Category Archives: home visit

If you don’t have what you want…

–Joseph Gibes

Dr. Gibes periodically does home visits to Amish patients in Wisconsin.  He tells a story about performing a circumcision on an infant.  You can see him read this on <YOU TUBE>

I gently lifted the little patient from the bassinet and laid him on the board, molded to cradle a newborn baby, and secured his legs with the Velcro straps. He struggled and fussed for a few seconds, but then settled back down, oblivious to his fate. I put on the gloves and started the procedure. Elim [his father] gently held a pacifier with a little sugar water on its tip in his son’s mouth, which was enough to keep him quiet. I tried to keep up a little conversation with the farmer as I worked.

“Cold, isn’t it?”

“Yes,” he replied. “I think it gets even colder here than it did in Pennsylvania.”

“What kind of stove is that you have?”

“Kerosene.”

While we spoke I worked quickly. Two clamps on. Probe to reduce adhesions. Third clamp on, to mark the extent of the foreskin to be removed. Then apply the Mogen clamp and close it. The patient remained stoically quiet through the whole thing. The procedure was all over except for the actual cutting. I reached to the sterile field for the scalpel. I couldn’t see it in the dim light. I pushed the instruments around, looked under the gauze: no scalpel. Trying to sound calm, I asked Elim, “Is there anything else in the kit?”

The farmer obliged by reaching in and feeling around. “Nope,” he said.

It suddenly seemed to be getting warmer in the little room, and I started to sweat. The nurse and I had checked and double-checked, and I had checked again, to be sure that everything was there, and we had missed the most important instrument.

The scalpel.

It was a twenty-five minute drive from the clinic and hospital. A little apologetically, I asked the farmer, “Do you have any kind of knife I could borrow?”

If he thought this a strange request, his face did not betray it. He stepped out of the room and said something in their own language to Rebekah [his wife]. A moment later he returned, bearing in his hand the instrument his wife had found, an eight-inch steak knife. “Will this do?”

Given the situation, I wasn’t sure I was going to get anything better. Fortunately, this part of the procedure required neither a sterile instrument nor finesse. “Sure,” I said, trying to sound nonchalant, trying to sound as if doing a circumcision with an eight-inch steak knife was a routine occurrence.

The knife was quite dull, and I had to saw at it a bit to get the job done. The patient lay there placidly, Elim looked on placidly, and I tried to look placid. I left the clamp on for another minute and a half to minimize any bleeding. When I removed the clamp, there he was, as good as if I had used the finest sterile precision surgical instrument in the world…

Once outside, I started to berate myself in earnest. I can’t BELIEVE I was so stupid to forget a scalpel! They must think I’m an idiot! Nevertheless, I attempted to keep up an air of nonchalance as I walked to my car. I opened the door and collapsed into the seat. The mental strain of maintaining a matter-of-fact exterior and trying not to appear completely inept had exhausted me.

I sat and stared out the window for a moment, and as I did, in the midst of my self-reproach, a phrase suddenly popped into my head, a phrase I had heard from a missionary doctor while I was a resident working in a bush hospital in Kenya: “If you don’t have what you want, you gotta want what you have.”

Well, that certainly was true in this situation. And as I stopped berating myself long enough to realize what had just happened, I started to smile. I couldn’t help it, as I thought about it: the absurdity of the situation, the complete stupidity in forgetting the scalpel, me sawing away with a kitchen utensil; and the farmer and his wife so gracious and thankful. The smile became a good belly laugh, and I laughed and laughed until tears rolled down my cheeks.

I was still laughing as I drove down the long driveway. Only in rural practice! I thought how I was going to tell everyone back in my own world about the day’s events: “Y’ know, I’m probably the only doctor in the world to perform a circumcision with an eight-inch steak knife. . . .”

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

Medicine demands we think outside the box and find creative solutions. Iit may be very concrete—identifying physical substitutions or it may be more abstract, making emotional or metal links. To secure the scalpel, Dr. Gibes had a 25 minute drive. He deemed that to be impossible. He made do. He reflects that that is often true in international settings. It can be rewarding to see how folks in low resource countries make do with what they have. Listening to fetal heart tones with a cone constructed from cardboard, feeding infants from a cup or by dipping one’s finger in the milk and then dripping it into the infant’s mouth, washing and drying gloves as the way to deal with limited supplies. Such expansion of your normal experience is often humbling  and  gratifying. You realize what you take for granted in our life and you can pat yourself on the back for your problem solving. And sometimes it results in a good belly laugh.

Helping patients change to healthier behaviors often demands creative mental and emotional gymnastics. Instead of lecturing a patient about what they should do, it often works better to help them explore the pros and cons to making a change. If we use motivational interviewing techniques we ask questions that help patients see the ambiguity in their thinking—what benefits do you get from your cigarettes? What else in your life provides that benefit? Which cigarette is the least meaningful to you during your day?

Do you like walking, what do you like about walking? How could you manage to do a little more? Such questioning demands that the provider follow the patient’s lead and explore the same old thing in a new way. That way we might bring obstacles and resistance into the sunlight as well as assets. Uncovering new angles or feelings might facilitate and empower the patient to try again to change. It may be more time efficient to give a lecture, but we already know that our lectures rarely change a patient’s behavior.

Think about a situation where you saw one of your preceptors bring creative thinking to patient care or when you did so yourself. What did you learn? Was there an “ah-ha” moment for the patient?

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Home Visit

As a medical student in North Carolina, Dr. Fleg did a home visit with his preceptor and received a gift for his heart.

 The Sisters

–Written in Love

by Anthony Fleg

My watch said it was time to go,

But my heart spoke otherwise,

Fortunately, I listened to the latter

And went with Dr. Stuart to see

The Sisters

Miss Minnie and Miss Viola

Hailing from Georgia,

With ten scores of wisdom between them,

They spoke first, without words

Perfuming the room as we entered.

They began to tell of their aches and pains,

Joking about whether Dr. Stuart or I would be their “catch” for the day

When asked about the key to their longevity,

Viola answered, “God has been good to us,”

While their relative with them offered, “It is because they were good to their momma.”

Which caused me to pause,

Trying to shut off that medicalized, left-brain-oriented way of hearing that afflicts many of us in medicine,

They spoke not on the recipe for reaching the holy feat of triple digits,

But instead on the way to appreciate each and every day whole-ly,

as something holy,

They teach that the goal is not to reach an old age

But instead is about how to be on your way there

They remind us that the goal is not to avoid death

But to fully embrace life

I am thankful,

I am refreshed,

Dr. Stuart and I leave smiling with our minds and hearts

If someone asks me why I am late

I’ll simply say, “My teachers had something I needed to hear.”

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

Many patients have lots to teach us, especially older patients, who know their bodies and themselves pretty well. One of my favorite elderly patients, a retired farmer, cannot do much on the farm now that he’s reached 90, but he takes great pride in growing tomatoes. He’s given me many pointers and improved my green thumb. Despite the pressure of seeing lots of patients, Dr. Fleg reminds us that we need to take the time to listen and connect with patients on topics beyond their health and diseases. These kinds of connections nourish us and are the rewards that come from taking care of people. If we don’t take time to bask in these, we will get burned out and cynical. What are some of the treasures you’ve heard and witnessed on your rural rotation? What wisdom will you carry with you for a while? Urban patients have many treasures to share as well. Urban or rural, have you seen interactions between your teacher and a patient that remind you of Dr. Fleg’s. Sometimes you are working with teachers who are burned out. What opportunities to interact with patients have they missed?