Thursday, November 11, 2010
The big picture
Her eyes were bloodshot. She responded to my casual greeting of "How are you?" with a sigh. "How am I? I'm alive; I can tell you that much for sure."
She went on to describe a situation with her adult son who is in a bad marriage and has struggled with addiction. She sighed again, "I feel weak. I don't know if I can deal with this one. I've had so many hard things in my life already. When will it stop?"
Many hard things. Yes, I agree with that assessment. She's been my patient for more than a decade, and I've had a front row seat to her life. Her husband died a few years ago (while in his 40s) of a longstanding chronic disease. Her daughter also has this disease, and has been slowly declining over time. I've watched her bear that burden, and have actually shared some in that load, being the doctor for the whole family.
I've also taken care of her parents, who had their own psychological problems. They were difficult patients for me to manage, and they had died long enough ago that I had forgotten that difficult chapter of her life.
I've helped her with her emotional struggle from all of this. It was hard, but she hung on as best as she could. I know. I was there when it was happening.
To me, this is the biggest benefit of primary care. Yes, it's nice to have a doctor who knows what's going on with all of your other doctors. It's good to have a doctor you are comfortable talking with about anything. It's good to have someone without a financial stake in doing surgery, performing procedures, or ordering tests. But the unique benefit a long-term relationship with a primary care physician is the amazing big-picture view they have.
I had a man come into my office with his daughter, who was struggling with emotional problems. We discussed the situation for a while, and the subject of extended family came up. When he reminded me who the girl's grandparents were, I laughed out loud. They saw my moment of insight as to how the grandparents might be influencing this problem, and they both started laughing with me. Nobody had to explain anything. Nobody even said anything about the grandparents. He just reminded me who they were, and I already knew more than enough.
I have now been practicing for more than 15 years, and have a longstanding relationship with a lot of people. When they come in to see me, it isn't just for my expertise, knowledge, or to listen to my jokes; they come for my perspective. They come because they know that I know them like no one else. I have spent years gathering information for this visit. I saw them when they were depressed. I took care of their dying child. I broke the news of their spouse's cancer. My care for them is not just an office visit, it is a legacy.
When she stopped explaining her present situation to me, she let out another sigh, deeper than the rest. "Can you help me?" she asked.
"Sure, I can help you," I responded. "But let me reassure you that you are not weak. I've seen you weather the storms in your life and have been impressed by your strength. Sometimes when you are being crushed by a weight, it isn't that you are weak, it's that the weight is too heavy. I've seen you carry heavier weights than most people could carry. I'll do what I can to help you, but don't get discouraged with yourself. You aren't weak."
She paused in thought--thinking about all I have seen of her life and my qualification to make this pronouncement. She sighed, then nodded.
She knew that I knew.
As always, I have changed details about both of these situations to protect the identity of these patients.
This post appeared at Musings of a Distractible Mind. Rob Lamberts, ACP Member, writes the blog and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes. He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.
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