I was going to write something really scathing about the Lilly drug rep who brought tons of the best pizza in town by way of explaining to us about the new black box warning on Strattera because of suicidal thoughts in kids, which of course made us feel much more like ignoring the news (although one of the doctors swears by Strattera for all depressed patients, anyway, so he would have given the drug rep’s speech anyway, even without the lunch). But the afternoon was so great, I haven’t got any sharp speeches handy.
I was working with the really sweet Irish Catholic doctor, the one who had a really serious illness, and had to take medical leave, and now feels so empathic with his patients that he schedules half hours for everyone, and spends an hour on each visit, sharing and communicating. (Between the lines, read great person, very slow doctor; but his bedside manner can’t be beat; he’s worth waiting two hours to see.) The third patient of the afternoon was a guy with a cervical vertebrae injury while working in a factory several years before. He’s struggling to get the surgical care he needs, because his employer (a huge national company) has a really stingy compensation bureau (obviously) which keeps leaving him with $100 debts at his surgeons’ offices, so they keep thinking he’s delinquent and refusing to talk to him (to make a long story short).
So my doctor told the following story: After he was forced to take medical leave, he decided to apply for Social Security. About six months after sending in his application, he was told he was denied, and an appeal would require that he see a psychologist, because there was something in his medical file from a psychiatrist (this, because all prospective transplant patients are required to get psychiatric clearance, so they don’t go crazy or get horribly depressed and waste that nice organ). So he saw a psychologist, who obviously didn’t find anything. After several more months of rumination, Social Security told him he was denied again, and he needed some other paperwork if he still wanted the benefits. At that time he was recovering from the transplant, and ready to go back to work part-time. So he sent them a letter explaining that he didn’t their money anymore. Pretty soon he received a letter saying, “We would like to pay you $20,000 in benefits, but we don’t have your social security number.” Not to mention that this is from the agency which created his ss number, and the letterhead addressing him contained his name, address, and number! He wrote them another letter, explaining that he didn’t need the money. Several weeks later he received another letter, saying, “We have already written you the check for $20,000, but do not have your address to mail it to you.” This, of course, with his name and address printed at the top, and mailed to him at that same correct address. Our patient was horribly amused, and could hardly stop laughing all the way out the door.
The doctor and I had a discussion about differentiating real chronic, debilitating back pain, from psychogenic or malingering chronic back pain. He said that when he was young and healthy, before everything fell apart, he used to have trouble believing most people with chronic pain, and he guessed that I felt the same way. What a nice way to tell me to have compassion on people. Well, lo and behold, the next patient I saw was a younger man who had to limp the whole way down the hall to the room, and could hardly sit up off the table. He was new to the practice, and had an awful story about injury at work, and a neurosurgeon who, if the patient is to be believed, seriously messed up his back, even worse than it was before. Not only so, but he had the MRI reports to prove it. And he was really almost jumping off the table (only the second time I have seen that legendary response) every time I touched his back. I went back and told the doctor the guy sounded genuine. It was a good thing I said that, because when we went back together, the doctor got him to pull off his long pants, and his whole leg was atrophic and hypotonic, and he had hyperreflexia all over the place. The doctor assured him repeatedly that there was no way he could be faking that, and prescribed him all the pain medicine he would take (which wasn’t much). We needed to get a second opinion from a neurosurgeon, but the chances of getting that without insurance aren’t too great. However, I did arrange to refer him to a pain specialist (my father) who would do nerve blocks for him without insurance. That felt really good. I can refer my patients to my father. Whoah. And I could promise my father that this pain patient was genuine. This colleague thing is pretty great. (Not sure that my father will appreciate the referral so much, but oh well.) The weird thing about the encounter was the man’s teenage stepdaughter, who was helping him walk, and driving him home. She sat curled up on a chair in the corner, alternately laughing almost hysterically at her stepfather’s sad story, then ducking her head or holding it as if in pain, then playing with some kind of injury on her ankle. I found out she had a headache, and, with the doctor’s permission, twisted the arm of one of the office girls to give me some tylenol for it (she objected to giving medicine without a prescription, because of the legal liability). On their way out, she ran back to get something left behind in the room, and the doctor identified the marks on both of her legs and the back of her hand as burns. He asked her how they happened, and she said she didn’t know. When he asked again, she grinned and ran off. Definitely warrants further investigation! He would have called children’s services already, but she’s old enough to be doing it to herself, too. And she’ll be back with her stepfather probably, so the doctor is planning to ask him next time, and then depending on his answer call the police, or call a psychiatrist.
The other great thing about the afternoon was that the doctor taught me to identify carotid bruits, which I always mistook for simple heart sounds before. And, I diagnosed an aortic stenosis murmur which he had down in the chart as mitral regurgitation, but it wasn’t, it was really aortic. And to get that on such a careful clinician as this doctor is really something. Maybe I do have some clinical skills after all. Didn’t get out of the office till 6:15, but it was the best day ever.