Reality Stories of Medicine: Things About Patient Care You Don't Learn at School

Growing

Part One

In The Office or Hospital: Patient Observations

The laundry list office visit

This is a classic issue in the office setting. The patient comes in for a routine physical examination. He or she has neatly compiled a written list of their problems to discuss with you. Usually it’s on one of those yellow tablets of paper that you used in math class while in high school. I have seen these lists 3 or 4 pages long, single spaced! From the patient's perspective, they just don't want to forget anything. One can’t blame them.

If you let the patient review each problem, the exam might take over an hour or longer. But does the patient care? He doesn't know that you are likely behind already. Maybe a half hour or an hour even before you started with them. Now it’s their time.

These lists are often generated by patients who may have OCD (obsessive compulsive disorder), are journalists, have forgetfulness, or they are engineers.

Do yourself a favor and gently get the list out of the hands of the patient. Review each problem that they have expeditiously. I have found that if you let them keep it, they will go through their list slowly and methodically. You should kindly take the list, review it briefly and thoroughly, and bring the patient back for additional exams if need be.

The practitioner needs to be in control of the exam, or they will be lost for the day, and this will bring much consternation. There is an art to doing this. Take care of all the patient problems and do it with grace. Have them come back if you can’t finish.

I am all for lists of problems and communication, but there has to be a balance.

What about the second opinion?

The desire of a second opinion can be nothing more than a lack of trust in your treatment or diagnosis. Call it what it is. Patients will demand it at times, but more so, their family members will do it. They will probably be careful not to hurt your feelings, but often they will get them without your knowledge.

I don’t have any problem in obtaining second opinions on difficult cases or in cases when the diagnosis of the patient’s problem is not known. We have to know our limitations.

But there are many superfluous second opinions obtained because of non-trusting family members. Case in point: a recent healthy, 80 year old male was in the hospital with a SBO. He got better after 3-4 days and went home. He had had gallbladder surgery a year before. Thorough work- up now with CT abdomen/pelvis, blood work showed no other problems. We were up-to-date on colonoscopy. Our diagnosis was adhesion-causing-SBO, like many SBOs are.

This didn’t satisfy the family. They opted to have their father go see a gastroenterologist in a local larger city to get his opinion so he could agree nothing else needed to be done. The wife of my patient told me, We trust you completely, but you know, my kids, well they wanted us to get a second opinion. Did they find anything? No. But thousands of extra dollars certainly were spent!

Second opinions can be a rubber stamp and only serve to increase the cost of health care. But we still live in America, and people are free to seek out second opinions. Now if Medicare or other insurances wouldn’t pay for the second opinion, then certainly there would be a money issue in getting them. But remember that places like the Mayo Clinic thrive on them.

The patient with newspaper article clippings from their favorite newspaper MD

Dr. G*** is kind of like a Marcus Welby MD type doctor from the 1960s-1970s. Marcus Welby was not only a compassion old GP from years back, but also a great guy, and everyone loved him. Dr. G*** has been our newspaper MD for years; last page in the front section. He’s a throwback to the old General Practitioner. He has a daily, syndicated newspaper article published in the local pap (and 100s of others) where he answers the public’s questions on health issues from bladder infections to low back pain to onychomycosis to restless leg syndrome. The article is found on the last page of the front section of the paper.

For nail fungus, his solution is rubbing Vick’s Vapo-rub into the nails daily. For restless leg syndrome, but a bar of ivory soap under one’s bedsheet at night. Nothing backed up by scientific studies. But patients swear by him. Often, our patients will bring clippings of his article in to share with me a particular answer that Dr. G*** has for a medical problem that they have had. And that smelly ointment for my toenail fungus really works they are sure to tell me.

One patient came in telling me that Dr. G*** recommended Neurontin for pain after shingles. Why didn’t you suggest that for me when I had that awful condition a couple years back, doctor? Mrs. Smith, I did suggest it. And we did put you on it, and it was called gabapentin. That’s why you don’t remember; we called it by its generic name! And remember you couldn’t take the drug because of the prominent side effects of fatigue and dizziness from it? Oh, that’s right, doctor, I didn’t realize that gabapentin was Neurontin.

Sometimes, it appears that patients want Dr. G***'s opinion about a medical problem they have. You’ll have to figure out how to deal with this.

The internet search patient who wants to direct their medical care

It has been said that the internet’s number one use is in health questions for the masses of people out there with access to it. You got a hang nail? Look it up on how to treat it. You got a sore throat? Look it up. Hemorrhoids? Look it up. Sarcoidosis? Look it up. Cough? Look it up! The layman is looking up the answers to their medical problems on countless healthcare websites. Nothing wrong with that, you say. It helps to educate people. Absolutely.

The problem however, becomes sorting the information and knowing what is important and what might not be as important.

Let me give you an example. Typically, I will walk into a room to see a new consultation. The chief complaint of the patient might be, I have chronic fatigue syndrome, or I think that I have Lyme’s disease, or I have a disseminated yeast infection. There may be others. Accompanying the patient is reams of internet searches (maybe 2 or 3 inches thick) on their associated topics. We are talking about hundreds of pages. The patient is trying to academically prove to me, the physician, that they have a particular medical condition based on their internet search. All the symptoms that I am experiencing are just like this particular disease, they say.

Frequently, after a thorough history and physical examination, and review of x-rays and labs, I will burst their bubble and tell them that they do not have so and so a diagnosis that they thought they did, and actually their diagnosis is something quite different. (And maybe it is all in their head.)

Sometimes they leave the room disappointed that I haven’t supported their research, and then it’s off to another doctor to see if they can find someone to support them. I remember a particular patient who thought that he knew that he had a new diagnosis of Lyme’s disease. He didn’t have it clinically. But he thought that he did. He found a website on the internet of some laboratory company in Virginia who prided themselves as the only company available who can make an accurate laboratory diagnosis of Lyme disease. Any other technology was behind the times, and would give a false negative result. Send your blood to us for definitive testing, they said! He was adamant that his blood be sent to this laboratory in Virginia for definitive testing. What a sham. But there are many companies out there that take advantage of people.

Conclusion: Kindly set the patient straight early on in the visit. Help them sort out their internet search. The internet has them confused.

The Family Leave scammer

President Clinton and congress passed the Family Leave Act back in the 1990s. It seemed like a good thing to do; giving family members a chance to take care of their loved ones when they were sick. They could then miss time from work without repercussions.

There are the governmental, paperwork forms to fill out that the family member must submit to their employer. Though you are not the family member’s doctor, it is your responsibility to fill these out as you are the doctor of the patient. (Doctor, would mind filling out these forms for me?) Of course not, because more forms to fill out brighten our day. It's only going to get worse.

As usual, good things get taken advantage of. Fortunately, most people are reasonable about family leave time. But you will see over time that there are those who don’t really need the family leave time off because their loved one is really not that sick. But they will apply for the time anyway, so that they can have time off from work for a while. Yes, this is true. I have seen this numerous times over the years. It is difficult to police this as a doctor, as you want to give people the benefit of the doubt.

I had a middle aged daughter of a patient of mine that wanted time off from work to take care of her ailing 75 year old widowed father who had fallen and broken a rib. Sure, he had pain that would continue for a few weeks, but he was completely functional. The daughter wanted to be around to take care of his every need, so she said. Enough said.

The while I am here patient

This kind of patient sees you infrequently in the outpatient setting, but they should see you at least yearly, because they usually have a number of issues to discuss. Everybody has a few patients named Joe like this.

Your office staff double books Joe onto an already busy schedule, who is a 55 year old guy who still likes to play in the summer softball league. He has developed shoulder pain in his throwing shoulder and wants to be seen. The staff obliges to a shortened appointment to address the shoulder. Joe is a long term patient but does not come in for yearly or bi-yearly physical exams by his choice. He's generally is a pretty healthy guy. After you have examined the shoulder and diagnosed the problem and set up treatment, the patient says, Doctor, I don’t get in very often to see you and I know that you are busy. But while I am here, can you quickly check this rash on my lower leg, and also what’s wrong with my toenail.......it’s thickened and yellow. Oh, and can you check my blood pressure, ‘cause high blood pressure runs in my family. And would you mind ordering blood work for me?

You have two options here. One is to check his BP, look at the rash and toenail, and be done with it in another 5 minutes. The patient has gotten what he wants. He comes in for shoulder pain, and you have taken care of 3 other problems. The other more viable option is to book him for a physical exam in a week or two. That’s fairer to you and the rest of your patients, and your patient will get a more thorough exam!

Be careful though with the patient who comes in with a new skin rash which you easily diagnose and treat. But then as you are walking out the door they say, By the way, doc, I’ve been having bright red blood in my bowel movements and toilet bowl off and on over the last few weeks. It’s not bad but I thought you should know. You quickly survey the patient’s chart and see that they have an internal hemorrhoid history. Though likely hemorrhoidal bleeding, don’t ignore this off the cuff complaint for a follow up in 4 months. Take the time to check for a bleeding colon polyp or a new colon cancer. This patient should be scheduled minimally for a flexible sigmoidoscopy or colonoscopy. If you assume hemorrhoid bleeding, see the patient again for routine visit in four months, and the bleeding problem turns out to be a rectal cancer, you have not only done your patient a grave disservice by a delay in diagnosis.

Non-English speaking patients

It goes without saying, but one of the keys to effective medical care is good communication. When the communication is poor, the patient really gets left in the dark. Thank goodness for our foreign language translators. We have many bilingual people employed here in our healthcare system, primarily for our Spanish speaking patients.

When my older patients are Serbian, Russian, Polish, Romanian, or Lithuanian, and don’t speak English, often times a family member is present to help with interpretation. I find that younger family members are more than happy to be present for routine office visits. Without open lines of communication, it is impossible to convey important patient education and medical plans regarding x-rays and laboratory testing that is needed.

If one has a non-English speaking patient, make sure there is adequate interpretation. This will make the patient much more comfortable regarding his or her care. It often takes extra time. Sometimes, when we get busy, we bull-doze through our patient visits, and forget the importance of this important two-way communication. Never skip translation.

The looking at their watch patient

Very occasionally in the course of a day, a patient that I am seeing will stealthily glance at his/her watch as I walk into the room. Often I am behind. But yes, people are often conscious of how much time I spend with them. And of course, they want to spend as much time with me as possible, and sometimes they will time the visit. Watch for it.

This often flies in the face of the patient visit in the tertiary university setting, where healthcare providers are generally salaried and they are able to spend more time with their patients. (Community oriented healthcare practitioners generally have much higher patient volumes). How efficiently they see patients are not an issue. After a visit to the sub specialist in the university setting, my patient will frequently say, that doctor spent well over an hour with me. What they are trying to tell you is that they want me to spend more time with them!

What patients may not understand is that after years of experience, it doesn’t take as much time to take care of their problems. For example, a consult patient recently came in with a rash that a couple of other physicians had looked at (primary care, prompt care or even the ER physician). I saw the rash in 3 seconds and knew the diagnosis. It was dermal blastomycosis. I had seen it many times before and was confident of the diagnosis. I had the patient on her way in less than 5 minutes and she was satisfied. (It was shortly later biopsy proven blastomycosis by a skin biopsy). The point is that time itself doesn’t always qualify for a valuable visit.

There must be something wrong with that urine drug screen test

It is amazing to me. Should it be surprising? No. You catch people red-handed with the accurate urine drug screen, and they will still lie about their drug use. It seems to me that when it comes to alcohol use and illicit drug abuse, patients will always minimize their habit or lie about their addiction. Even if you catch them at it!

Recently, I had a 25 year old patient in the hospital who had multiple medical issues but before admission while in the emergency room, also had some confusion. The emergency room doctor ordered a urine drug screen and it showed positive for marijuana and cocaine. When I sensitively confronted the patient in her room on the second day of hospitalization, she said, Oh yes, I do smoke some reefer regularly to help me with my nausea, but no, I have never done cocaine. There must be something wrong with that urine test! I explained to her that a false positive test is highly unusual with this test and that it is very accurate. No way, Doctor, I swear. I don’t do cocaine! I must be the first person where it was wrong. Now most patients would confess to their usage. But like in this case, occasionally you will find the stingy liar in denial, trying to save face.

A 55 year old female patient with a chronically failed back syndrome with lingering pain is on opioids with a contract through the pain management specialist. Recently, she was escorted to the ER by police when she was found to be out of control at a party. She repeatedly banged her head against the window in the squad car. Urine drug screen done in the ER showed cocaine. What was her excuse? When she followed up one week later in the office, she said, Someone at the party must have laced cocaine in the party punch, because I wasn’t aware of it!

What is the doctor to do with a patient that doesn’t fess up to the truth? It is a difficult problem, because you really want patients to be honest with you. If they aren’t honest, they only hurt themselves in the end, because you can’t help them if they don’t help themselves. Either way, it strains the doctor-patient relationship.

Recently, an elderly lady was hospitalized with Malignant Neuroleptic Syndrome secondary to a cocaine overdose. It turns out that her grandson has got her hooked on snorting cocaine, but her son was trying to help her get off that stuff. When confronted in the ICU about her positive urine drug test for cocaine, she was in denial. What are you talking about?, she said in an irritated tone. I can do whatever I want, she said. After all, I’m 64 years old. She was kindly lectured on the dangers of using cocaine, and that she could kill herself next time.

The cover up alcoholic patient

Alcoholism is a dreaded disease that affects many millions of people worldwide. Obviously, certain culture groups are more prone to the destructive power of alcohol on the body, because of its metabolism through the liver. Many families and relationships have been ruined by fire water. The land of sky blue waters is Wisconsin, and it seems to contain more than its share of alcoholics. In fact, the states of Wisconsin and New Jersey have some of the highest rates per capita population of bars on its streets. The abuse of alcohol in Wisconsin costs the state an estimated $6.8 billion a year in health care, lost productivity, crime and premature death. And taxpayers are picking up more than 40% of the price tag. (Racine Journal Times; 3/13/2013)

There are countless other people who are not alcoholics but who clearly abuse the consumption of alcoholic beverages. They will try to cover this up.

We see the destructive power of alcohol on our patients and their families on a daily basis in the hospital and outpatient clinics.

As a healthcare provider, you will be faced with taking histories on alcohol consumption on all of your patients. What you will find is that 1) many adults drink alcoholic beverages and 2) for those who drink excessively or who are alcoholics, they will habitually lie through their teeth to you regarding of the volume of alcohol that they consume. While most people exaggerate their abilities, alcoholics are in denial about how much alcohol that they consume and will minimize the abuse. Comments that you will get include, I only drink socially, or I only have a few drinks regularly. The key is, what is drinking socially, or a few? To you, a few might mean two beers a week, but to them, that might mean two six-packs a week. Try to be careful to quantitate the volume of alcohol consumed. You will be surprised. Spouses who don’t drink alcohol will be the truth-sayers and nail down the exact amount of alcohol consumed by the patient.

J.P. is an unfortunate young man in his mid-thirties who was a former triathlete, and long distance runner. He fell on hard times, lost his job, and went through an ugly divorce. Instead of constructive ways of dealing with overwhelming stresses, he turned to the bottle for solace and before you knew it, he pickled his liver with cirrhotic scar tissue from daily over-consumption of ETOH. He now lives with nine month pregnant ascites, esophageal varices, and despite treatment, hepatic encephalopathy from high serum ammonia levels. He incessantly lies about his alcohol intake, emphatically denying intake of the devil’s brew in spite of positive alcohol levels. Must be something wrong with that blood test, he tells me.

The patient who doesn’t have a primary care doctor

There are basically two kinds of people who don’t have or don’t utilize a primary care doctor.

There will always be an unattended call roster of patients for the emergency room that primary care physicians must fill month after month. These patients simply don’t have doctors. Believe it or not, a significant minority of the population likely chooses not to have a primary care doctor! It may be a financial issue. Most of the time, they don’t have insurance, like millions of other Americans. They can use the local emergency room as their medical office, and of course the law requires that they be seen and taken care of. They can be generally undesirable to take care of because of their noncompliance for follow up in anything you want them to do for themselves. In my experience, they often don’t keep appointments for follow-up with you.

But there is another kind of patient who either rarely sees a primary care doctor or just doesn’t have one. They tend to be higher on the socioeconomic ladder and may be even executives. Maybe they have been to the Mayo Clinic or some other tertiary care center for executive physicals in the past. I have a few patients like this. You will probably not see many. They might go for 5 or ten years in between visits with me. They often are connected in the local community and know a lot of doctors socially, maybe at the local country club. It is not like these people are devoid of medical care. If they have a nosebleed, they seek out the ENT physician. If they have a hip or knee problem, they go to their orthopedic friend. If they develop a palpitation, on their own, they seek out a cardiologist. If they get a rash, they go straight to a dermatologist. If they have a rectal itch, they go to a gastroenterologist. They are sophisticated doctor shoppers, but they skip the primary care practitioner.

Whereas most people go to their primary care doctors to sort out their medical problems and triage, these patients use their social network to find specialty doctors for their problems. They will leave the primary care physician out of the loop of their medical care.

Hurry up and see me; (I’ve had this problem for six months)

Unfortunately, this happens on a regular basis at the office. It is more of an irritant to your staff and of course other patients of yours who have a scheduled office visit. They have to wait longer, and you, the healthcare provider gets farther behind.

You have a typical full day of appointments. Every day, our office tries to save a few openings for patient urgents. Normally, we might have forty to seventy phone call-ins a day which are triaged by trained nurses. A patient with a bad back, a sinus infection, a bladder spasm, a side effect from a new medication, a bad headache, a new itchy skin rash that doesn’t respond to hydrocortisone cream, a new lower abdominal pain, or a nagging cough are all typical problems that we deal with on a given day over the phone.

What becomes frustrating is when the patient has had a particular problem for over six months. It might be a cough, or perhaps a hurt shoulder that just won’t go away with home remedies. The problem is not really urgent...in fact it has become a chronic issue. Their problem should be addressed by me, but it could wait for a week or two when the office schedule has a few more openings than today, the day that they call. Their perception is that they must be seen right away. When my triage nurse fields their complaint and tells them, Let’s put you in next week, sometimes they don’t like it. You know doctor, I really like you and your staff, but I can NEVER get into see you when I want to, they tell you. But they don’t want to go to the walk-in, prompt care clinic either, which is an alternative for them. They only want to see you. So you are between the proverbial rock and a hard place with patient satisfaction.

And then when you get double-booked in a particular time slot, the next scheduled patient gets put off for more time, and then they wonder why they wait so long. I thought you forgot about me, the waiting patient says. They say it nicely, but quite honestly, they are put off by the wait. After all, their time with their provider is valuable also.

What is a primary care physician to do?

I have a personal problem

This is usually a chief complaint in the office of males between the ages of 18 and 75. Bluntly stated, a personal problem is always related to the males’ sexual apparatus. They are too embarrassed to talk about it except with the physician. If the patient is younger, they may have developed a sexually transmitted disease like a urethral drip or a warty growth on their genitals. If they are over 50, they probably have erectile dysfunction and want Viagra or a Viagra-like medication, and want to know why they can’t perform like they used to. I think I have low testosterone; can we check for it? they say. The advertisement on television said to consult with your doctor. They will want drug samples if possible. I have an 82 year old man who still asks for ED sample medications every time he comes in.

Leaving the hospital A.M.A. (against medical advice)

Foolish is the best term to describe the individual that leaves the hospital before the healthcare provider(s) clears them for discharge. This does not happen very frequently, as I can only recall it happening a handful of times in the last 27 years.

First of all, the usual going home A.M.A. patient is generally not a long term patient of yours. They are often unattended, irresponsible patients admitted through the emergency room. They generally don’t have a primary doctor. They generally use the ER as their doctor’s office.

I was assigned an unattended patient who came to the hospital with abdominal pain from alcoholic pancreatitis. Their pain improved a little over night and they discharge themselves the next morning. I didn’t even see the patient on the day of discharge. Leaving without prescription medicines shows a lack of understanding of their problem.

Not a good idea! The individual promptly went back to drinking alcohol and had to be readmitted on the following day with recurrent pain. If there is another hospital not too far from your hospital location, they may choose that one, just to get a change in scenery, and save face and the ire of the medical staff. Instead of doctor shopping, they hospital shop. The Against Medical Advice patient definitely challenges the medical care system. Be aware of them. They don’t get it.

Why some patients like going to the Mayo Clinic, or some other tertiary university medical center

Some of your patients will go to the Mayo Clinic or a university medical center if they perceive they are dealing with a more serious medical problem. The local hospital and its doctors just aren’t good enough to take care of their condition. That’s how they feel anyhow. By going to Mayo Clinic, they feel like they are going to get the best possible medical care. And sometimes patients will go there for routine care also. I have several patients that go to the Mayo Clinic every year for their physical exams where they are monitored for their atrial fibrillation or hypothyroidism, etc., or any of the other pedestrian problems that we see. A couple of these patients are in their eighties! They have been going to Mayo Clinic paying top dollar for their healthcare for over 40 years. Most of these patients started going to Mayo Clinic as young executives in their 30s and 40s when an executive physical was a perk at their company. They still like the efficiency of the Mayo Clinic and the fact that all the tests can get done in a few days.

I have a patient who flies to Texas every 3 months to go to MD Anderson Cancer Institute for treatment of his leukemia. He has been doing this for over ten years! He could get all of his care at the local cancer clinic but he feels that he needs to go to MD Anderson because they’re the best. He can afford the trip. Many of my patients will go out of town to the tertiary university center for their healthcare rather than stay in their smaller town if they develop a more serious problem.

Remember something. After medical school and post-graduate training, if one decides to practice medicine in the community setting rather than the university setting, one needs to understand that a minority of their patients will leave and go to the university medical center to get their medical care if they have a perceived serious medical condition. That’s just the way it is. Try not to take it personally. The best for the best is the theme, from the patient’s perspective. It’s all about perception.

In the big picture, I appreciate the Mayo Clinic. I do send some patients there. If they have a rare condition that we cannot treat, I am on the phone with Mayo networking to find the best treatment! But in fairness to Mayo, they frequently don’t have easy answers for patients either. Sometimes, there just isn’t an easy answer.

The positive review of systems patient

This is the patient who says yes to almost every question that you ask them when you are taking a history. You could spend at least three hours with taking a history of their medical problem(s). And they have a story to tell along with the answer. If all of our patients were like this, it would be a long and impossible day. Fortunately, there are not too many of these patients around but you will regularly run into them. They inadvertently will control your interaction with them because of their love of talking.

I have found that there are two types of patients in this category. The first type is the most common. They are basically either neurotic or have some kind of mental imbalance (perhaps PTSD-post traumatic stress disorder) and have a special need to tell their story. For example, M. K. is a patient who loves to talk. She had an ugly divorce from a cocaine abusing husband. When she comes in for an office visit, not only does she have a positive review of systems, but she has a notebook with her that has pages of information that she wants to share with me. Most of it has to do with dysfunctional relationships with her ex-husband and one of her abusive sons. Of course, we try to aim her towards psych counseling. She is a handful to try to redirect.

The second type is the more unfortunate individual who literally has a medical list of twenty problems, from osteoarthritis to high blood pressure, to heart disease, to diabetes with complications of retinopathy, neuropathy, and kidney problems. This patient has earned the painful way of a positive review of systems because of their multiple illnesses.

The bottom line is that you will need to learn how to control the patient interview process or patients will control you.

The golden slipper patient

This is the description of a particular type of patient who generally comes from significant wealth. They have to have their golden slippers and expensive robes even while being a patient in the hospital. I saw this trait in certain patients while training 25 years ago in the opulent northern suburbs of Chicago. Let me first say of course that not all wealthy people are like this. But every large urban area has its affluent suburbs. One doesn’t see them as often in blue-collar towns as in the upper-class suburbs.

Beware of this clientele of patients. They and their families can be more challenging to take care of. Why? They often have higher expectations for you and your performance and their medical care in general. They only want the best that money can buy. We call that being demanding. Wealth can do that to people, especially when it comes to healthcare. They want Cadillac care. Providing that care day in and day out can be stressful. Just talk to physicians who practice in the affluent northern suburbs of Chicago or Milwaukee.

Want extra stress? Take care of the wealthy. Sorry wealthy people, but you can be difficult. It is what it is.

Women are medically more responsible than men

This is a general observation of men and women over the last 25 years. It is a trend and has been observed in many different cultures. No matter if it is in the US, Haiti, the Dominican Republic, India, the Congo in Africa, or Central America. Believe me. I’ve worked in those areas of the world. Women are the patient nurturers of their family. They are with their needy children at the clinics. Having been involved in numerous primary care clinics over the years in different places of the world, it is clear that mothers take care of their children more definitively than men do. Women seem to be more aware of their own medical needs also. Whereas men seem to be more in denial that they have any medical problem at all! I don’t know if this is in men’s DNA or what. It is definitely cross-cultural.

And it's not about men are out working and women aren't.

Here is a typical scenario. I had a little chest discomfort off and on for a few months and I just blew it off. When my wife finally heard me complaining about it, she high-tailed me to the emergency room and here I am! Little did he know that he had suffered a heart attack and was experiencing accelerated angina pectoris. Thanks to the wife, the patient is still here.

It seems as sometimes men just don’t have a clue.

I only want to talk to the doctor!

The above statement will be made by a few of your patients in the outpatient setting. It can demonstrate a lack of sensitivity to the physician’s busy schedule and a patient who generally has a pretty large ego. I have an Italian patient who owns a restaurant in town and he repeatedly makes this comment to my staff. It shows a lack of trust in the people who work with me. These valued team members are my extenders! Some patients perceive that they need to talk to you, but they generally don’t. I try to talk to as many of my patients as possible, but sometimes it’s just plain impossible. My nurse can call a patient back and tell him that his right wrist x-ray was normal! I don't need to do that.

J.A. had routine check done of her nares for