In medicine, as in life, it is often the little things that matter.
For several years she came in every three months for scheduled visits to monitor her blood pressure (stable on hydrochlorthiazide and lisinopril), elevated lipids (nearly at goal on a mid-range dose of atorvastatin), and gait problems resulting from childhood polio causing RLE atrophy and weakness. A retired college librarian, she had significantly outlived her husband of 57 years and, at 94, she still lived alone in the house where they had raised four children.
We start each visit catching each other up and sharing events in our lives: her granddaughter’s status as a first year medicine resident, a book about the history of the Presidentials she thought I would enjoy, the birth of my first grandchild. We both enjoyed the sharing, though it not infrequently made the visit run long, for which she would apologize (“I’m so sorry. This silly small talk is going to make you late. You have more important things to do than listen to an old lady ramble on.”) I would reply: “There’s time, and I enjoy our conversations. They always make me feel better.” And she would smile and reply: “Me too.”
Earlier this year, she had had a small neurologic event with left facial weakness and slurred speech that lasted nine hours, long enough to be documented by me in the office, and by both the ED doctor and the consulting neurologist. Her evaluation had shown no evidence of arrhythmia, large vessel source of clot, seizure, bleed, mass lesion, alcohol or drug use. She went home on clopidogrel and aspirin.
This visit was a month early, which usually meant she had a concern, so I opened with: “You’re here early. Is there something going on?” She had had a second event, identical to the first but much shorter, and had seen the neurologist who told her to increase her atorvastatin dose to 80 mg, replace the clopidogrel with coumadin, and not to travel to North Carolina next month. Her distress was obvious to me through her practiced veneer of positivity.
Calling up the neurologist’s note in the eHR, I found confirmation of the medical details. Under Plan he had written: “Rec change to coumadin for anticoag, target INR 2-3, advised against Florida snowbird cycle. Pt agrees, voices no questions.” The cause of her distress was now obvious to me, though it was apparently not appreciated by the neurologist.
She was not a snowbird, someone who flees Maine to a Florida condo every winter, but rather a traveling grandmother and great aunt who helps keep a widely distributed family knitted together by making regular visits of several weeks to places like North Carolina, Pennsylvania, Connecticut, New Jersey, and Oregon. From our years of ‘small talk’ I knew many of these extended families by both name and habit. A few had accompanied her to office visits during summer or fall trips to Maine. She thrived on being a regular part of this diaspora, and was a cherished and expected visitors in many homes.
ME: “Did he explain his concern about traveling?”
SHE: “He thought it would be too hard to find a place to get my blood checked and my coumadin dose adjusted.”
I said that monitoring her INR while traveling was easily accomplished with a home meter and email or phone contacts, but that we should spend a moment discussing the risks and benefits of coumadin in her setting. After some discussion, she said she thought she would prefer to avoid the additional risk of coumadin but smiled when I said she should also discuss it with her medicine resident granddaughter. She had already had that conversation and her granddaughter had been ‘barely luke warm’ about coumadin and shared my concern about the added risk of bleeding with her intermittent falls.
As she stood to leave, she thanked me for the visit:
“You know me so well. You understood what traveling does for me without me saying anything. The neurologist, you know, he’s really smart and I trust him about neurology. He’s a good doctor. But he doesn’t seem to be interested in anything but neurology. I didn’t think there was any way I could explain that I’d rather die than stop being part of all my families.”
A few months later I ran into the neurologist in the hospital. He’s a bright, sensitive, caring and extremely competent neurologist whose clinical judgement I trust. He’s both well rounded and well read, and we often discuss non-medical topics. When I told him that Mrs. Greenville was planning to continue traveling - and why - he was non-plussed:
HE: “Wow. I had no idea.”
ME: “That’s what I love about primary care,” I said. (But I thought to myself, of course you didn’t know. You didn’t ask.)
Medicine is not just just science and data. It is relationships and negotiations and communication. Small talk is not a luxury or an extra. Certainly in primary care - and I would say in all clinical medicine - it is essential. It shows respect. It helps maintain focus on the whole patient, not merely on the disease. And it builds the relationships and partnerships on which patient-centered clinical decisions can be based.