by Melissa Walker, DO
“I don’t believe she deliberately became an abuser of narcotics but that somewhere in her life someone did not listen and simply began medicating her hurt.”
There is no typical start to my day. I may rise at 4 a.m. to finish some medical charting or start the day rounding on patients admitted to the hospital overnight. If I can begin my day with a short walk at 6 a.m., I pray while I’m on my journey. I pray for a good and productive day, I pray that I do my best to make a difference in the lives of my patients, and I pray for my friends and loved ones.
Arriving at my office, I’m usually met by one of my medical assistants saying that a patient wants to be seen but has not brought his insurance verification or is assigned to another primary care physician. Regrettably, these patients are turned away. This may seem a strict practice, but I have found that a great many patients in my practice area want to “doctor shop” because of their non-compliance with Medicaid guidelines.
When I was first in practice, I allowed patients to use my telephone to make these changes until it became a great burden to my staff and me. Now patients must make these changes at home and then schedule an appointment.
Inside my office, paperwork clutters my desk and stacks of information from my billing company await review. I turn on my computer and begin shuffling through some of the work. As soon as I’m in a groove I hear, “Doctor, patients are ready.”
In the exam room are a mother with two teenagers and a toddler due for a Texas Health Steps, or THSTEPS, exam. I begin, “Good morning, I’m Dr. Walker and I see you are here for your check-up.” Only the mother and the toddler reply with a hello; the teenagers look angry that they had to get up so early.
I begin with the 15-year-old male who is already seated on the exam table. His responses are muffled. I say, “Oh, I’m sorry. I thought you were 15.” He then smiles and begin to answer my questions in his adult-sounding voice. All is well until I get to the questions pertaining to sexual activity.
I inform the teen that I can gather this information with or without his mother present in the room. He says it doesn’t matter, so the mom stays – I feel she probably would not have left, anyway. The teenager admits to sexual activity and the mother angrily begins to question him about it. He ignores her and continues answering my questions.
He has had three partners since first having sex at age 13. He says he always uses a condom. The mom gasps and I try to encourage her, saying that many teenage boys I see are sexually active and I have diagnosed many of them with sexually transmitted diseases. At least this teen knows to protect himself. None of this matters to her and she tells the teen angrily, “We will continue this conversation later.”
Meanwhile, her teenage daughter sits quietly. I examine the toddler and then, surprisingly, the mother asks her son to take the toddler to the waiting room. She then says, “I’m concerned about her because two weeks ago she sneaked off to meet this man at the park.”
The girl sits quietly, avoiding eye contact. I ask if the mother can leave the two of us alone. To my surprise, she agrees. The 14-year-old hesitantly begins to answer my questions. She admits going to meet a 22-year-old male she had met at church. She says they had talked on the phone briefly and he’d asked her to come to the park. She reports that she did agree to kiss the man, and nothing else happened.
I ask if she thought her actions were wrong. She says yes, but that she believes her parents are too strict. I try to explain that her parents have her best interest at heart and that the man, an adult, was looking to take advantage of her innocence. I pray with her and she cries. She says she will never do anything like that again. I hug her and let her know I am here if she needs to talk about anything.
Later, an 86-year-old patient comes in with the same complaint she has had for 12 months. “Ooh, this arm hurts so bad; I think I had a stroke last night.” She suffered a stroke before becoming my patient and suffers from arthritis and peripheral neuropathy from her history of uncontrolled diabetes. Usually a daughter accompanies her but today it is a daughter I’ve never met.
She is totally unaware of any of her mother’s health history – that when I first started seeing her, she had a hemoglobin A1C of 14 and now it is 6.3. She is unaware that her blood pressure now meets ADA guidelines of less than 130 over 80. Her only concern is whether I doing anything about her mother’s pain.
Sure I am. I’ve evaluated her myself and sent her to pain management and to rheumatology and neurology. None of these specialists told her anything different or offered any other modality that hasn’t been used. The “new” daughter thanks me for my care of her mother and races off to her job.
The next patient is somewhat new to me and very non-compliant with her medications. When I first saw her, she had about 30 medication bottles, many of them duplicates. It took about 40 minutes to decipher what those medicines were, throw away outdated meds, and consolidate the duplicates. Her daughter-in-law had stated that the patient shows signs of dementia and/or depression.
At today’s visit, her son is present. He tells me his mother is not acting like herself and he is very worried. I voice my concern about her noncompliance with her meds. I tell him I have scheduled evaluations by both a neurologist and a psychiatrist. The son, who is medically knowledgeable, assures me that he will accompany her to these visits.
(Later, a report from the neurologist will indicate he can’t find anything wrong with the patient but he would have liked to talk to her son. A week after that, the son will call again to say he is concerned because his mother’s dog has just died. Should he bring her back to the clinic? I tell him it may be a natural grief reaction and let’s just see how she does.)
Next, I see a lady who is literally about to jump out her skin with anxiety – like a drug addict needing a “hit.” She says she suffers from narcolepsy and is treated by a neurologist. She presents a perfectly typed list of meds, many of them narcotics, and requests refills.
I advise her that I can’t refill these meds. She doesn’t understand why and I explain that I was not the physician who gave those meds and I have no verification that these are her present medicines. She reports having been a patient at the VA.
“Why don’t you trust me? I wish people would stop judging me and see me for who I really am. I used to be a top executive, you know, until this narcolepsy took over my life.”
I respond that I am not judging her, but I would like to tell her what many physicians won’t. I explain that her mannerisms, agitation, and desire for narcotics is very concerning. Although I will not refill the meds, I do listen to her and learn she once was an overachiever and an executive who lost her job and developed narcolepsy. I also heard her “heart” and the pain in it. I don’t believe she deliberately became an abuser of narcotics but that somewhere in her life, someone did not listen and simply began medicating her hurt. She continues to see me for osteopathic manipulative therapy and always thanks me for listening.
I often leave my clinic physically, mentally, and emotionally drained. But there are more days when I leave with a feeling of satisfaction that I have made a difference. I am learning that not everyone will receive what I try to give to them, but my solace comes from knowing I have given my best.
Dr. Walker is the owner and operator of Carol Clinic for Family-Centered Healthcare, a family medicine clinic named for her late mother, Mrs. Carol Williams Walker. Her mother suffered a stroke at age 52 and was semi-comatose for more than two years.
