Welcome to Elma

–Mitchell L. Cohen

Dr. Cohen, who practiced family medicine for five years in rural Washington, describes a typical day’s roster of patients to the third year medical student spending the month with him:

First on the schedule is a forty year old log truck driver coming in to get his physical for his license. I never knew how many log truck drivers were in this county until I started working here. Here’s a thirty two year old female with chest pain that’s probably either her asthma, anxiety, or both. She smokes way too much tobacco and marijuana. Then there’s a depressed patient with fairly newly diagnosed diabetes, high blood pressure, and elevated cholesterol. It’s so frustrating. He just doesn’t seem to care, but I know a lot of this is the depression. The next guy you’ve got to meet. He is eighty nine and coming in to talk about his gout. He’s a retired veterinarian and tells some pretty amazing stories. Just ask him about serving in Italy in World War II. A tough case of ADHD in a kid in foster care is next. We’ll do a skin biopsy on the next guy. His dad is one of my patients in the nursing home. Really sad; rapidly advancing dementia.  He’s having a tough time watching his father go through so much. 

Then it’s lunch time. Do you like Mexican food? Good. For lunch we’ll walk on over to this great Mexican place on the next block. The owners and most of the employees come here for their medical care too. I highly recommend the spinach enchilada.

In the afternoon we’ll start with a pregnant patient of mine. I delivered her last baby. I also take care of her parents and grandparents. We have quite a few third and fourth generation families in the practice. My partner holds the record for a five generation family, but then the great-great grandparent died and it went back to four generations. This guy here always comes in to get his ear wax cleaned out. Ahh, fascinating stuff there! Here’s a guy in his mid-forties with low back pain and, and, oh by the way, he’s seventy pounds overweight, smokes, and uses walking to his mailbox as his form of exercise. These visits are painful for both of us. Anyway, dispersed among all of those there are a few well child visits, other pregnancy appointments, some of these might be Spanish speakers. How’s your Spanish? I spent two years of my CME time learning Spanish. I am passable, unless it gets complicated, then I use a phone translator—but as you’ll learn, the visit fee hardly pays the cost. Then of course, more high blood pressure and diabetes, and the rest we’ll figure out when we take a look on the other side of the door.  Looks like about twenty-two patients total—pretty typical day.

Remember, you’re here to learn about rural medicine. Get to know the patients. Let them tell you about their families and what they do for a living. You’ll see that so much of what they tell you relates to their medical illnesses in ways that you haven’t ever considered. This is one of the intangible benefits of family medicine and it is best brought out in rural areas. It doesn’t appear in any proficiency scores or quality measures, but the continuity of care we provide for generations of families allows us to tailor modern medicine to fit their needs. This is the art of medicine. 

(Excerpted and used with permission, published in The Country Doctor Revisited, KSU, 2010)

Today we talk about the value of evidence-based medicine, knowing the best practice for your patient’s disease and situation. Research and science have their place in caring, but so does the art. Dr. Cohen describes the art as letting the patients tell you about their families, what they do for a living and about their lives and then comes the art—you adjust the science to make it work for them and their unique situations.  I am thinking of one of my new diabetic patients. If I want to get quality credit for my diabetes management I need to have the BP well controlled, the Hemoglobin A1C under 8, the LDL under 100, and the patient needs to take an ACE/ARB (like lisinopril) and aspirin. If I addressed all that with him during our first visit he would have been drinking out of a fire-hose—not fun for anyone. So little by little we examine the various issues and negotiate what he can and cannot do.

What has surprised you about the patients you have encountered on your rotation? Where have art and science intersected? How has your teacher/preceptor’s knowledge of the patient over a number of years informed the diagnosis and treatment?

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