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Twenty Years

Medicine is a funny business.

I did my residency in Tennessee during the time of TennCare, the managed care approach to medicaid that allowed Al Gore to brag that everyone in TN had health insurance. The problem is that it reimbursed so poorly that while everyone had insurance, not every doctor accepted it. We often referred patients to Arkansas, or more often Mississippi, to see specialists when there was no one in west Tennessee who would accept medicaid patients.

It meant that we saw a lot of really underserved patients. Patients who couldn't or wouldn't afford the lifestyle changes we recommended. Patients who gamed the system. Even more patients who were abused, forgotten or mistreated by the system. I think of them as the circumstantially sick patients. These are people who probably wouldn't be as ill or in as dire straits in regards to their health were it not for our broken health care system. Were it not for their circumstances, they'd likely be as healthy as you and I are. Not that we're all terribly healthy, mind you. But it would be less about money and access and more about lifestyle choices.

Despite all of this, in residency, we laughed. A lot. At things that would make you cringe. In my three years in west Tennessee, I met people who I still believe are some of the funniest I've known.

As first years, otherwise known as interns, we started to build a panel of patients who would remain our patients through our three years. These were usually patients who were new to the practice or who had been seeing last year's senior residents who were now graduated and gone. Some of those seniors assigned specific patients to interns, hoping that there would be a good rapport and personality match, and some patients were just left to be assigned to whoever happened to be on call when those patients came to the clinic or were admitted to the hospital. Because we cared for so many circumstantially ill people, the chances were great that they would be admitted to the hospital. Every day an intern is on his inpatient hospital rotation or every night she is on call, she has a chance to become the primary provider for these difficult patients for the next 3 years. We called it the heinous lottery.

You have to understand that we were young and shiny. We wanted to save the world. We had our crisp white coats, pressed green scrubs and our free stethoscopes and we were going to do it. We were going to teach people about their health and they were going to take medications as we had instructed them without skipping doses, they would eat well, exercise, stop smoking and take baths. By the end of the first year, our goals were less lofty: patients would take at least a few of the medications we gave them and they'd take a bath from time to time.

The perfect illustration of the difficult patient (and her family) was B. She was a heavy woman with a history of heart disease. She had heart failure (a condition where the heart cannot keep up with the metabolic needs of the body, often marked by retention of fluid--swelling in the legs, fluid in the lungs causing shortness of breath and cough). Her heart failure would normally be well controlled with the medications we gave her to improve her heart function. She lived with her son, who did not work, and they survived financially on disability and social security checks.

At fairly regular intervals, B would find herself in the ER. She would be short of breath, her legs would be swollen and she would be in florid heart failure. Her son would bring her to the ER and sit with her in the room and order her a meal and then proceed to ask if they could bring him a plate. And he'd be searching for the remote for the TV. This was the way that it worked: they ran out of money toward the end of the month: he'd stop her medication, she'd get admitted, they'd eat and watch cable (albeit the crappy hospital cable), she'd improve, and they'd head home. We'd see them again in another month or two. Lather, rinse, repeat. Maybe that's not the best metaphor.

In one of her rare appearances at the clinic for her hospital follow up (an appointment they usually missed), the resident who had inherited her via the heinous lottery had noticed a strange rash on the back of her neck. Given that we were in a teaching situation, the resident saw a chance to teach. He grabbed a medical student and said, "want to learn how to biopsy a strange looking rash?"

After getting her permission to biopsy the unusual rash, the resident proceeded to choose his biopsy site and clean it with an alcohol wipe to prepare it. One swipe with the alcohol wipe turned the wipe a very dark brown. The next wipe came back just as dirty. The rash suddenly started to look less and less pronounced.

At this point, the resident said, "I believe that this is dirt." But by hat time, he had committed to the process: he had students to teach, after all, and he just plowed on with the biopsy of the now just red skin. A week later, the biopsy results returned: "reactive dermatitis" (which basically just means inflammation) and "dirt." That's right, our resident had done a biopsy of dirt.

I still laugh at that entire situation. Not at B's poverty of care or hygiene, not at her heartbreaking situation (literally), and not at the dysfunction of her son. I don't laugh at the way the system has created her and her son to be a slave of "free" hospital meals and cable paid for by Medicaid. I laugh at the mere joy we all shared at reading that biopsy results that simply read "Dirt."

B. was such a perfect example of all the things that are right and wrong with medicine: we were able to resolve her heart failure and she would have been fairly well controlled, should she only have taken her medication consistently. When she was in trouble, she was able to come to the ER and get care and couldn't be turned away. But she was also able to go home and live in such squalor and poor self care that she became dirtier than any of us could recognize. She and her son were generally appreciative of their care, but incredibly difficult to convince that ultimately, her care was their responsibility, not ours.

Medicine is a demanding lover. It changes, it demands excellence, it demands growth. It rewards lavishly and punishes harshly. It builds up and breaks down, it can press you to incredible joy and near insanity. It can show you such cruelty and sadness, followed by such tenderness and love. It is the most fearful, wonderful, terrible, brilliant and awesome mountain I have ever chosen to try and climb.

For every demanding and entitled patient yelling at the operator because the pharmacy made a mistake on a prescription, there is a grateful one thanking that same operator for taking his call and making his appointment. One grateful patient makes 10 angry and entitled ones tolerable. One healthy pregnancy resulting in one healthy baby delivered makes so many frustrating patients seem less important. One day of laughter over a dirt biopsy makes another night of listening to B's son ask for a dinner plate and the TV remote while in the ER less frustrating.


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