“Primary care providers” are the thousands of family docs, internists, nurse practitioners, physician assistants and pediatricians who provide basic health care to you and about 200 million other Americans. We know more about you than most of us want to, but like most of you anyway.
So much is expected of America’s primary care providers (take care of us all, don’t miss anything bad going on with us, keep us all healthy despite ourselves, bring about world peace, etc.) I thought it would be illuminating for all of you to spend some time in my shoes with my stethoscope in your ears. So this is the first of an occasional series of columns about taking care of patients in my office. In each case, the patients are fictional, but the experiences are not. I hope you find the series illuminating about the primary care foundation of America’s health system and about how bizarre it sometimes is to be me.
So here’s a typical visit, with what I think in italics.
OK, Mrs. Jones next — uh, oh, she’s here for dizziness. I hate that problem — it could be caused by any one of about a hundred things; could be something simple or something that could ruin her life like a stroke.
I greet Mrs. Jones, and we chat about how her summer is going and my children. Observations about her register automatically as we talk: She had her hair done recently, she has a cane (that’s new for her), not a lot of energy in her voice, etc.
After complimenting her on the new hairdo (good thing I have been trained by a house full of women!), I ask her perhaps 30 questions about the dizziness, matching questions and answers up with algorithms in my head for the 50-plus causes of dizziness. When she has it, does it feel like she is moving or does it feel like the room is moving? Did this start after I put you on that new blood pressure med? Etcetera, etcetera. I take notes as we talk, trying to look at her while I type on the computer.
I watch as she climbs up on the exam table, assessing her balance, the precision of her movements, her strength, looking for clues. I do a rapid neurological assessment, check her eye movements, check her heart and pulses, then have her rapidly turn her head to different positions.
All the while I compare the information I get from the questions with the information I get from the physical exam, trying to figure out if this is a heart problem, a balance problem, an ear problem, a brain problem or an emotional problem. But none of this helps — I have no clue what’s causing her dizziness. This is why I hate dizziness — 15 minutes of questions and exam and I got zip. What could I be missing that might kill her; how do I figure this out without spending a million dollars in tests? The next patient is waiting.
Then I remember Question 31 and ask her to hyperventilate. When she does she gets dizzy, and bingo! She remembers then how this problem has come on each year around the anniversary of her husband’s death. As the light of day fades, the loneliness closes in and she remembers how he always came home from work so she was not alone in the dark emptiness of this big house with its strange sounds. And it makes her miss him and fear being alone, so she breaths fast and her heart pounds and she gets dizzy and anxious until she goes to bed and sleep comes because fatigue eventually beats fear.
I want to die before my wife does.
I put my stethoscope away, and we sit like old friends to discuss what might help her get through the evening without dizziness and without some new pills. We agree it’s not crazy for her to talk to him in the evenings as though he is still there, that she should call friends and keep busy at night, and see me again in a month in case I’m wrong about what’s causing her dizziness.
I’m running behind.
Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.