Fifteen Patients, Fifty Issues

Fridays are my long days. I see patients pretty much from 8:30 am to 5 pm, which really means being at the office by 7 am and leaving around 6 pm. On most of those long days, I see around 12 to 14 people. Of course, there are also all the week’s labs and radiology reports to check, urgent matters to address before the weekend, patients to call, emails to answer… By the end of the day, my brain is addled, my mouth is dry and my voice raspy, and I am physically just… limp. It’s a very full day.

Yesterday I saw 15 patients in total. That, I have to say, is about my maximum.

Now, I know that other primary care docs at other clinics see more patients than that in a full day. I’m not sure exactly how, but I have an idea.

I used to moonlight at an urgent care center at another primary care office, one that is well-known for being fairly factory-like. Patients in, patients out. We were instructed that if a patient came with multiple complaints, we were to limit-set, pick the one most pressing issue,  and ask them to come back for another appointment to address their other issues. We were supposed to type our chart note on the computer in the room WHILE we were seeing the patient. If we were seen dawdling between patients, even if it was for purposes of researching a case or documenting a visit, we were asked to move it along.

Even with all the cattle-prodding, I only managed to see 18 people in a full day. And I quit.

Now, in my own clinic, I’m happy to try to address as much as possible in a visit. I get it. I know when I see my own doctors, I usually have more than one issue. Who doesn’t? And who could reasonably come back for another visit, when there’s kids, and work, and co-pays? I typically start my visits by trying to draw out everything on someone’s mind, way at the beginning.

I do have to make people come back sometimes, especially if it’s for a procedure, like an ear cleanout, or a skin tag removal. But most people understand that even simple procedures require  setup and cleanup time that doesn’t work within a visit for something else.

But, despite best efforts, things come up at the end of the visit. It’s also true that my heart sinks a bit when, at the end of a 20-minute visit for one thing, a patient says “Oh, and I forgot to mention earlier, but I have this other problem I wanted to discuss…” Almost as a rule, that “hand on the doorknob” issue is something important. It’s usually what was really on someone’s mind the whole time.

Yesterday, as always, there were a few “hand on the doorknob” issues. One example:

A lovely older lady came in for a blood pressure check and to review her fasting cholesterol results. She has high blood pressure and high cholesterol. Not terrible, but beyond the guidelines. And she doesn’t want to take medicines. She’s quite overweight. So we talked for a long time about all the diet and lifestyle changes she could make to lose weight, get fit, and possibly avoid an antihypertensive and a  cholesterol-lowering med. I love it when patients are motivated towards a natural, non-medicinal, lifestyle modification approach to health! I get really into these talks, and we chatted on about jump-roping and spinning and Pilates classes.

But as we were wrapping it up, she asked, “Can I bother you with one more question, something that’s been bothering me for some time?”

My heart did the habitual dip, but I smiled and said “Of course”.

“Well,” she began,  “I’ve got this irritation on my vagina…” and she talked about how sex with her husband, who she loves very much, is very painful lately. She doesn’t want to upset him, but she dreads sex recently, and it makes her sad.

I listened and nodded. She was obviously and understandingly a bit embarrassed to talk about it. I tried to be sensitive as I asked if she had ever had any STDs in her entire life, or if she was worried at all about infidelity. I did also, admittedly, think: Drat. Now I have to do a pelvic, and we’re already cutting into the next patient’s time.

But, there’s nothing else to be done but to deal with it, graciously and gently. Who knows? This could be herpes. It could be a vaginal squamous cell carcinoma. It could be simple postmenopausal changes, with vaginal dryness and irritation, and an over-the-counter vaginal moisturizer or a hormone cream may do the trick. Regardless, the vaginal irritation bothers her alot, and addressing it now is certainly, clearly more important to her than the silly blood pressure and cholesterol, despite my personal enthusiasm for cardiovascular fitness!

So, having determined that she is very happily married and very confident that her relationship is monogamous,  and then reviewing her record to make sure she is up to date with her Pap smears, I then asked her to disrobe from the waist down, and examined her. The exam revealed the expected postmenopausal changes, with nothing concerning for an STD or cancer. I had her dress, and we talked about her options, weighing the over-the-counter stuff like Replens versus the vaginal hormone preparations. She wanted to go right to hormones, so I wrote a prescription.

And then I was  running over 30 minutes late for the next patient.

The next patient was a colleague’s patient, a young lady who had had an organ transplant several years previously. She had an intimidating list of medications and specialists. The chief complaint listed on her check-in paperwork read “Cough”.

Sigh.

This is primary care. We never know what is going to happen. I do sometimes feel like a jack of all trades, master of none.

But, I’m never bored!