Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, March 30, 2007

When Keeping a Straight Face Causes Actual Pain

Today I saw a 67-year-old smoker with hypertension and diabetes who only comes to the office for acute problems. The last visit was three years ago for a sore throat; his blood pressure was 180/80. He promised to come back in two weeks to address his other health issues. Today (three years later) he comes in worried about a week of diarrhea (that's getting better.) His blood pressure is now 190/90 and his pulse is 130, though he's afebrile and in no distress whatsoever.

His exam is basically normal, though I can easily feel his aorta (he's skinny.) I want to do an EKG, a blood test (worrying about kidney function, diabetes control and anemia, among other things,) get an ultrasound to rule out an abdominal aortic aneurysm, give him a dT booster and suggest a colonoscopy. All he lets me do is draw the blood. I want to give him samples of Toprol 25 XL but all I have are 50's; it takes twenty minutes of explanation to get across that I want him to take half a pill every morning, and that I need him to come back in two weeks.

This is what I say to him (many times; he will not stop talking, asking the same questions over and over):
If you don't do what I say and come back to take care of these things, you are probably to have a stroke (or a heart attack) within five years, and probably less.
I wish to Gd I was kidding as I report his response (no sarcasm; not trying to be funny; deadly serious; a statement, not really a question):

"You're levelling with me, aren't you."

Disclosure (sort of): yes, there are intellectual issues somewhat beyond not being the sharpest tool in the shed. But still...geez!

4 Comments:

At Fri Mar 30, 07:55:00 PM, Blogger Dreaming again said...

Sigh.

I can just see my mom's doctor's writing something like this about my mom ... especially the last line.

The frustration about not quite being able to get the instructions through to her, her not understanding them ... and her talking non stop, lack of social skills ...and not being the sharpest tool in the shed ...

and it's written off as dealing with an older person.

The problem is (and that's where my frustration is driving MY blood pressure to the point of ME needing Toprol XL 25 mg, literally)
She has her masters in education and has been an award winning teacher ...

Her not knowing the social cues of when to not talk ... isn't normal.

Her not understand to take half a pill ...isn't normal. (she taught school for 25 years! Has her masters in EDUCATION, I think she knows what a half is!)

Her not understanding what 2 weeks is ... is not normal.

Not being the smartest person and talking to her like she's a 5 year old ... and what a sweet 'old' woman (she'll be 68 in 6 weeks) doesn't help.

Sorry, I know this gentleman isn't my mom ...but it struck a nerve. What was this man like at 30, at 45 ... at 50 ... what did he do for a living ... did he always have poor social skills? Was he always hard to communicate with?

 
At Sat Mar 31, 07:04:00 AM, Anonymous Anonymous said...

So, he doesn’t show up in two weeks. He will have a stroke or MI.

What is your responsibility?

 
At Sun Apr 01, 08:28:00 AM, Anonymous RJS said...

"So, he doesn’t show up in two weeks. He will have a stroke or MI.

What is your responsibility?"


Well beyond not wanting to see people sick, there are economic implications as well. It's much less expensive to prevent adverse events than it is to treat them once they've happened.

Assuming he survives, it's going to cost his health insurance company/the state thousands of dollars to pay for his medical care when he could have managed his comorbidities for probably $200/month. Possibly a lot less, depending on the severity of his DM and if you avoid TZDs.

But I think mostly it's the seeing a train wreck slowly unfold and being able to do nothing about it, even though it's preventable.

 
At Sun Apr 01, 07:33:00 PM, Anonymous Diora said...

RJS - the economic implications are less than clear.

Consider my cousin's husband for example. An obese 50-something with high blood pressure whose father died from heart attack in his 40s or early 50s. Not a smoker, granted, and not a diabetic (although it is difficult to say for sure since he hadn't seen a doctor in 5 years or so before he died).
A friend of mine who saw him at one gathering called him a "walking heart attack" just based on the way he looked - fat, red faced, getting all upset whenever someone disagrees with him, all the while eating butter and mayonnaise.

Guess what. One day he just fell and was dead before the ambulance arrived. He was 56. Cost of medical care - $0.

Going to a doctor, controlling his blood pressure, cholesterol, etc. might've prolonged his life. But I doubt it very much it would have saved money.

Yes, I know, it is anecdotal, and that treating complications of diabetes is expensive. But still.

 

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