My Wednesday off

A free day to pamper herself turned into one filled with terror for this physician.

Kerri M. Peterson, MD 
Family Practitioner/Carmel Valley, CA
May 23, 2003

I'd just begun working a new schedule of four-day weeks with Wednesdays off—a day to indulge and pamper myself. I snuggled into my cozy comforter, set the pillow just right to ease my aching neck, and picked up a novel from the stack beside my bed.

Then the phone rang.

I considered letting the answering machine pick up, figuring I could be paged if anyone really needed me. But then I remembered my pager was downstairs. So I picked up the phone. It was Dorothy, a neighbor I barely knew. I'd exchanged a few words with her last week.

"Hello. Is this Kerri?" Dorothy sounded upset, as if she'd been crying.

"What's up, Dorothy?" I asked, dreading her answer.

"I need you to come over right away," she cried. "And . . . bring some of your doctor stuff."

"My doctor stuff? What do you mean?"

"Come quick" was all she said before she hung up the phone.

Alarmed, I jumped into jeans and a sweatshirt and dashed toward her house. Halfway, I turned around and went back for my car, realizing that I'd need it if this were a real emergency.

I called to Dorothy through the screen door and, getting no answer, let myself in. I followed a trail of fresh blood that led from the bathroom to the kitchen, and found her there rinsing her wrists under the faucet. Blood was everywhere—it soaked several towels, dripped from the countertops, and smeared Dorothy's face and T-shirt.

"What happened?" I cried. As if in response, Dorothy sank unconscious onto the floor. I quickly wrapped towels around her wrists and called 911.

I spent the better part of the day at Dorothy's side. The first person I called was her mother.

"This is Dr. Peterson, your daughter's neighbor. Dorothy's had an accident and has lost a lot of blood. She's stable now, in ICU, but she's in very serious condition."

Dorothy's mother cut me off abruptly.

"What'd she do this time? Slit her wrists? Oh, for Christ's sake! How much more of this do we have to take?"

I was aghast and confused.

"You mean this isn't the first time?"

"God, no! She's been pullin' these tricks since she was 13—cutting on herself, making herself sick, anything to get attention. One time she even rubbed her own excrement into a cut she'd made so it'd get infected. She was in the hospital for two weeks with that one! IV antibiotics, the whole nine yards. She probably was in her glory!"

"Well, she must be in a lot of pain to keep doing this. I think you should come."

"I know I sound callous, but these dramas eat up her father and me. We finally decided we'd had enough. We just don't come anymore. So now you know. Next time, don't bother calling." She hung up, leaving me perplexed and angry.

Next I called one of Dorothy's friends. This time I got a little more sympathy, but still, an indifference that I found difficult to accept.

"Poor Dorothy," she said. "She's a lost soul. She seems okay some days, but then goes into this self-destructive mode. But hey, she's strong. Don't worry about her, Doc."

I wasn't so sure. I didn't know how serious her previous attempts were, but I did know this one was life-threatening.

The picture that was emerging was not a pretty one. On the one hand, I was outraged and incredulous at the lack of feeling on the part of her family and friends. Dorothy obviously needed help, and she wasn't getting it. On the other hand, she'd pushed them to their limits. How much more could they be expected to take?

I went back to her house to clean up. The bloody carving knife in the kitchen sink sent a chill through me. I reflected on my conversations with Dorothy's mother and friend and wondered, was Dorothy really trying to kill herself? Or was this merely another attention-getter that had gone awry? Why had she called me, if she was serious? Should I be angry or grateful?

The answer was clear. Thank God Dorothy did call me. My Wednesday off hadn't turned out as I'd planned, but Dorothy might have died if I hadn't been home. She might not have had the strength to make a second phone call. I took a moment to think about being a physician. Faced with an unexpected crisis, I was able to jump right into it and handle it efficiently, without feeling panicky or overwhelmed. We are truly a privileged few, to be witness to the heights and depths of humanity, in all its vulnerability, fear, and joy. How grateful I am that I'm a physician.

I opened my home to a homeless patient

Looking for some relief from her hectic pace, this doctor made a deal with a destitute woman. Here's how it turned out.

By Kerri Peterson, MD 
Family Practitioner/Carmel Valley, CA
June 19, 2000 

Megan Smith looked like trouble from the moment she first visited my office a few years ago. A 39-year-old former truck mechanic, she was unemployed, homeless, and had come in complaining of back pain—the result, she claimed, of a work-related accident two years earlier. Her disability payments had been denied, leaving her angry and discouraged.

Even though I knew that many back-pain patients malingered, I listened patiently to Megan (not her real name). I was skeptical about her claims, especially after a physical—including a Pap smear and neurologic, pelvic, and rectal exams—revealed no problems. Still, I arranged for physical therapy and, fearing she wouldn't keep that appointment, gave her a printed description of back exercises she could practice on her own. Finally, I prescribed an NSAID (which she insisted wouldn't help) plus 10 hydrocodone tablets that I told her to reserve for severe pain.

"So, Doc, you gonna fill out my disability papers?" she asked as she put on jeans and a plaid workshirt.

"I can't do that yet, Megan," I explained with a sigh. "I want to see you again in three weeks. We'll discuss it then."

"Okay," she mumbled. "None of those other doctors I been to were worth a damn, so I guess I've got nothing to lose with you." While I don't think she left my office entirely satisfied, she seemed somewhat placated. However, I hoped she wouldn't return, and I remember thinking I wouldn't be surprised if she never did.

But three weeks later, Megan came back, again requesting opiates to relieve her pain. As I'd suspected, she never went to the physical therapist and hadn't filled her NSAID prescription, though the hydrocodone tablets were long gone. I explained that narcotics weren't the best option for managing long-term, nonmalignant pain, and asked whether she was open to exploring other approaches.

We then talked about alternative therapies and lifestyle issues. When I asked about personal stressors, Megan began to cry.

"You can tell me about it," I began. "It's okay."

"I broke up with my partner recently," she sobbed. "We were together for years. It's been really tough for me." She added that she was spending nights in her car and hadn't slept well in months, which was probably making her back worse.

To help her cope and enable her to get some sleep, I put her on low-dose tricyclic antidepressants. We spent several more visits discussing her personal issues—her lesbianism and the alienation from her family that it had caused, her feelings of despair over the death of her infant son 20 years earlier, and her struggles with drug addiction as a teenager and young adult.

Over time, we began to trust each other. One afternoon, she told me that she had been experiencing terrible, disabling menses that kept her in bed for days at a time. A second pelvic and rectal exam revealed a firm mass in front of her sacrum. Ultrasound results suggested extensive endometriosis, largely involving her retroperitoneum. Ultimately, a gynecologist had to perform a hysterectomy.

After her surgery, Megan's back pain completely resolved, and she no longer requested painkillers. One day, however, she appeared unexpectedly at the doorstep of my home, bearing a bouquet of flowers.

"I want to thank you, Dr. Peterson, for taking my back pain seriously," she said. "Thanks to you, I feel like a new person." I felt more than a little guilty, since I'd initially had serious doubts about her claims.

"Would you like a cup of coffee?" I asked, after thanking her for the flowers.

"That would be nice," she replied. "I'm sorry for showing up uninvited, but your neighbor is my friend. We grew up together. While we were talking last week, I mentioned your name, and that's how I found out you live here." Megan said she'd tried calling me before stopping over but was told that my number was unlisted.

While we sat and sipped our coffee, Megan offered to play guitar and sing for my triplets if I ever needed a bit of time to myself. "I might take you up on that," I said, thinking that I probably wouldn't. Nevertheless, after we'd enjoyed a long conversation, I suggested that she might play for my triplets' fourth birthday party the following weekend. "I'd be honored," she said.

After she left, I wondered whether I'd breached the boundary between doctor and patient. But in my haste to be polite, I'd already opened the door. Little did I realize how far.

Megan played at the party that Saturday, and my children adored her. As they jumped all around her, she offered her services as a babysitter. The boys were so excited at the prospect that I found it impossible to refuse. Besides, I hadn't gone out with a guy on a Saturday night since my divorce, so that alone was reason enough to accept.

Everything went fine. The kids adored Megan, and I had a great time on the town. But when she dropped by unannounced two weeks later, guitar in hand, I again felt a bit skittish. As I reluctantly let her in, the boys scurried toward her, eager to show off their bedroom. What I initially viewed as an intrusion wound up affording me an hour and a half of peace and quiet.

Megan came by twice more during the next month, and each time, the kids were delighted to see her. It was obvious that they loved being with her, and vice versa. So trusting my intuition, which had always served me well, I invited Megan to move into our guest room. She'd been living in her car for nearly three years by then, relying on her charm and the charity of friends for the occasional hearty meal and comfortable bed. I was a single mother who had long struggled to find a flexible, fun, and reliable sitter for my boys—someone who could be home if I got called to the hospital or pick them up from preschool if my clinic hours ran late.

How did my parents, friends, and colleagues react when they found out I had taken in a homeless person? My parents and friends weren't surprised. On the other hand, my fellow doctors thought I was out of my mind, though none of them said so. They did tease me quite a bit about the possibility that Megan would steal all of my money and belongings.

As it turned out, I had nothing to worry about. Megan was a wonderful caretaker for my children, and she saved me $800 a month in day care costs. Plus, she cooked wonderful meals and took care of my plumbing, landscaping, electrical problems, and home repairs including some masonry work.

After about six months of living with my family, Megan found a job as the maintenance manager at a local shopping mall. Around the same time, her mother went through a difficult period and needed someone to stay with her for a while. So Megan rented an apartment and moved there with her mother. Despite having to contend with her mom's problems, she thrived in her job at the mall. In fact, its owners recently named her employee of the year. She's even saving for retirement—something that once seemed out of her reach.

The story might have ended there, if not for the fact that I need Megan in my life now more than ever. The cancer I was diagnosed with five years ago has sapped so much of my strength that I recently stopped seeing patients and invited Megan to live with us again. (See Memo From the Editor's Guest: "Living with chemo, learning to be human," Oct. 25, 1999.) She readily accepted, her mother's tough times having passed. Now, in addition to helping around the house, Megan pays me a small amount of rent.

Naturally, the kids are thrilled that she's back to play music and sing for them. She's the one person they never object to staying with when I'm not home. In fact, she's like a second mom to them. These days, when I tell Megan how lucky I am to have her in my life, she laughs and tells me how grateful she is that someone took her complaints seriously and helped eliminate her pain. But beyond all that, Megan is my friend. She listens to me when I tell her about the difficulty I have accepting my loss of energy, and I listen to her talk about her struggles, too.

Did I overstep a line that shouldn't be crossed in a doctor-patient relationship? Maybe. But my friendship with Megan has been valuable to both of us. If a similar situation were to arise again, would I let another former patient move in with me? Given how well things have worked out with Megan, why not?

Thank God for noncompliance—this time, at least

The elderly patient had been hoarding medications from various sources. What if he had taken them all?

By Kerri M. Peterson, MD 
Family Practitioner/Carmel Valley, CA
May 21, 2001 

During internship, I worked in a clinic where I'd often see patients who came in only to refill medications. One memorable encounter involved a 70-year-old retired Navy officer I'll call Daniel Turner. He was dealing with heart failure, hypertension, emphysema, diabetes, osteoarthritis, and, at the time, toenail fungus. He was on lots of medications.

"Which of your pills are we refilling today?" I asked him.

"Oh, it's that little white one," he replied, confident I knew what he was talking about.

"Which little white one?" I asked. Although just an intern, I'd had variations on this conversation with many other patients.

"The round one. It's scored down the center."

"Do you think it's the Lasix?" I inquired.

"Could be. What's that for?"

"It's a water pill," I said. "You take it in the morning."

"Could be . . . could be. Which one is for my blood pressure?"

I flipped to the lengthy medication list on the front of his chart. You're on three different pressure medicines," I explained. "Hydrochlorothiazide, lisinopril. and Hytrin."

"Which one is for my diabetes, then?" he asked, a quizzical look on his face.

"The metformin—and the Zestril helps, too," I replied.

"And for my heart?"

"That would be the digoxin, the Zestril, and the Lasix," I explained.

"I thought you said Zestril was for my diabetes," he stated, becoming exasperated.

"It works for both, Dan, and for your blood pressure, too."

"You didn't say that one was for my blood pressure."

"Yes, I did, Dan. But I might've said lisinopril instead of Zestril. They're the same, though. I'm sorry. All the drugs have a generic name as well as a brand name, and it can be confusing."

He looked at me skeptically.

"I'm afraid to ask you which of these medicines are for my lungs," he said.

"Oh, that's a whole different set of medications," I assured him. "Nothing to mix you up with there. They're all the inhalers."

"What about the prebbacin? I thought that was for my lungs."

"The what?" I asked. Now I was becoming confused.

"The prebbacin, or prebbadone, or prebbasone, or something like that," he responded.

"Do you mean the prednisone?" I asked.

"Yeah, that's it," he replied, clearly pleased we'd solved the mystery.

"You're not supposed to be taking that all the time," I said. "Yes, it's for your lungs, but it's only for when they're really feeling bad. Besides, you shouldn't have any of that medication left, not if you took it correctly the last time you were on it. I only give you enough to get you over one episode."

"Well, the last episode went away quicker than you thought it would," he explained. "So I stopped the medication early. Then, a few days ago, I was feeling kind of wheezy, and I started on it again, and I've been on it ever since. That along with the rest of sepera."

"The Septra, you mean?" I inquired apprehensively. Besides the prednisone, Mr. Turner, I realized, had also saved some of his antibiotic medication for acute episodes. I was feeling frustrated: How many times had I explained to him the importance of taking the full course of his antibiotic treatment?

"Yeah, the Septra," he affirmed. I repeated my usual speech, knowing full well it was once again falling on deaf ears.

"Dan, I think it would be helpful if you brought in every medicine you have in your house," I said. "Include the over-the-counter stuff as well, along with herbal treatments and whatever home remedies you might use. We can sort through it all, and see what you're really taking."

"Okay," Dan agreed. "But could you at least write me a prescription today for that little white pill?"

"And what's that yogurt maker for, Mr. Turner?"

A week later, Mr. Turner came back, toting a large paper bag. As he laid it on my exam table, he said: "Here you go, this is everything! You asked for it!"

I couldn't believe the array of stuff before me—Baggies, pill bottles, plastic containers of all kinds. Rooting around the bottom of the bag, I noticed what looked like a yogurt maker—a plug-in, plastic contraption that held six or eight little cups.

"What's this?" I asked, genuinely curious.

"Oh, that's a system I used to have. My old doctor had me on so many pills that I couldn't keep 'em straight to save my life, so I just put all the yellow ones in one container, the white ones in another, the green in another, and so on. I'd take one of each in the morning, one of each at night. Made everything real simple. But my doctor didn't like that system much. Chewed me out real good when I told him. I gotta say, though, I never saw the inside of a hospital while I was doing it that way!"

"Good advice your doctor gave you," I said, shaking my head in disbelief. "Why the yogurt maker, though?"

"On account of the basement," he replied. "That's where I was staying at the time, back when Maggie was still alive. She had me sleeping in the basement for a spell, because she was mad at me about something—don't remember what. So damn cold down there, I figured I needed to plug this thing in just to keep my pills at room temperature, like the pharmacist told me."

"Wouldn't want you to eat frozen pills," I agreed, as I opened one of the yogurt cups and dumped the assorted orange pills on the exam table.

"Oh, you might as well toss those, Doc," Mr. Turner said. "They're real old. Never could figure how to put them back in their original bottles. Guess I didn't miss 'em much."

I continued rummaging in the box. I counted out fourteen Baggies of what looked like marijuana, all fastened tightly with tiny rubber bands. With some difficulty, I opened a bag. Mr. Turner saw the look of curiosity on my face, and explained.

"Those were Maggie's idea—some health kick she was on. Everything had to be home grown and herbal. I got oregano, parsley, tarragon, rosemary—you name it, an herb for every ailment. Maggie thought they needed to be sealed tight to keep 'em fresh. But I found it all too much to bother with."

I took a whiff of the contents of the Baggie I'd opened. Basil, I thought to myself.

There were 42 containers in all, some more than 20 years old. There were also no fewer than seven bottles containing hydrochlorothiazide in various combinations, and five other bottles labeled "Lasix," although two of them looked like they contained something else. I held up three small Ziploc bags filled with white pills.

"Rounds, ovals, and irregulars," Mr. Turner offered by way of explanation.

"I'm a little afraid to ask," I said hesitantly, "but which of all these are you actually taking?"

"Here, let me show you my new system," Mr. Turner replied, pulling out a prefabricated plastic box labeled with the days of the week.

Oh, good, I thought to myself. Some semblance of a real system. At least he's not as daffy as I'd thought.

Mr. Turner showed me how he filled the container from his pill bottles every Sunday night.

"There's one space for Monday's once-a-day drugs, another space for the twice-a-days, and this here three-times-a-day space I don't use very much," he said. "And it's the same for every day of the week."

"And where are the pill bottles you use to refill this?" I asked. He began pulling bottles from the paper bag, seemingly at random, and I must have look worried because Mr. Turner immediately tried to reassure me.

"All the bottles I'm using now have this little black 'x' at the bottom," he explained.

I lined the x-marked bottles along my desk. As I feared, there was a bottle marked "Lasix," and another labeled "furosemide." There was a bottle marked "Zestril," and one "lisinopril." The two bottles marked "captopril" and "enalapril" each had a different doctor's name on it. Yet another bottle, this one labeled "digoxin," contained pills in three different colors, which I was able to match to pictures in the Physicians' Desk Reference. The dosages were 0.125, 0.25, and 0.5 milligram, respectively. If Mr. Turner was really taking all these, he ought to be dead. Thank God for noncompliance, I thought.

Patients on multiple meds? Follow these simple steps

I carefully sorted through the various bottles, discarding everything except those pills on Mr. Turner's updated medications list.

Not including the inhalers, I managed to pare down his regimen to seven prescriptions: furosemide, lisinopril, digoxin, hydrochlorothiazide, metformin, celecoxib, and terazosin. I might have consolidated further, but I didn't want to make too many changes in one visit.

I then made sure the med list in his chart was accurate. I wrote down all the medications, including both generic and brand names, the prescribed dosages and frequencies, and the condition each one treated. I gave a copy of the list to Mr. Turner, and had him read it back to me to ensure that my handwriting was legible and that he understood my directions. When he finished, he folded the sheet into quarters and stuck it into the chest pocket of his shirt.

"Make sure you keep that with you," I said. "I want you to try taking all of these exactly as prescribed for a week, and then come back and see me."

I made a note to myself to discuss prescription refills with his cardiologist. I thanked Mr. Turner for bringing in his medications, and wished him a good day.

That was seven years ago. But the lessons learned in my encounter with Mr. Turner serve me well to this day. True, I haven't seen many patients quite as confused about their prescription regimens as he was. But I've seen many patients who've labored under similar misconceptions.

That's why I keep in mind a few critical steps for dealing with patients on multiple medications. First, maintain an updated med list, and share it with patients.

Second, at least once a year, encourage patients to bring in all their medicines, vitamins, nutritional supplements, and herbs for a physical inspection. I've done this repeatedly over the years, but it never ceases to amaze me what patients keep in their medicine cabinets.

And third, keep in mind that our patients may not really need all the medications we give them. As physicians, there's a balance we should strive for—between prolonging life and needlessly compromising its quality through piling on the pills.

- See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/clinical/clinical-pharmacology/thank-god-noncompliancethis-time-least#sthash.kkxLlIm5.dpuf