John is probably squirming over the "unsung heroes" part, but he is one to me, so I though I'd call it out.
Gordon
Here's his story:
Just a little today example of why this sort of practice is worth it to me, and why I hope it can survive.
80+ y/o lady comes in with her nurse daughter. Has been declining cognitively and physically for years. On presentation, obviously has dementia, bad edema. Still lives alone, needing more assistance from family, but denies she has much of a problem. Has only been seeing her gyn, who tried to send her 1.5 hrs away for neuropsych testing, but pt would have none of it.
If I was still in a fast-paced practice: I would have been frustrated by the slow history-taking. Would have managed a rushed MMSE (mini mental status exam). Would have given her Aricept that she would not have taken. Would have tried to send her to a consultant to confirm her diagnosis, and she would not have gone. Daughter would have been quite frustrated at not getting enough answers. Appropriate care would have been delayed, and the patient may not have been safe.
Today, I was able to spend nearly 2 hours with this patient. We didn't get to everything, but we became comfortable and respectful together. We completed a full MMSE, a fascinating clock-drawing test, and a vascular dementia score, and basically confirmed the diagnosis of AD-type dementia, although we are doing a few tests to screen for other issues. She was comfortable with a trial of medication. We discussed safety and prognosis issues at length and are getting a full home evaluation and assistance through home health. Maybe, when she's ready, we'll get a neurology consultation. We were able to meet (figuratively) where the patient and her daughter were, not where I was in my day, even though I was awfully busy.
This is why I do what I do.
Unfortunately, my ability to provide for my family would have improved if I had spent 30 minutes, ordered more tests and consultations, written a prescription, and had her return with great difficulty for a 15 minute visit next time. We saved the system a lot of money today...a shame that a portion of the savings came out of my pocket.
John Watts Haresch, MD
Kill Devil Hills, NC
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