Difficult Conversations

I am really liking my Family Medicine rotation a lot. Hands down, I like it even more than my Pediatrics rotation, very much to my surprise. I still see kids but now I get to hear their heartbeats while they are in their mother's womb. I see them as they miraculously go through the birth process. I see them reach their developmental milestones. I see kids go through adolescence. I see grown-ups, moms and dads, grandmas and grandpas. You see a whole gamut of patients each presenting with an interesting story. Even the family dynamics are quite fascinating.

We got asked earlier in the week what kind of doctor we pictured ourselves to be when we first thought of becoming a doctor. This is very much what I imagined a doctor will be doing, taking care of each member of the family. I still remember our town doctor, Doktora Palacol. I don't think she delivered babies but she took care of adults and children. I don't know if she continues to practice. I remember her favorite diagnosis: kidney disease! She would hit you on your sides and if you complain of flank pain, she'd say -- aah, you have sakit sa bato! (kidney disease!) :).

Today was very interesting. My first patient was almost near death a couple of weeks ago. She has long-standing pulmonary hypertension and she was being worked up for its cause. She went in for a routine outpatient endomyocardial biopsy and the last thing she remembered was somebody saying, "oh, something is terribly wrong". They had punctured her heart! Her husband was told that they weren't sure if she would live through it. Obviously, she did, thankfully! :). She just got so wary of medical interventions now that she did not feel comfortable starting a CPAP for her sleep apnea which may very well be the cause of her hypertension. Another patient was a teenager with bipolar disorder. She came in with her mom who she adores and thinks of as her best friend. I went through the review of systems and physical exam. Then she requested that her mom leave the room because she wanted to tell me something. I thought she was going to confide some sort of risky behavior but it turned out that she just has questions about female stuff. It amazes me how much trust goes in a patient-doctor relationship. Another patient was a 9-month old girl with congenital heart defects. She has a very loud heart murmur complete with a palpable thrill that even I could not miss :). They were initially waiting for her to grow more prior to additional surgeries but my preceptor suggested that they call the cardiologist immediately since she seems to be getting worse fast. I pray for her surgeries to be successful.

My last patient for the day was a 17-year-old on Vicodin for migraines and joint pains. He is a new patient and I was curious to find out whether he should really be on Vicodin which is a strong narcotic. His mom was in the room when I came in. I
asked about his migraines and whether he would be willing to try out anti-migraine meds. His mom was adamant that he stays on Vicodin which he's been on for 2 years now. I tried to explain that it's not good for him to be on Vicodin long-term. I told them that there are different kinds of pain and we have different medications to treat them. I even mentioned that if he is really in so much pain, we can even refer him to a pain clinic for pain management. I left the room with the feeling that I have at least let them know of different options that we have in managing his pain. I staffed him with my preceptor and then we came back to the room. My preceptor told him right off the bat that she is not the type of physician who would prescribe Vicodin to teenagers with migraine pain without exhausting other alternatives. His last doctor prescribed him 60 pills and he finished it all in less than a month.

They were really upset about this so when my preceptor left the room I purposely stayed behind. I felt our conversation earlier went very well and I had a connection with them. I told them earlier that my classmates tease me that I have the genetic condition he has because I can bend my little finger all the way down. I told them that I have a strong fascination with Medical Genetics and he is the first person I've met with that syndrome. So I tried to convince them that my preceptor has his best interests at heart. And I didn't think it was a bad idea to try other medications. So I eventually convinced them that they should at least try some of the sample meds that we have. I didn't realize that I had a lengthy talk with them. My preceptor teased me later that she wasn't sure if I needed "rescuing" :). I just didn't want them to leave totally upset. Pain is one of those iffy areas for me. Maybe they'll come up with a blood test or something to diagnose the level of pain :). Maybe it will be easier to figure out if a patient is having legitimate pain. Then I don't have to second-guess myself whether or not a patient is really having as much as pain as they say they do. Maybe they would not have to manufacture fantastic stories or harm themselves even just so they can get their hands on strong pain meds.