Sunday, November 5, 2017

Not Zen 192: The Prescription

"Look, that pill makes me dizzy," Linda's patient said. His name was Benjamin Perry. She looked down to where that was written at the heading to his chart, then back to him, a heavy, middle-aged man. Except for his hair loss and his pot belly, he appeared to be healthy. He pointed to one of the pills from the set that he'd brought in with him. "I can't take that in the middle of the day."

"You have to take it on schedule," Linda told him. She raised her hand for a moment to hold off his next comment. She stuck her head out into the hall. The paint on her clinic walls was new but beige. The lights weren't friendly but they were bright. She didn't love the building. But she did like the clinical staff. She felt lucky to get her first job after residency in a place this nice.

The co-worker she wanted was the oncology nurse. Linda's patient Ben, who kept complaining about dizziness and other side-effects of his treatment, had a form of thyroid cancer. The oncology nurse could usually get uncooperative people to return to their drug regimens. She was an expert at it. And if, for whatever reason, she couldn't persuade the patient, she always seemed to know what the next-best solution would be.

Linda saw that the nurse's office door was closed. It was probably a day off for her. At the same time, she saw the counselor step into the hall. He would be the next logical choice.

"Do you have a moment?" she waved at him.

"Is this for a patient?"

She nodded.

"Let me finish the last paragraph of this report. I'll be right there."

Linda turned back into the exam room and smiled at Mr. Perry. Here in the examination areas, the walls were a brighter shade of beige. It made a difference. She felt more comfortable during the exams than she did when walking through the building. She felt confident that she could get her patient back onto his drug regimen.

She set herself down on the pale blue stool. It was elevated and had no back to it so she would keep alert. Her patient remained where he was on the exam table, also not letting himself relax, hands on the edge.

"It says here," she said, glancing at her notes, "that you're having problems with other parts of your treatment. Did you come in because you feel that the cancer has progressed or are you looking for help with the regimen?"

"Just need different drugs, really," Ben grunted.

"Okay, I'm going to check you for symptoms and ask you a few questions about the thyroid cancer. Then I'm going to have Dr. Harrison come in to talk with you about the specifics of your regimen."

"Good." Ben brightened as she rose. He bared his neck cooperatively when she manipulated the bulge of his thyroid. Linda glanced at her notes. The prep nurse hadn't done this part. A blood sample hadn't been taken, either, and it was necessary. She had to make sure that Ben wasn't coming down with any of the immune disorders that would complicate his cancer treatment. When the thyroid stopped regulating his body's hormones, as would happen if the cancer progressed much more, a lot would start to go wrong.

The first sign of progression would probably be a difference in metabolism. Ben already had a hoarseness to his speech, a symptom that was barely noticeable. Linda had heard an occasional cough from him.

"How's your voice?" she asked.

"Better than last month," he said.

"Any changes in weight?" She wanted to get a sense of how his thyroid was functioning. "Problems in getting up in the morning? Or in staying asleep?"

"Thought I'd gained a few pounds but your scale says no. I guess I feel slower. That's probably the medicine."

A moment later, the doorknob turned. The staff counselor poked his head through the door, nodded at Linda, and smiled. He reached out and shook the patient's hand.

"Jim Harrison," he said.

"Ben," came the response. The patient followed up with a polite nod before he released his grip.

Jim tucked one hand into his pocket as he accepted the patient's file from Linda in the other. He was a man of middling height and build, about a half-inch shorter than Linda. He wore a white coat like hers. His demeanor was pleasant at all times, at least as far as she'd seen. Aside from administering to patients who came in with mental or emotional disabilities, Jim held weekly, private sessions with each of the medical staff. The clinic allowed him to counsel them professionally as part of their benefits package. Not everyone took him up on it but Linda had gone for counselling a few times. She felt better for it.

He spent a moment on the file. Linda called for the prep nurse.

"Okay, I see four drugs listed in this regimen," Jim said. He turned to Ben Perry to begin his interview. "They're taken at six different times. Tell us about the effects of the drugs, as you see them, and about any problems you're having with the schedule."

"The green one makes me sick," Ben told them. He turned to Linda, explaining to her as much as to the counselor. "That's why I'm here, really. Is it supposed to make me throw up? I can't take it as much as I should."

"It's part of the regimen, Mr. Perry," Linda said. She couldn't resist reiterating her point, especially since he'd addressed her directly. "You're on the best treatment that's available for you. If you don't follow it ..." she started to say he would die but held back out of a well-trained reflex. "It's going to have serious consequences. Very serious."

"Yeah, I guess."

"Well, let's take the drugs in the order I see on the chart," Jim reiterated. "I'll name each one. Let's check the pharmacy notes on the bottle. You tell us about the side effects as you see them personally."

Jim was a good listener. With a great deal of patience, he stepped through the regimen and listened to the complaints about each medicine. In turn, he explained the benefits of each and how they all worked on the body together.

While her patient conferred with the counselor, Linda scheduled a cancer screening for Mr. Perry at their imaging facility.

"That's the second time you've mentioned the dizziness, Mr. Perry," said the counselor. He raised his voice slightly as if trying to get Linda's attention. She put her work aside to look at him. "What is it about that symptom that concerns you. What's your job in the day?"

"I'm a line repairman."

"Up on a cherry picker?" Jim clarified.


"What's a cherry picker?" Linda asked him.

"The right name is a bucket lift," Ben answered from his seat on the examination table. "I get into an open-top cage that looks like a metal bucket. Then the truck operator lifts me into the air with a hydraulic arm and sets me next to the wire that I need to repair."

"Dizziness would not be optimal," the counselor said.

Linda hadn't known the name but she knew exactly what equipment they meant. She'd seen it many times.

"Can't you do something a bit different?" she asked.

"Like what?"

That stopped her for a moment. While she put her hand on her chin and thought, she heard two beats of hollow patting sound. She glanced down to notice that Jim Harrison giving her the notepad-tap signal. It was the clinic's common way, between staff, to ask 'let's go talk.' He wanted to get some privacy from the patient for a few minutes.

"Excuse us, Mr. Perry," she said. "We're going to look at your records for a moment and confer. We'll be right back."

Ben nodded. He leaned back on the examination table and sighed.

Linda gave him a polite wave as she left. She led the counselor over to a side office. Jim trailed in and half-closed the door, not enough for the latch to hit the metal strikeplate but enough to stop their voices from carrying.

"I know you want Mr. Perry to take those drugs," he said. "I want to back you up. You're one of our best GPs. But I can't tell a patient to do something that puts him at risk of injury."

She thought about how the clinic had three other women doctors on staff. They all seemed to like Jim. She didn't get any bad vibe from him. He wasn't in her specialty, didn't try to compete with anyone, and he wasn't butting in. She'd invited him. She had the sense, even before he said it, that he would have preferred to defer to her opinion.

"Okay, what is it?" she said.

"Try something else." It was a statement that, in his voice, sounded like almost a question. "Maybe you could prescribe the older chemotherapy method for him. Send him back to the oncologist and say this one isn't working."

This is why you're not a medical doctor, she thought. But she kept it to herself for the moment.

"Why would you want an oncologist to prescribe the old way? Those drugs were full spectrum against all cells. They were brutal. And they don't have the best chance of success."

"In my experience in counseling to this urgent care unit, the old stuff works better for a lot of patients."

"You don't follow the scientific literature."

"I do." He leaned closer and lowered his voice rather than backing up and getting louder. "And I know that you can make a case for your treatment above others. As a counselor, I have to urge you to prescribe for each specific patient. That means not simply looking to the journals for the treatment with the best overall success rate."

"According to clinical trial outcomes, this is the recommended treatment."

"Have any of your patients been cured by using it? Ever?"

"Not mine, personally. Others." There were some, weren't there? She couldn't remember who had seen the successes. She tapped her forehead as she struggled to remember. "Anyway, the issue is that my patients haven't followed the regimen."

"It's a difficult one."

"It gives people the best chance to live," Linda insisted.

"But only if they follow it exactly, according to a schedule that gives them six times per day to take varying doses, sometimes of multiple medicines together." This time, Jim backed up as he spoke. He turned to face the wall she'd been looking at but not noticing. "And only if they continue despite how it makes them feel worse."

"I've had a handful of cases. None of them have continued for the full regimen." She stepped into his field of view. "That's the problem. They should. I warn them in advance. They agree. They just don't follow through."

"A warning is not enough," he said. "Can your patient come in every day to be supervised in the treatment?"

"None of them can afford that." She almost laughed. "Anyway, my schedule wouldn't permit it. I can't watch them three times a day, much less five, to make sure they take their doses exactly as prescribed. We can't even spare a nurse that much."

"In the testing of this treatment, that is what doctors did."

"That was in a lab. I mean, it was a clinical setting." She had interned at a place doing drug trials. She understood the situation. "The trial subjects lived in the hospital for the duration. But with ordinary lives, in ordinary circumstances, that's not possible. I can't follow them around and given them pills and injections when they don't want them."

"Do you see why I feel the old, simple treatment will have a better outcome for Mr. Perry?"

She shrugged. "Maybe."

"I don't know oncology, it's true. But I'm hired to be good with the people. That includes the doctors like you."

"Like me?" She smiled. "Not the patient?"

"You as one of the doctors. I can see that good doctors know what solutions to try. But they don't always anticipate what will go wrong with the patient. And the best doctors, only a top few, have seen enough treatment failures to know more than the illness. They know the patient's environment. They understand what a patient can do and can't. They aim at a solution that fits the disease, the environment, and the patient all together."

"That's a lot," she said. "For a fifteen minute appointment."

"Yeah," he agreed. "But that's a life."

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