Sensible Medicine

What does our philosophy have to do with RFK Jr and MAHA?

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4 mistakes people make in systematic reviews

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The woman with palpitations.

The man with whom you used to joke and trade barbs who now sits silently, absent, while you talk to his wife.

The woman whose depression dominates every visit; her depression being the one problem she refuses to address.

The man whose joy and charisma makes every visit an absolute pleasure, despite his painful disability about which you can really do nothing.

The man who never complains. Well, not never. The two times he did complain he ended up with emergent bypass surgery and a diagnosis of acute myeloid leukemia.

The woman whose concerns are always uninterpretable. You wonder if the problem is your lack of cultural competence, that her language skills prevent her from articulating her problem, or maybe that her ineloquence keeps her from even knowing what she is experiencing.

The woman who asks how you are doing because she recognizes that caring for her, with her dreadful prognosis, is hard.

The man who, forever unsatisfied with his health, never accepts your advice, dismisses consultants, yet never misses a visit, praises you as the greatest doctor, and brags about you to his friends.

The man whose world is spinning.

The healthy 27 year old who is sure that her tension headaches are from a brain tumor.

The man who berates the front desk staff, makes inappropriate remarks to the medical assistant, and has made racist comments to your nurse, but in the exam room – alone with you -- is the perfect gentleman.

The man who laughs when you pull down his sock to examine his edema and a wad of cash and a dime bag of cocaine fall on the floor.

The 75-year-old daughter who accompanies her 95-year-old mother to visits. You know that the older woman’s death will liberate and devastate the younger woman.

The man who always exaggerates his symptoms because he is terrified by his own mortality and worries that he won’t be taken seriously.

The woman who seemed impossible when you first met her but now brings you joy when the urgent care doctor calls and asks, “How have you taken care of this lady for 15 years?”

The woman who doesn’t seem to like you and never seems to trust your opinion but, after 20 years, refers her daughter to you.

The woman with six years of dyspnea and no diagnosis.

The man you agree to see after he was “fired” by a colleague. His care, and your relationship with him, become an inspiring, and even rewarding challenge. He fires you after a year.

The woman whose relapses, lies, and prescription forgeries angered and exhausted you for a decade now sits in a wheelchair, caregiver by her side, vacant.

The woman who comes to see you for a new patient visit because her husband, your former patient, insisted that she start seeing you after he died.

The man who hanged himself three weeks after he saw you. He had complained of fatigue.

The man who apologizes because he sees it has been difficult for you to give him the news about his recent scan.

The woman with painless jaundice.

The patient who fires you, deservedly, because you made a rookie mistake.

The man who brightens your day when you see him on the schedule but honestly, if you didn’t know him, you would probably move to the next train car if he got on.

The patient you secretly hoped would change doctors and then, when she does, you feel bad that you failed her.

The man who steps off the scale, places a thick wallet, two rings of keys, and a Glock on the exam table before getting back on the scale.

The man who wrote a thank you note that he had his wife mail to you after his death.

The man who fought you until the end, always wanting more treatment, even after every doctor told him we had nothing left to offer.

The woman whose diagnosis you could never make, until you got a pretty good idea of it ten years after she died.

The man who just has a cold.

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This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This podcast is one of three we will be posting to answer the questions that came to us in response to this post. We had a nice set of questions so we will certainly be doing it again.

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I learned a lot from Elizabeth Fama’s multipart series on the back-to-sleep recommendation for infants. She agreed to put the entire series into an audio file. Here you go. JMM

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Ask general internists what they love about their field, and they are likely to talk about long-term relationships with patients and the pleasure of solving clinical puzzles. 

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My lecture to the cancer care staff at a county hospital.

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Even when a decision is clear, and things turn out badly, the lack of a counterfactual allows endless second guessing.

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