No More Headaches!

My 11:45 patient today was Sue Maddocks, who just turned 40. She is a relatively new patient, who told me she had had daily headaches for twenty years. She was taking 20 Tylenol (acetaminophen/paracetamol) a day, and she still had unrelenting headaches along with some pretty severe neck pain. She had had MRI’s of her head and neck and tried all kinds of medications, but nothing helped.

When I first met Sue, she had problems with anemia and that is what we had to deal with first. Two weeks ago we got down to business with her headaches. It was clear that she suffered from rebound headaches; she would have to stop taking Tylenol in order to get rid of her headaches.

There are several methods described in the literature for getting rid of rebound headaches, some more drastic than others – everything from steroids to hospitalization for frequent injections of dihydroergotamine.

My proposal to Sue two weeks ago was that we give her a simple muscle relaxant, cyclobenzaprine 10 mg, 1-2 tablets every night, and that she take the leap of faith to wean herself off the Tylenol. “It’s not helping you anyway, so what do you have to lose?” I suggested. She was willing to give it a try. I warned her she probably would have worse headaches for a while. We agreed on a two-week follow-up.

It was a busy morning, but I was running on time. I took a deep breath as I entered Room 8 at 11:47, not knowing how things had gone since I saw her last. I thought about how to proceed if she hadn’t been able to cut down on her Tylenol.

I knocked and entered the room. Sue got up, gave me a big grin and shook my hand.

“They’re gone!” she exclaimed. “No headaches for a week – for the first time in twenty years!”

“That’s great”, I replied.

“Yesterday I was driving around, and I turned my head and noticed my neck wasn’t hurting – it was only holding up my head!” She was ecstatic.

“That’s all it’s supposed to do”, I said.

I wrote a refillable prescription for cyclobenzaprine and we talked about how long to take it for, and how to taper and stop it.

By twelve o’clock I was out the door and headed home for lunch – much sooner than I had imagined.

A Day Without a Diagnosis

Thursday I saw 29 patients, but I didn’t make a single diagnosis. I did three physicals and saw several patients with diabetes, hypertension and high cholesterol. A migraineur came in for a shot, and we double booked a few sick people who already knew their diagnosis and what treatment they needed.

One of my physicals was a Registered Nurse, about my age, who left clinical nursing a few years ago and now does research for a group of surgeons at the hospital up the road. Her research focuses on quality of care.

That got me thinking about the differences in health care between my early days in this profession and today. The spectrum of diseases we deal with has changed, and lately also the notion of what constitutes quality in health care.

Physicians today spend more time managing chronic diseases, some of which weren’t even thought of as diseases twenty-five years ago. A cholesterol level we feel obligated to treat today was considered normal back then; Type 2 Diabetes was something our grandmothers developed in their late seventies, not a multisystem disease we looked for in children and young adults; Attention Deficit Disorder wasn’t something primary care physicians concerned themselves with. And who would ever have thought that Fibromyalgia, a term coined in 1976, would be such a common disease, along with Restless Leg Syndrome (Ekbom, 1944), obesity and toenail fungus?

My conversation with my R.N. patient moved toward the issue of what really constitutes quality in medicine. I worry that some things are measured mostly because they are easy to measure: What percentage of heart attack victims is currently taking beta-blockers? What is the average Hemoglobin A1c among a physician’s diabetic patients (as opposed to how is this value trending over time)? I never hear statistics on how often we as doctors make the right or wrong diagnosis, or how difficult it was to move a particular patient from one set of numbers to another.

The practice of medicine has become more a matter of housekeeping, if not downright bookkeeping. The days of brilliant medical mavericks that could ferret out the correct diagnosis and quickly move on to the next heroic act are history; today’s focus is on long-term management according to evidence-based guidelines (“evidence-based”, now there’s another topic for a post…).

There is no point in lamenting the shift over time in what our patients need from us; I am merely reflecting on what has happened during my years in practice. If we as doctors want to see more bad, untreated and undiagnosed diseases, we need to move to more remote places – my underserved corner of Rural America isn’t the place for that anymore.

Managing chronic illnesses can be very meaningful and satisfying, but it isn’t quite what I imagined I would be doing to this extent. But it is one of the reasons we need to hone our skills as physicians; it is no longer enough to be a good diagnostician when almost every patient we see in a given day already has a diagnosis established. Our challenge is to help them manage that diagnosis. That means we need to practice motivational interviewing for our patients with lifestyle-inflicted diseases, serve as our patients’ medical home in a fragmented health care system and be a voice of reason in an era of information overload.

In a brief moment of worry about what I would do if I didn’t get accepted to medical school I had considered teaching, and I worked as a substitute teacher for one semester between my military service and medical school. I don’t think that was a waste of time at all.

Once in a while as a physician, you’ll make a diagnosis. Most of the time you help patients manage a disease they already know they have.

The Good Mother

Brenda Norwood was a single mother, doing her best. Her new boyfriend was not necessarily helping her deal with Sadie, and Sadie was a handful.

Sadie was the most sullen teenager I had ever run into. Her hair was orange, her eye makeup looked like something in a late night movie, and she wore a dog collar around her neck. She seemed to despise her mother.

For a brief while I thought I might be able to reach Sadie, but I was mistaken. Her attitude in general, and mostly toward her mother was so terrible that I did something I had never done before: I asked her to leave the room.

Brenda and I talked for a while alone. I gave her some suggestions about what she could do, counselors she might want to call, even the psychiatric hospital’s outreach telephone number and the youth crisis stabilization hotline.

Sadie was physically healthy, and as I wasn’t able to do much for her or her mother, I saw neither one of them for a while. Then one day I heard from Autumn what was happening with Sadie. I swear, Autumn knows more about what is going on in this community than anyone else, even when it comes to the small minority that she isn’t somehow related to!

Word was, Sadie was pregnant, and the father was Mickey Leblanc, a nineteen year old with a similar background history. We were surprised to hear that they were getting married soon after the pregnancy became public knowledge.

Imagine my surprise when Sadie and Mickey brought their newborn son to see me. I must say I didn’t quite know what to expect. There was Mickey, now working as a painter, wearing his work overalls, calm and completely focused on what his son and young wife were doing; Sadie, a pretty strawberry blonde with earnest, kind eyes and a soothing voice, was completely focused on the most beautiful baby boy, a calm, contented little soul, whose entire being seemed to be one with his mother.

Without missing a nuance of our conversation, Sadie did everything automatically for her baby as if she had done it all her life. She was in charge, and Mickey was in quiet attention, ready with a cloth or a hand when needed.

The other day I saw little Sam for his four-year-old well child visit. As usual, Sadie and Mickey were both there; Mickey in paint splattered overalls as usual.

Sam counted fingers, wrote down numbers, named colors and copied shapes for me. He walked toe-heel along the floor tiles and he hopped on one leg.

“This is the five year old stuff we’re doing at age four,” I pointed out. Sadie and Mickey both beamed.

“Sam is a great kid, you know that,” I said. “And I’ve told you this before: You two are doing a great job with him.” Still vividly remembering Sadie in her dog collar, I added: “He’s smart enough that if he gets bored or sees the adults around him not measuring up, he could turn into a real handful for you.”

They both smiled knowingly.