Mexico Medical Student |

As part of our community medicine assignment for the semester (apart from our crazy-long complete patient histories–I swear they want us to ask about their dog’s illnesses during childhood), are two home patient visits that we’re required to do. Usually, these wind up being for the elderly or those that couldn’t make it to the clinic for whatever reason. In an otherwise uneventful first day at the clinic, a patient having her own minor problems started asking for some help for a neighbor of hers that couldn’t leave the house. The doctor appropriately responded that there was nothing he could do without establishing a chart there, but [gesturing to me] offered that I could go and do the history and physical exam, report back to him and from there see how to proceed further. I was happy I had an opportunity to clear 2 maybe 3 things (SOAP notes included) off my semester’s “to-do” list in one shot on the first day.

When I got to the patient’s house, I was surprised to find a relatively young woman. I had it in my head from the beginning I’d be getting a little old lady; instead, here was this 37-year-old woman with her feet up on a foam wedge and her left leg in a compression stocking. I suspected peripheral vascular problems immediately, but I had no idea why or how. I was still reeling from the fact that the woman was not all that much older than I am.

I explained that I was there to do a history, a basic physical exam, and most of all act as liaison between her and the clinic until she can make it in. She had a pending appt with a doc at the hospital the next day, but she needed consistent outpatient management, which is what I was trying to help facilitate.

Proceeding with the history, she said her chief complaint was “pain from her thrombophlebitis.” I swallowed hard. I knew what thrombophlebitis was, but I was surprised that she put it in those terms. [read: she was well versed in her illness, something you don't find a lot here, and the implications of the disease] She said she was in the hospital for a few days and they sent her home a day or two ago. She showed me contrast CT angiogram films they took from her legs, along with what looked like a computer image reconstruction of her leg vasculature, clearly showing several points of stenosis in her left thigh and popliteal area. Still reeling from information overload having expected grandma’s easy 1-2-3 history/physical, she starts recounting something about a clot last year in her groin and [greater] saphenous vein the time before this last time she was hospitalized…

I started having a mild panic attack. I felt like a complete fraud, alone and exposed. Mind you–I explained I wasn’t there here to treat her, but it didn’t matter: she looked to me for help. I was in way over my head, like I couldn’t even see the surface of the water much less try to reach up to gasp for air. All I could think about was how clueless I must have seemed trying to take everything in during this exhaustive and complex history, trying to keep track of everything and their implications, like a baboon trying to make sense of differential equations. While I do know some clinical aspects of her problems, I obviously have no experience to place a clinical context to that limited knowledge, much less help the patient. I didn’t know if she was a pulmonary embolism waiting to happen or a well-managed patient who was just overly worried, who got the neighbor worried, who got me there, etc.

To add insult to injury to this poor lady, she had a son born with cerebral palsy, and much of her quality of life is suffering because of extreme stress having to care for him while sick herself. Her husband works and provides money but is emotionally abusive to her because 1) he can’t bear having a disabled son so he takes it out on her verbally and emotionally, and 2) since she is sick and can’t do as much housework, he constantly calls her “lazy” and “good for nothing,” since all this “is in [your] head.” Oh yeah, and while I’m wondering if there are dormant clots waiting to be dislodged, she referred chest pain, deep and intense with radiation to the left side, with numbness in her arms and fingers. Great–I think at this point I started having chest pain of my own…

I had to field innumerable questions about her problems, her CP child, her depression–you name it. I had to balance my desire to help with what I could answer with what I SHOULD be answering, all with some semblance of time management because she could have had me there all day. I continued the history, got vitals, did a basic physical exam, talked a bit more and then as I was getting ready to leave, she said, “How much do I owe you?” Stunned, I said, “No, you don’t owe me anything; this is part of my responsibilities at the clinic,” to which she replied, “But you came all the way out here, I need to give you something.” I reassured her and she kept thanking me over and over. Maybe I wasn’t so obviously clueless after all. Honestly, I think no one has ever talked to her that long about her problems, and if so, certainly not in the relaxed atmosphere of her home. As a patient myself, there’s something different about a doctor’s office, a sense of urgency and business that gets erased when visiting at a home–the patient’s home–that allows more peace of mind. I got a glimpse of the time-honored “house call” of days past (unless you are in the growing concierge medicine business, in which case, that’s part of your job).

Remember, all this was for an assignment, and under normal circumstances, all the writeups wouldn’t be rushed since they’re spaced out over the semester; however, the patient was wanting to come into the clinic ASAP, so I was also freaking out about having to get this done to start the chart. Frantic, I stopped by the clinic on my way home to talk the attending. He reassured me to take my time, get it all written up well and that if they come in, he’ll get the basic data and add my information after-the-fact. He assured me that my helplessness was normal and that I WAS helping the patient just by being there, acting as an advocate on her behalf since she didn’t have a PCP or a “home base” to coordinate everything. He was so interested in the case, that he said if she didn’t come in before next week when I am there next, that we’d both go together to her house for a follow up.

I was full of conflicted feelings: helplessness, a desire to help yet not overstep my bounds, to reassure yet not give false hope, and feeling upset to have to hurry up and get this done at the expense of immediate exams/assignments when I should have weeks to do it because the patient needs it. I know that in the future, many sacrifices will have to be made of my time and energy to do what’s right for a patient, but I didn’t expect to feel the beginnings of these things this early, even in my own little way given my limited experience and responsibility. Perhaps that’s part of the greater plan, having us do more and more every semester. All I know is that more than ever, in spite of all the conflicting feelings, this is definitely what I want to be doing.