Tuesday, September 25, 2007


I usually love clinic, even now that the patients I see call me doctor, and I have to have a plan pretty much figured out within half an hour of seeing them. What I don't like is patients like Mrs. Fortnight.

Mrs. F showed up in clinic to be seen for hospital follow up. See my hospital has a policy that every patient is seen in follow up within a month by the intern who admitted them. No matter how complicated, or how many other medical problems they may have. I admitted Mrs. F about a month ago because she was dehydrated and low on magnesium, but of course, this being internal medicine, she also has heart failure, an obscure and ill-characterized propensity to lose electrolytes, chronic diarrhea, Parkinson's, depression, and diabetes. She's the kind of patient who can make almost anyone wish they had picked another specialty.

So she shows up in clinic, and right away the complications start. The triage nurse checks her blood pressure and gets a value of 90/30. This is not good. However, blood pressure machines are not infallible, and any abnormal value they give you should be rechecked. So the triage nurse duly rechecked the pressure three times, getting the same value, but still using the machine. When I came out to see what was holding up my clinic, I found they had not checked the pressure manually. I did so and got a completely normal value. Meanwhile, the nurse had checked a blood sugar and found a value of 232. This is also bad. Especially since my patient hadn't eaten since the night before.

Things never really went uphill from there. She had stopped the magnesium I had started, which necessitated a stat magnesium check. She hadn't rescheduled two appointments with specialists that she missed (and needed.) She hasn't ever written down her blood sugar when she checks it, and neither she nor her husband can tell me where it usually is. She was surprised when I told her she should check it with every meal. 90 minutes later I am an hour behind on clinic with two patients yet to see in the morning session. Goodbye lunch.

I felt bad for her, but there's only so much I can do, and I'm only supposed to be seeing her for her dehydration follow up. She has a regular doctor who should be taking care of all these other complications. But evidently he's doing a poor job. Maybe though, she's just minimally adherent to her regimen from him, like she was from me. So, schedule follow up with her doc, get her a glucose level diary, counsel on foot care, schedule follow up with subspecialties, refill Sinemet, smile, bid goodbye.

Next patient, rinse and repeat.

Please, dear reader, bear this in mind the next time your doctor is late for an appointment.

On the positive side, I finished my infectious disease rotation, and my attending was singularly complimentary in my evaluation. He asked me to consider applying for fellowship in his department in two years too, so we'll see. I did love it, but the siren song of cardiology is still ringing in my ears.


mrstandfast said...

ahh yes, the seductive, dulcet tones of Cardiology. Not unlike the beguiling warble of the temptress Accountancy...

pre-ID said...

I would kill for an ID fellowship. never mind that i haven't even gotten into medical school yet... but ID is just so damn awesome.