Role models

Independent practice was a foregone conclusion for me, since all of my personal physicians from childhood practiced solo. My doctor of earliest memory was a kind, elderly general practitioner who worked out of his home. His enclosed porch was his waiting room, and an adjoining room, partitioned by curtains, functioned as his exam area. His daughter worked as his nurse. Although he didn’t deliver me, he did give my mother prenatal care and took care of me while I was an infant and small child. When he retired, he referred me to a local pediatrician. (We didn’t have family physicians back then.)

Dr. Zatz also worked out of his home, using the basement as an office. His wife worked as his nurse. As I had a fairly healthy childhood, my only memories of his office were going for precamp physicals and getting yearly tetanus boosters. I also remember Dr. Zatz making house calls when I was sick. If I fell ill on a Saturday, he, being an orthodox Jew, would walk the mile from his house to my apartment building, bypass the elevator and hike up four flights of stairs, and knock on the door rather than ring the bell. He usually gave me a shot of some kind of antibiotic, which was probably unnecessary but seemed to make me feel better. When I turned 18, he eighty-sixed me to an internist he knew.

Dr. Cohen used his whole house as an office and moved his family somewhere else. Unlike my previous doctors, he did not have a family member working as his nurse/receptionist. But, like my other doctors, he worked alone and gave personal care. I remember once getting the last appointment of the day to see him about some panic attacks I was having. I had almost forgotten about the appointment because I was feeling better and then rushed to get there. I arrived 30 minutes late, fully expecting Dr. Cohen to have left, but he was waiting for me. After an appropriate reprimand about my punctuality, he reassured me that no one had ever died from anxiety and I would be OK. He was right.

Freud’s theory about the influence of early childhood experiences has proven true in my life. I’d been programmed for independent practice since infancy. What about the young docs coming up today? I often wonder who their role models are going to be.

Horses vs. zebras V

If I had a dollar for every time one of my elderly patients told me he or she felt tired, I’d be in a higher tax bracket. My 76-year-old patient Ellen’s chief complaint on her annual physical was fatigue, so I included a thyroid-stimulating hormone test along with her yearly complete blood count and chemistry panel. Everything was normal.

A week later Ellen called to say that she was feeling worse and now had a daily low-grade fever, anorexia, weakness and joint pains. Exhausting my repertoire of tests for these types of complaints, I had her come in for a rheumatoid factor, antinuclear antibodies (ANA) test, erythrocyte sedimentation rate, a Lyme titer, and blood and urine cultures.

Much to my surprise, her sedimentation rate was 90 mm/hr, and her ANA was positive. “Ellen,” I told her, “you have some kind of connective tissue disorder. It’s a little beyond my scope of expertise, so I’m going to call a rheumatologist for a consult.” I started her on some low-dose prednisone, set her up for an abdominal computed tomography (CT) scan to rule out an occult malignancy, and said I’d get back to her.

Jack, the rheumatologist, gave me a curbside over the phone, recommending several tests with exotic names for diseases such as Sjögren’s syndrome and scleroderma. He also recommended an anti-DNA Ab and serum C3 and C4 complement to firm up the diagnosis of lupus, which he said was uncommon in the elderly. In the meantime, Ellen had experienced a syncopal episode while awaiting her CT scan, and a work-up in the emergency department disclosed a platelet count of 35,000/mm³. “She’s improved on IV fluids,” Tom, the ED doc, told me. “Do you still want the CT?”

“Not now,” I said, realizing that Ellen probably had a circulating anti-platelet antibody and the diagnosis of lupus was becoming much more likely. “Give her 60 milligrams of prednisone p.o. and send her home.”

Jack advised continuing the high-dose prednisone until her platelet count rose and discounted the risk of a bleed. “If they’re not already bleeding, we don’t usually worry until their platelets hit 10,000 to 20,000,” he said. He also recommended that I give a divided dose of the prednisone three to four times a day for better coverage.

Over the next several weeks, Ellen got better. First, her joint pains stopped, then her fevers abated, and finally she began to perk up. Her platelet count rose to 65,000/mm³ after two weeks and was up in the normal range the next week, while her sedimentation rate dropped to 5 mm/hr. At her last visit she was upbeat, reporting an improved appetite and a weight gain of seven pounds. As an afterthought she said, “But I have these terrible sores in my mouth, Dr. Brown.”

“Let’s see,” I said, looking at a bad case of thrush. “I think we can start tapering you off prednisone now, Ellen. What good’s an appetite if you can’t eat?”