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Here Comes Trouble
As I prepared to walk into the room, my nurse handed me a chart, saying, "She’s not too happy." She meant Margie, a "frequent flyer" in our office, whom I was seeing for the first time. I knew her by sight, of course, having seen her and her husband in the hallway many times. Many people in our community know them by sight. I walked through the door. Margie, a round woman in her fifties with flame-red hair that today is in two Pippi Longstocking tails, sits in the chair, mouth set in a hard line, refusing to make eye contact. She is unhappy that she is not seeing her regular doctor. Her husband, Albert, however, a slim, dignified-looking man and quite a natty dresser, nods pleasantly and says, "Iiii uhn, owa ooh?" This is to be my first lesson in Albert-ese, a language in which, three years later, I am now fluent. After a moment, my mind translates this to, "Hi, hon, how are you?" and I respond warmly. Albert and I visit, and I gradually pick up the cadence of his speech, affected by both tardive dyskinesia and a lack of dentures—he doesn’t like them. Margie looks on, the sullen look on her face gradually thawing until she is forced to jump in. Albert has just finished telling me that Margie won’t take her medicine because she’s stubborn and won’t listen. "Shoot, I listen to everything," Margie says. "He’s just being ornery!" Margie begins to talk, becoming more animated as minutes pass. She tells me her stomach hurts, that she feels "no damn good," that she wants to have a baby. I review her chart while, referring to me, she chatters to Albert (Daddy), "Looky, Daddy, how pretty she is and she’s wearing my favorite color, too. I bet she’s ornery, just like Dani and Susie [two other nurses in the practice]. Are you ornery?" she demands. "Well..." I cast about for an answer. Margie laughs delightedly. "See, Daddy, she knows she’s ornery—I bet she’s Trouble. You’re Trouble, all right, Pumpkin." Despite my protestations, by the end of the visit I am clearly Trouble, and one of Margie’s new favorite people. Margie likely falls into the category of a person with mild-to-moderate mental retardation. Albert has a mostly unknown history. We assume that antipsychotics caused his speech deficits. They are two of the most un-self-conscious people I have ever met. When they are in the office, everyone knows it. I am to discover that most visits follow this pattern: Margie presents a pitiful countenance, one that gradually brightens as the visit wears on, to the point of absolute radiance by visit’s end. Our interaction is clearly therapeutic. Her typical complaint is abdominal pain or respiratory infection. Fortunately, most times nothing serious is wrong. I say "fortunately," because Margie is a patient who rarely complies with treatment. I don’t classify her as strictly noncompliant, though, because Margie cannot read. Her ability to follow the treatment plan is limited. When I treat her, I make little charts with pills taped to the paper, showing her how many times a day to take them. Sometimes she brings large bags of medicines that she has not finished. We sort through them, keeping the ones she needs—allergy, laxative, blood pressure pill, "nerve" pill. I destroy hundreds of dollars’ worth of medicine. At the end of each visit we have social time, for which I am prepared. Margie waits for me to comment on a new t-shirt, hair bow, or piece of jewelry that Albert bought for their anniversary. They celebrate by the month—I think they’re now up to fifty-six. Albert dotes on her—taking her to dinner, to the casino, dancing. They are very romantic. I give Margie my pen, which she blatantly covets from the moment I enter the room. At the end of the visit Margie will stop to say hello to all of her favorite staff, even if they are in the middle of work. Albert, like all long-suffering husbands, wisely goes to wait in the car. Eventually, after hugs and kisses and loud accusations of orneriness in general, Margie will leave. I’ve also discerned a rhythm to the frequency of her visits, a tempo that keeps pace with the intensity of external life events. When Margie is unhappy about something or is having trouble with her neighbor—a frequent point of conflict—I see her more often. Lately she’s been coming about once a week. Some days my heart sinks when I see her on my schedule. Despite my affection for her, she is frustrating because essentially there is nothing wrong with her. We worry, however, about missing something, so I work her up, within reason. I rely mostly on a careful history of recent life events to tease out what brings her to my exam room.
One of the reasons I can do so little for Margie is that her problems are mainly psychosocial. I can and do provide social support, but she is convinced that something is physically wrong with her. Her symptoms often escalate if we refuse to see her. She also tends to doctor-hop. She has Medicare, which requires no referral, and she has an open Medicaid card so she can go to whomever she pleases. She has seen most of the other providers in town, sometimes the day before she sees me. If we make her wait too long, she might also go to the ER. This is a big part of our frustration. Margie’s overuse of medical care concerns us. She is a poor historian and signs few releases. Consequently, she is overtreated or given duplicated treatments, and each layer of privacy legislation fragments her care a bit more. Once she received two colonoscopies within the same month. With patients like Margie on Medicare and "open" Medicaid, a case management or utilization review mechanism does not seem to be in place, at least not prior to visits or procedures. I suppose payment may sometimes be denied at the other end, but someone ends up paying—usually the provider. This seems to be a real failing of the system. Margie likes to get multiple opinions, and so she does. Other patients do not enjoy this luxury. Her primary care physician and I get frustrated when recalling the hours spent precertifying and preauthorizing traditional insurance patients for a test, visit, or prescription and comparing this with the unbridled and often unnecessary care used by Margie. As we pick up "chart 3 of 3," we say things like, "I can’t believe our tax dollars are paying for this. What a waste." We also fear the "boy who cried wolf" effect—that one day when something is really wrong, she will be ignored by an exasperated provider. So we put her on the schedule, her physician and I taking turns seeing her. Most days we can accept the reason that Margie really comes here: We matter to her. We are the people she thinks of when having photographs made, like the one of her and Albert that hangs on my bulletin board. We listen to her. She pours out her life’s sadness and disappointments in the exam room. For example, Margie is postmenopausal, so I gently explained to her that she wouldn’t be able to have a baby. She cried. How we are also matters to Margie, so she asks about my husband, my girls. We chat. Most days I examine her, reassure her, and send her home. It’s no burden to me personally, but in a health care system weighed down with expense, it’s difficult to see patients accessing medical services merely to experience caring human contact. Where is the gatekeeper who ensures that their use of health care dollars is warranted and wise? Even if patients like Margie were subject to case management services, its main purpose would be to save dollars, not attend to patients’ psychosocial needs. Indeed, this duty falls not to the insurer, but to budget-stretched community services. However, as is often the case in health care, the systems interlock in a cause-and-effect manner. Where is the system to support Margie and Albert, to give them a caring presence in their lives? If a system were in place to ensure adequate social support and to help them deal with day-to-day concerns, perhaps their medical visits would be reduced. I wish in vain for a solution, one that would fix the problem but not leave the patient feeling abandoned. I don’t know what the solution is. For now, costly and impractical as it may be, I am the solution. I lift the two-inch-thick chart from the rack on the door and check the chief complaint. Abdominal pain. I sigh silently, then open the door. "Hey there, Pumpkin! Look, Daddy, here’s old Ornery." I look at Margie’s open face. Albert smiles at me from the corner. I enter the sweet warmth of the room.
Karen Roberts, amazonratz{at}sunflower.com, is a nurse practitioner and writer in Lawrence, Kansas. She works for the Internal Medicine Group. The names in this story have been changed.
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Riding The System
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