Tuesday in Family Medicine: Honoring Our Patients and Ourselves

We started the day with a team huddle.  Startled MA said, "what's that?"  I replied, "Meet me in the conference room and we'll plan the day."  She said, "OK, I'll see you in the break room."  I said, "It's the same room, depending on the intention of the individual.  In this case let's think of it as the conference room."  One MA off for family situation, FNP not here yet.  Other MA has to get the front desk with phones and people.  Small huddle today for the first one ever called a huddle.

"Let's look at today's schedule and figure out what's happening.  Do you have any MA patients this morning?"  She looked at the schedule and said, "No, no labs or treatments."  "OK, I don't remember my first patient, is she one of Dr. C's?  This patient at ten is better to see the nurse practitioner to review the lung status before I discuss the brain situation and family stresses.  Add her to the FNP schedule, as well as this little girl and this woman with all these problems. I'll wrap up with her remaining complex problems and a lot of issues about her home-bound husband.  We'll do three visits worth for this woman, since she can't get away from her husband very easily.  We make house calls on him every few months.  Pull his chart when you get hers to take her to a room.  The FNP is light for patients, so we can tag team with those three people.  We'll both see them."

"Hello." I greet our nurse practitioner and quickly summarize what I intended, if it worked with her.  She said, "How are you today?"  I had to shift my thoughts to think of me and remembered that I don't do that until everything is finished for the day.  She's a nurse and a family nurse practitioner, therefore caring about everyone all the time.  An asset for her and our patients.  I guess I should remember to remember me, but I get into other people's frame of reference and value systems all day every day and it paints my aura with their colors.  I want to help them to stay aligned with their life goals and dreams.

Recently, after input from my friend and colleague, a human systems engineer, I'm better understanding how to balance my values, goals and dreams with those of my patients.  I, like many family physicians, had de-valued me which, I'm learning,  doesn't actually serve them as well.

The first patient, an alternative practice believer, rarely comes in and it had been over a year.  The BP part was doing fine on the lisinopril that she finally agreed to after the headaches wouldn't abate with herbal therapy.  "This blood pressure medicine helps me.  I need another prescription."  I point out after examining her that the blood problem and lymph nodes weren't going away. She redirects the conversation, one of her 40 ish children was unemployed and moving back home with spouse, two children and one dog.  The patient, also, was between money making part time jobs.  We discuss her job market briefly before I note that the blood problem seems more medical to me than alternative.  We discuss boundaries between natural, supernatural, medical and alternative therapies.  She decides that the blood problem is still natural and alternative for therapeutic need.  She relates to God (the supernatural therapist) in her own way. 

She has two alternative practitioners, an herbalist and an energy practitioner, neither of whom promises her anything about the blood problem.  They speak to her of health and functional enhancement.  I agree that health maintenance is important and  she's wise to pursue it in a way that is consistent with her personal beliefs.  I present my position about what might constitute a medical urgency in light of her blood problem (weight loss, night sweats, persistent infection, etc.)  She nods and states a willingness to return if those things are happening.  I again edify the hematologist that she refused to see 18 months ago, just in case she ever has a need.  She smiles.

I am comfortable with our boundary discussion.  She is free to make decisions that may lead to her premature demise (the negative part of my physician-self thinks this) and I am obligated to inform her of "medical options".  She makes decisions, I give her medical information.  We respect each other and honor each other with listening.  I feel comfortable in my heart about her.  That is what I might call "evidence based" decision making.

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