Small and Personal: Old-World and New-World Common Sense

“I… took a moment to marvel at the idyllic time-warp experience that had been arranged via cell phone and text messages.”

I don’t think she knew how perfectly she had set it up.

She and her husband are both my patients, high-functioning seniors living in their own antique home only a few miles from my office.  I had been there before, when I first enrolled them as patients last year.  He had been struggling with a new swathe of health issues during the 6 months before I met them, hospitalized a few times in that short time frame.  But well into his eighties he still works from home, self-employed for decades, contemplating retirement in the very near future.

Overall, they’re quite independent – I’ll call them Elaine and Robert to protect their privacy.  They don’t like to drive long distances because his limbs aren’t quite as responsive as they once were, and she struggles with her vision, although their very supportive daughter helps get them around when she is available.  Set up with a specialist, physical therapy and occupational therapy, things have stabilized for Robert quite nicely.

But something wasn’t quite right on Monday.  Elaine called me because Robert was dizzy when he awoke that morning.  This isn’t uncommon for him, but it typically clears after just a few minutes and he is able to go about his day.  This time it didn’t clear.  Several minutes had gone by and merely attempting to get up to go to the bathroom made the dizziness much, much worse.  He had laid back down and was staying in bed.  She was hoping I might be able to see him.

I was booked through mid-afternoon, and Robert’s hospitalizations had included situations like mini-strokes and pneumonia, and I didn’t want there to be a delay if God forbid he was having a stroke.  I asked to speak with him.  I’ve only seen them twice, but I’ve been able to sit with them for over an hour each time, plus have spoken to them on the phone a few times, so I have a good sense of his baseline.

He was his pleasant self, conversing easily, speaking clearly.  No fevers, no respiratory symptoms, no gastrointestinal symptoms, no pain, no weakness in any particular part of his body.  Just unsteady if he tried to get up.  Not so bad when lying down.  Back on the phone with Elaine, I got her confirmation that there was no drooping on either side of his face.  Sounded like a non-emergent situation; I could be there in about 4 hours and asked Elaine to encourage clear fluids in the meantime.  She agreed this sounded fine.

I checked in on them again by text once in between patients.  Robert was the same, even a little better.  I ran a little late after my afternoon appointments, but texted again to say I was on my way.

When I arrived, I kid you not, the only difference between the scene I beheld and the photo above was the age and/or gender of the people – and perhaps the mirror-image orientation.  Elaine guided me to a small bedroom where twin beds with sturdy, traditional wooden headboards aligned each side wall and a small desk was placed in the middle where a nightstand might be.  They had moved into this bedroom, Elaine explained, which seemed to be working better for them since it was close to their living space and no stairs were involved.  Robert was tucked cozily under soft, fuzzy blankets in the bed to my left, and his friendly eyes greeted me with brightness that offered reassurance his illness wasn’t too serious.  Elaine had already placed the desk chair oblique to the bed, whereupon when seated a wastebasket could be found immediately below my right hand.

I had managed to arrive to their home with all my equipment except my ear thermometer.  I sheepishly borrowed their own thermometer, placed it beneath Robert’s tongue, situated myself briefly in the chair so carefully set in place for me, and took a moment to marvel at the idyllic time-warp experience that had been arranged via cell phone and text messages.  I feel confident Elaine didn’t know this photograph has adorned the home page of my website since launching it last summer.

Robert’s vital signs and exam were essentially normal.  I prescribed some meds that they could pick up just in case, with a snowstorm brewing for the next day like only New England can deliver in mid-March after 70-degree days in February.  We collected a urine sample that I brought right back to my office for dipstick testing (no infection – texted them to let them know) then sent to the lab for confirmatory processing (next day result: definitely no infection).  Meanwhile after chicken soup and a day in bed for Robert, I learned per follow-up again via text messages yesterday and today that Robert continues to happily drift towards his usual state of health.

Big modern medicine promises so much.  We can test everything with fancy equipment, treat anything with top-of-the-line pharmacology, and fix most things with the latest interventional procedures.  Never mind that sometimes rest and chicken soup are enough… but the only way to safely discern this is with a trained clinical eye.

So if you’re in your eighties, and in the past year you’ve had to go to the hospital to rule out a stroke and get treated for pneumonia, when you are too weak to get out of bed chances are when you call your doctor unsure if you’re seriously ill, EMS will get called to rush you to the nearest hospital.  Then when the testing all comes back normal because you might have a little virus or perhaps a touch of dehydration, you get an eye-roll for taking up precious emergency resources followed by 4- to 5-digit bills 6 months later for everything from the ambulance ride to the unnecessary CT scan.  None of which you asked for.  You just wanted advice from a doctor because… well… you aren’t one.

It’s a mutually beneficial arrangement.  Elaine and Robert help keep my practice afloat with their monthly membership, and I’m able to be there when they need me to provide what they need from a physician: nothing less, and nothing more.

I in no way claim to be better than primary care doctors who are embedded in the broken health care system.  I have simply found a model that permits me to be a physician – employing my conscience and judgment as patients should appropriately expect of professionals with multiple years of post-graduate training – rather than an over-qualified assembly-line worker shackled by unpredictable checklists, metrics, and billing codes, left with no time to accommodate patients for same-day visits, let alone house calls.  Great doctors have to send valued patients to urgent care or the ER.  These docs don’t like it any better than patients do.  We don’t need better docs, we already have them.  What we need is a better way.

Direct Primary Care offers something better.

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