WE ALL ARRIVED TOO LATE

My day begins with a smart watch buzz to my wrist at 6:30 followed by grooming and coffee. French press, Comex, Melita filter, and Keurig, ample choices all. Doctors have prosperity and prosperity enables variety. On patients we follow mental algorithms with variation for circumstance. On ourselves our druthers prevail. My K-cup varieties number six, beans two with a burr grinder that creates sixteen textures. So this morning, teeth run through the Oral B and floss, ample time for some leisure before dressing for the day, I select the Sapphire Blue Melita plastic cone with supermarket brand ecru filter of fitted shape, and just over a coffee measure of Moonrise Blend discounted at my last megamart visit, ground for drip preparation. Boil some water, let it cool a mite, then three aliquots through the pyramidal filter to take advantage of the coefficient of extraction that they once taught me about in college chemistry lab but I long since forgot. One cup of laudable coffee, 10 ounces, about 295 ml now that I’ve mastered thinking metric. Some powdered coffee whitener harvested from three airline flights ago, no sweetener, a shake of Pumpkin Pie Spice purchased last Thanksgiving, all into a cylindrical porcelain mug with the logo of my CPA, while fifteen minutes of what should be Me Time spirals downward to Daily Outline time. It’s my weekly full day patient day, morning and afternoon sessions. I could look at who’s coming but it’s more gratifying to sip customized Moonrise Blend now and let the schedulers surprise me. My month as specialty attending to the fellows commences next month, somebody else does consults on my full outpatient day, put some Swiss cheese into a bagel adorned with Dijon and pickle chips for lunch. Moonrise Blend starts the day well. Then creating a half-Windsor knot with stylish dimple for my tie, getting wet between my front door and my Honda’s front door, and backing out of the driveway assures me that my day had crested at about mid-mug, except for the later task of tending to patients who seem to trust me more than my teenagers do. Coffee and challenging outpatients who have seen three other worthy doctors before me each spark my mind in their own way.

Relocating my ID lanyard from its resting place over my transmission handle to its functional place over my collar, I encounter negligible traffic, no NASCAR wannabes in the lane to my left, a gate to the hospital’s parking garage that recognizes my ID, and an open parking space close enough to the entrance to realize that God really does provide for my most trivial desires.

Early in my fellowship, the chairman chastised me in his condescending way when I told him I needed to attend to clinic. That center did not have clinic, he corrected me. Clinic is for patients that nobody else wants and who resent their copays. We had office sessions, fees justified by our talent and good relations carefully nurtured with referring doctors around our University. That imprint remained. Two office sessions populated by patients spanning the spectrum of human stratification from criminals in manacles to the judges who incarcerated them. Ably assisted by a fellow on her way to medical superstardom, the morning brought its variety of medical challenges with a few diversions from what the textbooks teach us about the conditions we saw. Chronic medications adjusted, imaging ordered, a surgical referral or two, notations on a crib sheet of what to look up for the two patients we will present at our section’s next weekly clinical conference. For the most part a morning that reinforces why doctors like being doctors.

Receiving professional gratification from patient care rarely isolates individual patients as memorable, even transforming. That only happens sporadically and nearly always unexpectedly, though this unique type of encounter would appear with that afternoon’s session. This 40-ish gentleman did not seek me out personally but a friend shared with him the Best Docs issue that the monthly magazine which highlights our city puts out every September. While my name appeared on this list, as it often has, this fellow was reaching the end of his welcome from his usual source of care, but had not yet received the formal notification of dismissal from that practice to add to the three medical evictions he had received over eight previous years. He needed an institution to accept him unquestioningly, which our schedulers are trained to do. Since he has no past with us, aside from two hospitalist run in-patient encounters while under the intermittent care of physicians from elsewhere, assignment of this new outpatient went to the intersection of which physicians had openings for new patients on the day he would find it most convenient to come. That lot fell to me and in my session without the fellow.

This man had the only New Patient appointment that afternoon, forty minutes allotted by our central electronic scheduling process, placed about midway through the session to assure my disposition would have started its afternoon descent before I entered that exam room. Physicians make an assessment medically from a PC screen, then personally with a friendly greeting. He had scanned records which in my own training era would have been delivered by fork lift but the PC allows us to travel light literally while remaining unable to read more than previous diagnoses and some lab work that my specialty training demanded I seek out before walking in to shake hands. He appeared imposing, at 203 cm= 80 inches and 146 kg=322 pounds, by far the largest fellow in an exam room that month. And with a tattooed swastika in a circle external to his thyroid. He presented his medicines in their bottles. I put those on the scale too: 0.93kg. That’s a lot of medicine. On extracting those amber tubes from their plastic grocery bag, they numbered 11 bottles containing 13 chemical substances, as two were combinational pills. More importantly they had 8 different prescribers spanning three institutions, each with different pharmacy programs, and labelled from four different pharmacies and one hospital. He had hypertension, not unusual at age 42, with a decent BP measured by the department’s Medical Assistant. He apparently wished he felt better, in a quest for just the right chemical balance to make his Review of Systems less positive. Something for the mood, prednisone 5mg for joints that ached, hydrocodone from a pain specialist whose building has a banner that drivers can see as they pass the highway exit, testosterone patches to feel more manly, an anxiolytic, a hypnotic, an antiarthritic that needs a prescription, a PPI that doesn’t but Medicaid will cover with the prescription, and some hemorrhoidal cream and docusate to alleviate his opioid’s GI sequelae. He paid attention during our encounter, no doubt aided by that bottle of Adderall among his pharmaceutical collection.

Polypharmacy with a chemical solution to each symptom at its most severe, fragmentation or compartmentalization of care. That’s from a medical framework. But there were more telling interpretations. He had become a consumer of medical care and we the sources of purchase. Not different conceptually from seeking the pleasure of morning coffee by accumulating six varieties of K-cups to have in my possession. But why did he come to me? He saw a couple of alluring ads on TV for diseases he thought he might have including one in my specialty. I do not know if he trusted me more because of the testimonial in the magazine’s Best Docs issue or if he trusted the TV more and the magazine just gave him a source of purchase to seek out. Medical advertising of my training era showing patients as bored ladies who won’t stop calling until they get their Librax or enhancing their double chins with two spoons until they can slim down with Pondimin would be taboo in our journals today, if journal advertising even matters. People still quest symptom relief but we are no longer the ones informing them of the best path ahead.

As legitimate as his complaints appeared and my experience in getting Medicaid to pay for what the TV convinced him he should have, this consultation came far too late. He wants to feel good. I want him to feel good too though in a more enduring way. In another era of medicine, I could have just requested six months to thoughtfully but exclusively manage his medical best self. But like most American physicians, we arrived too late, shaped by social forces that undermine our trained judgment. Consumers seek access at the expense of the mission we wrote about on our medical school applications. I could have been very helpful to this fellow who still has forty more years of actuarial longevity, but the marketplace prevailed. He wanted his symptoms suppressed by a doctor who knew how to get Medicaid to pay. What he needed more was trust and objective insight, not easily restored.