowstorm, but she was scared, and so she did go. And it was, of course, a muscle strain in the chest and an ulnar neuropathy in her arm, both likely provoked by poor form in shoveling. I went to see her in the emergency room, and I spoke to the ER physician, a wisened guy with graying temples. I was embarrassed that I had sent her into the ER when it had turned out to be musculoskeletal.
“Uh, I’m so sorry,” I explained. “But it was hard to tell what was going on over the phone… I was worried about her heart, and she was also…”
But he waved it away, “Oh, this was the appropriate evaluation,” he said. “You didn’t know if she had ischemia and an arrhythmia and an embolic event! We were happy to see her.”
I was relieved, as not all emergency physicians are so nice when you send them an unequivocal non-emergency. But I agreed with him, that in her case, the ER was the right way to go, because in this job, you never know what you’re going to get.
Atul Gawande, surgeon/author/superstar, explores this, the variety and complexity in medical practice, in his newest book, The Checklist Manifesto:
“Over the course of a year of office practice… physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures…”1
When I read that, my first reaction was, “ONLY 250 different primary diseases and conditions each, in a year??? They must have been surgeons.” I feel like I see much more than that, even working part-time, in a year. I probably need to start writing it all down.
The week flew by. Christmas morning, Babyboy enjoyed the wrapping paper more than any of his gifts. Ms. Gosgrove’s family were by her bedside when she quietly passed away. Ms. Knipper ended up not having gastric cancer, only an esophageal stricture that prevented her from swallowing, and the gastroenterologist fixed that. She watched playoffs football, drank milkshakes from Nutrition, and slowly gained weight. My afternoon clinics were a blur of everything from migraines to coughs to sexually transmitted infections to sprained ankles to alcoholism and did I say coughs? And the breast lumps, gallstones, low back pain, depression, chest pain from reflux, chest pain from angina, chest pain from anxiety, and one chest pain from a disastrous session with a new personal trainer!
All this, and we only have 20 minutes with each patient (unless it’s a new patient or a complex physical exam), each patient a person who not only usually has more than one issue to address, but also Christmas greetings to exchange and old issues to touch base on.
And still, I like this, I like my job. I didn’t always, not until I developed some comfort level with the range and breadth of cases, as well as familiarity with my colleagues and my patients. This “liking my job” also coincided with becoming a mother. I think once I experienced bringing a child into the world, and could look at Life with a whole new higher purpose, I also relaxed into my work. It’s good work. In addition, we have a great team and a beautiful building with a solid support staff… We are the lucky amongst the primary care. So, hard as it is, I’ll take it, variety and complexity and all.
1. Gawande, Atul: The Checklist Manifesto: How To Get Things Right. Metropolitan Books, 2010.