Friday Afternoon in Family Medicine: Coal to Diamonds

"Some days are diamonds, some days are stones" is a line from a John Denver song, but it could be a line from a family doctor's blog. It would fit better with many of our family medicine experiences if the second part was, "some days are coal".  Obviously, coal under pressure (a lot for a long time) may become a diamond.  Many of our patient and personal life experiences are like that.  It looks and feels like a chunk of coal, but, with tons of stress over time, it could become a diamond, but it's not obvious during the tons of stress.
 

Sometimes one of our patients comes through some incredible stress (people, time and/or money stress) and has an amazing transformation.  If they just happen to be in the office Friday afternoon, it might be a week-defining encounter.  Like someone with horrendous back pain who goes through multiple therapies and medications before allowing us to order the MRI that (if all goes well) shows the bulging disc with nerve root encroachment and effacement of (pressure on) the spinal cord.  They continue the opiates, gabapentin, SSRI (like citalopram) trazadone, NSAID, heat, rest and laughter as prescribed.  OOPS!  They aren't able to rest because they have to work, and they might be in the office every ten days or so in a painful fit of dehumanizing pain.

They finally get the surgery, but they get fired from the job because they've been absent too often.  Their "brokeness" precludes continuing their health insurance through COBRA, so they have to use credit cards and money from relatives to pay for office visits and the medications (including the opiates on which they are now dependent).  They don't get the post op physical therapy, so they stay stuck and miserable.  We are pressed to continue prescribing the meds since they have no other doctor.

We start mentioning suboxone as a medication that might help them.  They start suboxone, immediately stopping the opiates.  The pain is controlled.  The brain returns.  The motivation returns.  They get a job, health insurance, resume PT and feel like a human being again, after 18 to 24 months of struggle, pain, suffering and hell.

I walk into the exam room late Friday afternoon and see this person re-humanized and I stare for a few seconds, reflecting on the intense struggles we had during parts of their misery, debating how best to go after the back problem and clarifying my worries about how the opiates were necessary, but risky over-time.  I remembered more or less begging the patient to find a way to get the physical therapy and move ahead.

Now, though, I am tickled at the person I am seeing who has made a come-back.  I feel satisfied about the struggle and the process of care that meanders along with the realities of the human condition and is sloppy but real.  I have the tears of relief now after two years in a sometimes contentious, often imperfect and always caring patient-physician, human-human relationship.

With only one or two patients remaining on the Friday schedule, I was soon able to reflect on the meaning of  this person's quest.  Together, we made a diamond from their coal.