Taking Patients Home With Me

This week has been a very rough week. Interestingly, my energy levels are up. (FYI this corresponds quite nicely to the fact that we ran out of sugar in our house, which in my pregnant state, I had been allowing myself to ladle into my coffee and tea in great quantities. Evil white powder!)

However, my patient load is also up. Especially the difficult/ complicated/ sick patient load. For some reason, every single day, I have had a case (or two) that was incredibly draining, emotionally and intellectually. And I bring them home.

I don’t bring them home in terms of I bring home files in a folder. I bring them home in my head and heart, and then fret, mull and obsess. This is not conducive to family time! I need to get some of this off of my mind, in a sensitive and completely confidential manner:

I have a young patient who has recurrent pain. Awhile back, at a small local emergency room, he was told that this pain was due to a chronic condition . And they gave him narcotics. Since then he has been seen at several different local emergency rooms for this pain, where he has told them that he has this chronic condition, and they have given him narcotics.

But here at our big hospital, all of our workup for any chronic condition, or any real reason for his pain at all, has been negative. There is no evidence that he has any chronic condition. There is a lot of evidence that he is, perhaps, pain med-seeking.

The problem is, he comes across as so innocent and honest, I have a hard time believing that his pain is NOT real. In addition, I have been burned in the past on this. I have suspected pain med-seeking behavior in a patient who turned out to have a real diagnosis, one that causes recurrent pain. And I felt so, so awful about that.

BUT on the other hand, prescription narcotics abuse is rampant and completely epidemic in our area (as in most). Given the lack of evidence thus far for any real diagnosis for him, and it has been a very thorough workup conducted by a trusted specialist, and the very typical behavior of presenting to varying local emergency rooms, rather than our own hospital, I am hard pressed to come up with any diagnosis other than narcotics abuse. And yet I don’t want to believe it.

I have a patient who is extremely medically complicated. She misses appointments with me, then calls for help. Last week, she called- several times in a day. I had not seen her in months. I called her back and discussed her latest list of issues with her for some time, and then I asked her to come in for an evaluation: for an exam and some labs. She came in, much against her wishes. She wanted me to treat her over the phone, though she is ambulatory and lives nearby. She was disgusted with me, and when she came in, she had a list of additional complaints about me and our office.

Now, I am generally one who trips all over myself to apologize for any errors that I or my office have made. I feel bad about things I have no need to feel bad about. But in this case, I know that we have done right by this patient. I wanted very much to blow a gasket when she laid into me. But I did not. I smiled, said I wished I could help her, but perhaps we were not a good fit for each other after all. She agreed and we agreed to part ways. What a relief!

BUT still, the whole thing weighs on me. The unfairness of it. On the one hand, I do feel sorry for her, as she has real issues and needs a good primary care doctor. But her care has been caring, and thorough, and quality, and not only could she not see it, but she called her care BAD. And that hurts.

And, there’s more. There always is… My lady with the unexplained uncontrolled hypertension. The guy with the lung abscess. The girl with her third STD.  Sometimes, I don’t know how to let it go at the end of the day. I think about what I could have/ should have said, what I should/ need to say tomorrow. What specialist to contact, what test to order, how do I explain this to that patient? What if I missed something? What if someone thinks I’m a bad doctor?

Part of it is that I am not moving around much these days. Exercise helps me to clear my mind. Running, ah, running, I miss it. But it is so, so hard to catch a toddler with this great belly stretching out forever in front of me… Babyboy helps, as it is hard to ruminate about work when he is, every day, doing new and amazing things. He’s starting to toddle, to speak, to recognize words and phrases… It’s pretty cool. But ruminate I do, and I find myself missing some of this precious time, because I simply am not present. My mind is at work.

And so, I write about it, in hopes to neither impose all the clinic workday worries on my family, nor to sit alone with it all.