A Day in the Clinic

waiting roomby Danielle Ofri
British Journal Journal of General Practice

8:30 a.m. Doing intakes—interviews with new patients to the clinic. First one is Carola Castaña, a petite thirty-five-year-old Brazilian who immigrated to the United States three months ago. She folds her hands in her lap as I begin to take her history. She understands my questions better if I ask in Spanish rather than English, but her Portuguese replies are Greek to me, so she struggles to answer in English.

Her main complaint is that her joints hurt. Which ones? All of them.

How long? Since age twelve.

Ever see a doctor? Once, as a child. They just told me that I had arthritis and gave me ibuprofen.

No X-rays or blood tests? No.

I start down the long line of questions, but we are stymied by language. I give up and reach for her hands. A principle of internal medicine holds that “It’s all in the history.” An astute clinician should be able to unearth any diagnosis just by asking the right questions. The physical exam is almost an afterthought, a mere confirmation of the already-ascertained diagnosis. But Ms. Castaña silently and unwittingly puts this axiom to shame.

Her history has led me nowhere, but her hands subsume the work of logical reasoning. Her hands are severely ulnar-deviated: the fingers sail off course, angling out to the sides instead of straight forward. They point away from her body as though she is gesturing for the waters to part. The tips crane upward, forming a line of swan necks. The joints that connect her fingers to her hands are swollen like robin’s eggs—bulbous, bony protrusions. This young emissary from Brazil has handed me the hands of rheumatoid arthritis, untreated for twenty-three years. These are hands that I have seen only in textbooks.

I explain what she has.

Is there is a cure? she asks.

Cure? I sigh. No.

But there are lots of treatments, I hasten to add. Lots of treatments—this time I say it with more energy in my voice. I wish I possessed diversity in my Spanish so that I could reword my phrases for extra emphasis and depth. But I have only one way to say each thing. If only I’d spent more time in Mexico.

I arrange for X-rays and labs and I give Ms. Castaña a prescription for hydroxychloroquine. Malaria medicines for arthritis—sounds crazy, but it works. I try to explain that in Spanish. At the last minute I remember to add a G6PD assay to the blood tests. Can’t give hydroxychloroquine until you check the G6PD. Whew, almost missed that one. G6PD deficiency is not that common in the general population, but it can cause hemolytic anemia with certain medications, and hydroxychloroquine is one of them. Good thing that some facts stick around from residency.

I instruct Ms. Castaña not to take the medicine until I call her tomorrow with the G6PD results. I am glad that she has a phone; I don’t take that for granted with my patients. In my head I plan to call the lab today at lunchtime to expedite tests and get the results by this afternoon and then call her before I leave work tonight. Wouldn’t it be great if she could start her twenty-three-year-delayed treatment today instead of tomorrow?

9:00 a.m. 54-year-old Dominican woman. Sore throat, back pain. No, señora, no necesita antibioticos por un virus. Have you tried exercise for your back? Heating pads are helpful.

9:20 a.m. 37-year-old Bangladeshi man. New-onset diabetes, limited English. Will it be pills or insulin? It’s my decision.

9:40 a.m. 41-year-old Mauritanian woman. Dizziness, can’t sleep, neck hurts, back hurts, stomach hurts, chest pain. Hmm . . . underlying depression? Drug use? Domestic violence? Political torture? The diagnostic possibilities are endless.

10:00 a.m. 72-year-old Puerto Rican man. Hypertension, ran out of meds last month. Señor, you can’t ever let your pills run out. Es muy importante. You’ve got to take those pills every single day, not just when you have a headache. Otherwise you could get a stroke or a heart attack. You can always come to the clinic for a refill—you don’t even need an appointment.

10:20 a.m. 63-year-old Ecuadoran woman. Back pain, shoulder pain, foot pain, raising little grandchildren isn’t easy at my age. Señora, I know. Es muy dificil. Is there anyone in the family who can help you? You might try getting shoes without heels. We do have psychologists who speak Spanish. And don’t forget about the mammogram; you’re way overdue.

Rushing through intakes tenses the muscles of my back, especially the spot just below my right scapula. These intakes are supposed to be screening visits—brief and to the point. The details of the history are supposed to wait until the next visit, but the details are everything and they spill out the minute the door closes behind us and we are alone in my small office. I roll my right shoulder backward to unkink the knot.

Next chart is Yang Qing Xing. I call out the name in the waiting room. No one answers to my probably mangled pronunciation. I seek out the Asians in the room and point to the printed name. They all shake their heads. But somehow, a Mr. Yang is produced from the crowd. He is a tall, lanky man with a face wrinkled far beyond forty-one years. He speaks no English but conveys with his hands that there is someone somewhere who can translate. He hands me a crumpled referral sheet and then I watch him limp awkwardly down the hall to find the communicator who can bridge his life to mine.

The referral is from endocrine clinic and the handwriting, thankfully, is decipherable. 41-year-old Chinese male with papillary carcinoma of the thyroid. Thyroid removed and radioactive iodine treatment given last year. Cancer cured. Needs general medical care.

I guess it finally occurred to the endocrinologist that Mr. Yang should have an internist to worry about the rest of him now that his cancer is cured. Mr. Yang is a young man—someone has to check his cholesterol and make sure he’s up to date with his tetanus shots. While I wait for him to locate his interpreter, I check his labs in the computer. His TSH (thyroid-stimulating hormone) level last month was way off: his thyroxine dose needs to be lowered or even discontinued altogether.

Mr. Yang returns with two young Chinese guys sporting baggy jeans, beepers, ice cream cones, and bottled spring water. Turns out that Mr. Yang speaks only Fukienese, though he can understand a bit of Mandarin. One of the young men speaks Fukienese and Cantonese but little English. The other speaks good English and Mandarin, but no Fukienese. Needless to say, each question takes an endless time to traverse the space between us.

I explain that I will be Mr. Yang’s regular doctor, that I will take care of his whole body, not just his thyroid. Mr. Yang conveys that his endocrinologist had told him to stop taking his thyroxine for two weeks (good, the endocrinologist saw that most recent TSH level in the computer). Ever since he stopped taking his pills, though, he’s had trouble with his right leg. It just doesn’t move well. He wants to restart his medicine.

I ask if he’s ever had leg problems before, and he denies any. I ask the question again, not willing to trust just one cycle of translation. One of the young men says that he’s translated for Mr. Yang before, at another clinic appointment, and that Mr. Yang didn’t have a limp then.

“Common things happen commonly,” the saying in medicine goes. Or, “When you hear hooves, think horses, not zebras.” I’m sure there is a simple explanation for his limp. What about an old sports injury? I ask. Or plain old arthritis. Maybe he tripped on the bus. Are his shoes too tight?

Mr. Yang shakes his head as each of my questions is processed for him. No, he insists. It all started two weeks ago when the doctor told me to stop taking my thyroxine pills. Just let me start the medicine again, he says, and I will be okay.

I scour my brain: can leg weakness be some bizarre rebound effect of stopping thyroxine? No, that’s crazy. The half-life of thyroxine is several weeks; his body probably hasn’t even noticed that he’s stopped taking the pills.

Somehow, via the circuitous linguistic orbit, the following line from Mr. Yang emerges: “I feel like Christopher Reeve—my head is fine but I can’t move my body.”

I give up with the questions, realizing that I am not getting anywhere with the history and that time is running quickly. The pile of intake charts is growing and if I don’t get a move on it, I will have to work right through lunch. Again.

I skip right to the physical exam.

Mr. Yang places one foot on the step of the exam table but wavers as he tries to pull himself up. The two young men spring to his side and steady him. Their squat muscular arms guide him up to the table and help him swivel his skinny body around into a sitting position. While I listen to Mr. Yang’s lungs I recall a patient I saw on my very first day as an attending in the clinic. My first day back at Bellevue. She’d been sent over from Employee Health because her blood sugar was 130; the referral said Rule out diabetes. I took a complete history, asking about all aspects of her health. Like every other patient I’d seen that morning, she also complained of back pain. I’d actually palpated her spinal column and even documented in the chart the absence of point tenderness—more than I usually did for back pain. But this was just run-of-the-mill back pain. Try some ibuprofen, I said.

Three days later she was paralyzed. Needed emergency surgery for acute spinal-cord compression—a lymphoma tumor at T7. Surgery, radiation, weeks of rehab. Now she has only a limp, thank God, and manages to walk with a cane.

With her limp in my peripheral vision, I do more than the usual neuro exam on Mr. Yang. Using my rubber hammer I bang not only his knees but also his elbows and ankles. I run through the twelve cranial nerves. I verify sensation of light touch, pain, and vibration—it all seems normal. I even check rectal tone to test the spinal nerves. But when I check flexion and extension of his muscles, his right leg really is weaker than his left.

I can’t decide what to do. Do I send him home and see if it gets better in a few days, like most every other ache and pain that I see in the clinic? Or do I need to do a stat X-ray right now? Is there something that I’m missing in his history? I leave the room to get a quick curbside consult with a colleague in the bowling alley. I tell her my story about the lady with a spinal-cord tumor. She doesn’t think it sounds like the same thing. But if it’ll make you more comfortable, she says, get an X-ray of the spinal column today and then have him come back in two days. See if it’s gotten better or worse.

My stomach nags at me. Am I about to miss something big, or am I making a big deal over nothing? Gotta decide quickly—the clerk has just tossed four more charts in the intake bin. The decision is mine, and mine alone. Two vastly different paths could branch out from my decision: I could reassure Mr. Yang that it’s nothing and send him home, or I could start calling X-ray and CT and orthopedics and cajole stat evaluations from them—thereby falling even further behind in my work—and make Mr. Yang and his two interpreters—who probably have other places to go—spend hours schlepping around the hospital to do all these tests.

My choice will send him marching down one path or the other. A wince in my right shoulder reminds me of that aching muscle. There’s no one hovering above me to whom I can punt the responsibility. There is advice from colleagues, but then I am left with the independence or loneliness—depending on how one looks at it—of my own decision. I can’t afford to guess wrong. If only I could speak directly with Mr. Yang to pick up the subtleties of his descriptions and match his body language to his history.

Or, my colleague adds, you could call neuro to come see him; they usually come reasonably quickly. But don’t bother trying to call endocrine; they won’t call you back until a week from Tuesday.

I call the neurology consult, who says he can swing by in forty-five minutes. I am impressed and thankful. I park the polyglot trio in the room next door and set about catching up on the stack of charts that is now spilling out of the intake bin.

My next patient is an elderly Egyptian woman from Alexandria. She screws up her mouth. “I here since eight thirty! Is it because I am new patient? Because my English is no good?”

No, I promise her. You know how things are in the clinic. I catch her eye and hope she smiles back sympathetically. But we’ll take care of your diabetes, don’t you worry. Her face relaxes a little bit. When’s the last time you’ve had a mammogram, Mrs. Jamila? Never? Well, it’s time.

11:00 a.m. 59-year-old Puerto Rican man with emphysema. Had another attack last week. Señor, necesite dejar de fumar! You can’t smoke if you have emphysema. And you have to get your flu shot every year, por favor. No, the vaccine won’t make you sick, I promise. I get the shot every year and I never get sick. Nunca!

11:15 a.m. 33-year-old white man with schizophrenia. Used to be a computer programmer before he had his first psychotic break. Now he’s in a halfway house and able to take care of the basics in his life on his current medications. Needs a physical exam to get his benefits. Are you in touch with your family at all? No? Is there anyone at all you can turn to?

11:30 a.m. The neuro consult knocks on my door. He has just finished examining Mr. Yang.

“Good call,” he says with admiration. “You just picked up a brain tumor.”

Brain tumor? The pinch under my scapula suddenly ratchets like a drill deep into my back. The consult leads me back to Mr. Yang. He demonstrates the subtle hyperreflexia of the right leg, the pronator drift of his right arm. Mr. Yang’s face is carved with wrinkles, maybe from years of laboring in the sun. I can’t read the expression among the deeply etched corrugations. How much, I wonder, has been translated back to him through the serpentine linguistic channels? Still dazed, I fill out the hospital admission forms, and the neuro guy whisks Mr. Yang off for an emergent CT scan before I can gather my thoughts. I wish I knew how to say “Good luck” in Fukienese. Or “I’m so sorry.”

11:45 a.m. 61-year-old black male. Arthritis in the knees. Exercise the muscles. Take the ibuprofen with food, otherwise your stomach will hurt.

12:00 noon. 32-year-old Dominican woman. Heartburn. Deaf patient. Sign language interpreter is stuck in pediatrics. That’s okay, we’ll just print on paper. Luckily she can read English. Take this pill twice a day, I write in block letters, careful to keep it legible. It will make your stomach feel better.

12:30. All the intakes are done. Finally. Grab my cheese sandwich and start preparing for the afternoon. There’s a third-year medical student coming to my clinic this afternoon. Our topic today is evidence-based medicine. I rifle through my files, hunting for an article that demonstrates those academic principles while still being relevant to clinical practice.

1:00 p.m. Explaining evidence-based medicine to the third-year medical student. She sits stiffly on the chair with her white jacket buttoned up and her Washington Manual of Medicine sliding over the edge of her pocket. She nods mechanically at each thing I say, even when I ask if she has any questions. Did I look this nervous when I was a third-year?

I leaf through the paper on coronary disease with her, pointing out the differences between primary versus secondary prevention of heart attacks and how not to be fooled by the relative risk reductions quoted in the study. You have to go by the absolute risk reduction. She is still nodding mechanically. I pause from my explanations. Have you ever even seen a patient with a heart attack? I ask. She shakes her head no. I flip the paper over and start drawing a simple diagram of the heart with its coronary arteries.  Got to start with the basics.

2:00 p.m. 64-year-old Puerto Rican woman with hypertension who hasn’t had a pelvic exam in decades. Elijida Rivera hates the GYN clinic. I don’t blame her; I spent time in that clinic as a medical student and it reminded me of cattle being herded through a factory. But she will allow the Pap smear in the medicine clinic. I am reminded of the young Navajo woman with acne and I am again honored that a patient would trust me with this most intimate of examinations.

I lug the exam table from the wall to free up the leg rests. It heaves forward in fits and starts, and I feel that spot under my right scapula strain. I jam a tongue depressor in the arm of the lamp so it won’t float up to the ceiling. I lay out my equipment on a clean paper towel spread on top of the industrial garbage pail. I print her information on all three lab forms, and I stamp labels for the specimens. I hold the speculum steady with my left hand while my nondominant right hand is forced to take the samples, spread them on the slide, spray the fixative. My kingdom for a nurse like Karen. But my Spanish is adequate to explain most of what I’m doing. Glad I spent that extra week in Peru working on the imperative.

3:00 p.m. The neuro consult drops by. Not one, but four! Four big goobers in Mr. Yang’s brain, he says. They’ll give steroids and radiation to shrink the swelling. That will improve his symptoms, but the neurosurgeons won’t operate if there are already four intracranial masses. Six months to a year, they say . . .

I close my eyes for a moment and I see Mr. Yang’s wrinkled face with the expression that I can’t read and can’t match with his words. And what did he make of my facial expressions that he couldn’t match with my words? I am suddenly overwhelmed by the fear and loneliness that I imagine he will feel, upstairs in a hospital bed, maybe for weeks, unable to communicate with anyone except when the Fukienese interpreter is available.

4:30 p.m. I check Ms. Castaña’s labs. No G6PD results to be found. I call the lab and they tell me there was no order for one. But I know I checked it off on the requisition slip. No dice, they say, we don’t have a requisition for it. Damn! I don’t want to make Ms. Castaña come back again for another blood draw. Twenty-three years of inappropriate treatment is long enough. I want to show her that we’ll do it right this time. That we’ll take care of her at Bellevue. That she’ll get care as good and as prompt as she would at any private practice.

I wish I could do something for Mr. Yang. Something that could change his prognosis. But he has been whisked away from me. Whisked away on a stretcher by the neuro consult, whisked away by the language barrier that reduces the doctor-patient relationship to its most crassly bare bones, whisked away by his disease that we had assumed was cured. Harrison’s says that papillary cancer of the thyroid—the type that Mr. Yang has—rarely metastasizes; that follicular cancer is the one to worry about. I remember memorizing that one for the boards. Another patient unwittingly disproving the rules. The least I can do is expedite Ms. Castaña’s treatment. I just need that damn G6PD.

Residency was only a few years ago; I still know the back channels. I call Central Accession and track down the sample number. I dial hematology and ask if there is any blood left over from her CBC to send to the special hematology lab for a G6PD. The tech is cranky: “There are a thousand samples; call back in an hour.”

6:00 p.m. Finally home. Got to leave for Spanish class in a half hour. Spanish is my lingua franca in this clinic. I telephone hematology while I stuff Gramática Española Avanzada in my bag. The evening-shift tech is much more pleasant. She’s able to locate the specimen. And there’s enough left over! Just bring over a lab slip, she says kindly, and I’ll pop it right in the machine. But I’m home already, I can’t bring over a lab slip.

Evening clinic. Who’s doing evening clinic tonight? Elaine’s got Tuesday nights. Maybe she can walk the lab slip over to the lab.

I call the clinic and talk to the clerk at the front desk, who puts me on hold. I pour a bowl of raisin bran while I’m waiting, trying to keep my crunch away from the phone. Still on hold, I finish my cereal. Where the heck is she? I wash the bowl, keeping the phone cramped between my ear and my neck. That spot behind my right shoulder is acting up. Still on hold. I’ve got to leave for class, where is she? Finally she returns, informing me that she was finally able to locate the chart in the chart room.

I slap my hand on my forehead, too dumbfounded and annoyed to speak. We don’t need the chart to get a lab slip, I want to scream. How could you waste so much precious time? But it’s not worthwhile to yell at the clerks. It never accomplishes anything and they’ll never do you any favors ever again. Gritting my teeth to modulate my voice, I ask her to please connect me to Dr. Feingold’s office.

6:15 p.m. I give Elaine the patient’s name, the medical record number, the sample number, the name of the tech who approved the add-on test, and which test to order. She fills out the form then transfers me back to the clerk so I can tell the clerk what to do, but there’s no answer. And no answer. And no answer.

Fifteen minutes I keep dialing. No answer. Where is the clerk? Where is anybody? I don’t know the direct number to Elaine’s office and can only phone the front desk. Over and over I call, hunting in my fridge for a snack to bring to the three-hour class. At least there’s a redial button on my phone. I finally dial the page operator and have Elaine paged overhead. No answer. No one ever hears those overhead pages anyway; it’s a total waste of time.

It’s 6:30, and I’ve got to get going. I can’t miss Spanish class—tonight we’re doing the preterit and the imperfect. I need those tenses. I start randomly calling every desk in the clinic, hoping someone will pick up. After ten calls and many pleas, someone has a heart and connects me to Elaine’s office. I am panting with relief.

“Oh,” says Elaine, “the clerk walked the lab slip over to the outpatient lab but it was closed.”

Of course the second-floor outpatient lab was closed, I want to scream. It’s after five p.m. You have to take it to the fourth-floor central lab! I slam a Granny Smith apple in my bag. Doesn’t anyone know the system around here?

Please, Elaine, could you please drop it off on your way out? Would you mind, please? She hesitates. It’s been a long day. “Could I bring it to the lab tomorrow morning on my way in?” she asks.

Nothing personal, but I hate to trust anyone to remember anything. Please, please could you bring it over tonight? It’s only two floors up. And there’s never any wait for the elevators at this time of day.

Mr. Yang is probably sitting all by himself in his hospital bed. The nurse’s evaluation is brief because she can’t explain about the daily routine of the ward or ask him if he has any dietary preferences for his meal tray. The interpreters have probably gone home for the day. All the nurse can do is take his blood pressure and pulse. I want it to be right for Ms. Castaña. I want to be able to call her tomorrow with the results like I’d promised. Just because we’re a city clinic doesn’t mean we can’t give our patients medical care like they get in private practice. I want to live up to my word.

6:45 p.m. Forty-five minutes working on this stupid lab slip. I could’ve gone back to Bellevue myself and walked it over. Elaine finally agrees. I dash off to Spanish class on my bike.

10:30 p.m. Home. Head still swimming with the preterit tense, I call the lab and track down the heme lady. She’s pleasant and helpful. The lab slip was received! Thank you, Elaine, thank you. The tech carried the sample herself to the special hematology section. The G6PD will be done first thing in the morning. Of course I would have liked to have it done tonight, but I’m happy that it will get done at all without making Ms. Castaña come back for another blood draw. Thank you, oh anonymous technician, for getting it done.

I hope.

11:30 p.m. Bed. A few pages of a novel before collapsing under the covers, as the images and people of today swirl in my head, pounding my consciousness. In less than twenty-four hours, my life has swooped into the lives of people of different sizes, shapes, colors, nationalities, and religions. We’re more alike than we are different, but the sheer randomness and devastating consequences of illness terrify me. Why them and not me?

My gastrocnemius and soleus muscles effortlessly allow me to bicycle to my Spanish class, while Mr. Yang limps from his tumor. My joints glide smoothly while Carola Castaña’s chafe bone against bone. I live in a culture in which medicine is so easily obtainable, yet Carola’s arthritis has gone untreated for so many years.

It pains me that there is nothing I can do for Mr. Yang. And that I lack the language skills to offer even the slightest balm of comforting words. Perhaps that is what is driving my obsession with Carola Castaña’s arthritis treatment. It is obvious that a one-day delay, after twenty-three years of inadequate treatment, is meaningless. Yet it has consumed my energy. I have spotted one tiny brick in the chaotic rubble that I can attempt to right.

The harrowing state of humanity can be chilling, and if I meditate too long upon it, the ache under my right shoulder bores its way though to my insides. I grab a heating pad, cram it under my shoulder, and crank it to the highest setting. The heat seeps in slowly and I can feel my brain gradually easing its frenetic grip on awakeness.

Yes, the world is random and cruel. And yes, there is not much an individual can do to alter that.

But maybe re-righting one brick will provide a scrap of order to the chaos, a sliver of support for a future column. Maybe Carola will finally get her medications. Maybe that is cause enough for joy.

Tomorrow: Another day at the clinic.

My eyelids give up fighting and finally sink closed.

(from The British Journal Journal of General Practice, with an introduction by Ian Bamforth)