Hundred: One

Some patients give me some of the most unexpected and unique perspectives about my clinical work. Yesterday was a very busy clinic. It was 2 PM and no major drama had happened till then. Mrs. O walked in with her granddaughter. She walked slowly with a mild stoop in her posture, but there was a graceful poise in her demeanour. A gentle smile that was somewhere between a smile of familiarity and a smile of meeting a new person was adorning her face. 

 

“I have a troublesome itch all over my body. I am unable to sleep at night because of this” she said and looked at me with anticipation. 

 

She was a woman of a few words. Many of my patients like talking. They express their symptoms with animated words and exclamations. They throw in a lot of onomatopoeic words like “jilu jilu”, “misu misu”, “jivvu…” etc. Some of them narrate their problems round and round in a loop. They would start with a main complaint, describe it in detail, skip to the next complaint and then to the next one, and then they would loop back to the main complaint and describe it all over again. I think it is the insecure feeling about missing out on the main problem that makes them repeat. But Mrs. O was not like that. She just stated her complaint as a matter of fact and went quiet. 

 

Itching as a complaint is not as simple as it sounds. It can be the manifestation of an infestation with a bug called scabies; it can be a fungal infection of the skin also called as ringworm. These are simple problems with easy solutions. But itching can also be the manifestation of something more ominous. Bile accumulation due to bile duct obstruction, kidney failure with accumulation of urea in the blood, cancer with secretion of some chemicals in the body, can also manifest as intense itching. In my practice of treating elderly patients, it is not uncommon to see patients with diabetes presenting with diabetes induced nerve damage, which leads to itching. In December-January, the weather in Chennai and its surrounding areas is chilly. We are not used to such weather. This weather condition could also lead to dry skin and itching. Over the years, I have learned the hard way never to ignore an itch, especially in the older person. So, I always get into a detailed evaluation of any older person who comes to me with an itch. I used to consider it the privilege of primary care practice where I can spend a lot of time with ‘just an itch’, but I learned yesterday that it might not be a privilege after all! 

 

My detailed evaluation starts with a set of questions to explore if there is anything to suggest any of the serious problems that I have mentioned earlier. I went down my question checklist and was asking her, “Did you notice yellow colour of urine, gray colored stools? How is your appetite? Do you sleep ok? Do you have any rashes anywhere? Do you have sneezing, cough cold? Is there swelling of your feet, breathlessness?” Somewhere during this interview, Mrs. O stopped me. The gentle smile on her face had disappeared and she looked a bit disturbed. “Why are you asking me so many questions for a simple itch?” 

 

I hadn’t noticed till then that my interview could be viewed as ‘asking too many questions’. It felt like someone extended their arms and stopped me midway through my smooth run. I stopped with a jolt and went silent to compose my thoughts. Then I said, “Itching can sometimes be a symptom of some problem in the internal organs of the body. So, to identify that I am asking you some questions. It won’t take too long.” By now the smile on Mrs. O had turned into a frown. She was angry and said, “There is nothing wrong with the internal organs of my body. You just give me something for the itching and I will get going. I don’t want to be interrogated like this as though I have done something wrong.” 

 

Mrs. O had not just challenged my clinical method, but she had dismissed my earnest attempts at helping her. I wouldn’t have taken it seriously on a normal day. It was a long day of clinic, and my patience was ebbing. I said, “Itching is not such a simple problem amma. It can be serious and I know it from my experience with other patients. Please allow me to get all the details that I need to treat you properly. I would be happy if some doctor spent so much time with me asking me for details” and I noticed that the volume of my voice had risen a few decibels. 

 

Mrs. O was probably not used to being spoken to like this. She snapped and said, “This is a small hospital. There are no facilities here. If I needed that kind of special attention, I would go to a bigger and better hospital. Do what you are supposed to do in a small hospital like this. Just give me the injection and tablets for itching. I don’t need your lessons.” Mrs. O, who seemed like this gentle and graceful grandma when she entered the clinic, now looked like an angry old woman to me. Within those few minutes everything had changed. I felt hurt and insulted. Her words ‘small clinic’, ‘bigger and better hospital’, ‘do what you are supposed to do’ were ringing in my ears repeatedly and made me feel very bad. I did not speak any further. I wrote a prescription for an anti-histamine drug and gave it to her. She got up and walked away without looking back at me.

 

This episode upset me in more ways than one. (1) I was forced to mechanically write a prescription which went against my integrity as a clinician. I would strongly criticize a physician who does that. (2) My work was seen as something inferior to what is done in a ‘bigger and better’ hospital. I have realized on several occasions how little some well-off people think about a small, simple, primary care clinic. But then seeing affluent people is a rare phenomenon in our place and so I tend to forget how they make me feel. And then periodically people like Mrs. O come and remind me. I don’t know about my other family medicine and general practitioner colleagues, but I often question my purpose and relevance and the importance of the work I do. It is not out of dislike or disrespect for my work; if it was, I wouldn’t be doing it. It is because of self-doubt that sometimes crops up. And people like Mrs. O push me down that thought spiral. I fell down that trap-door last evening. Nowadays I pick myself up and climb up quite fast. I guess it is because of the years of being down the same slippery slope many times. For every one Mrs. O who does not think of our work as ‘important’, there are hundreds of others who love to visit us and interact with us. I must just learn to remember the hundred when I encounter the one.