Disorderly Conduct

My friend Jordan Grumet wrote yesterday about a house call, a visit on someone else’s turf, as he put it. Read this short but poignant post, The Home Visit, here. 

This post stirred something in me, as Jordan’s posts often do, especially in light of my own recent thinking about the new year and what it means to me and how my life is run. As I have recently written, at this time of the year I think about putting things in boxes, into their proper places, just as his cancer patient had her home arranged just so, everything in its place. I pride myself on keeping a tightly orchestrated to do or reminder list, following it, organizing it by date or priority, and not letting things fall between the cracks. Everything in its place. Everything with its appointed timeframe and due date and project goals mapped out for me. This usually works pretty well. I feel comfortable with my work load, how it flows, and my ability to get things done. 

However, I practice medicine, and a type of medicine that can be very unpredictable just by its very nature and the type of illnesses I see and deal with every day. Just when I think that I have my schedule mapped out for the day, a code blue is called as a teen is having a seizure out front on the bench in the freezing cold. I excuse my self hastily from the present appointment and patient in my office, walk briskly towards the front of the building, and deal with whatever I find when I get there. When the paramedics and ambulance arrive and the child is safely loaded up for transport to the local hospital emergency room, I go back to my appointment, shifting gears quickly as my pulse comes back down to normal range. 

I carefully orchestrate my schedule for the first month of the year, coordinating two jobs that usually mesh together tolerably well, filling up each patient slot for the next six to eight weeks ahead. There is little room for error, few slots for extra duties, and very little wiggle room in general. Funny thing, that, because my third grandchild is due in the next forty eight hours, and I don’t think he or she will care much about what my schedule looks like on Tuesday or Wednesday or whenever the delivery date turns out to be. I will juggle and reschedule and make time for the trip to be with my family because that is most important to me. I will make it all work somehow. 

I will do my best this year to advise my patients on the best treatments available for their presenting complaints, utilizing the available evidence base and my own experience and crafting the best treatment plan I can for each patient who asks for my help. The problem with this is that mental illness is insidious, chronic, and debilitating. It affects mood, judgment and impulse control. No matter how diligent I am, no matter how good the plan is, sometimes it will fail. Like Jordan’s patient with cancer who decided not to have surgery or chemo or other “disorderly” treatments, my patients will decide to stop their oral medications, not come in regularly for their injections, forget to get blood drawn for lab work, and decide not to attend AA meetings after all. 

Medicine, again by its very nature, has a certain amount of built-in entropy. We schedule and plan and scheme against it, but to no avail. Sometimes things just don’t go our way. We doctors are trained to diagnose and fix things, to problem solve and make decisions and move logically from one problem to the next to the next. When this happens, we feel smart and happy and powerful and in control. When it doesn’t, we get irritable and angry and depressed and then we are not at the top of our game. 

Like Jordan, even if things don’t go exactly my way, I would still rather they are clean, crisp and orderly. The patient with schizophrenia may not live as long a life as I wish he would live, since he does not take care of his diabetes, he drinks too much and he goes off his medications every few months. The patient with bipolar disorder will get manic at intervals and spend too much money, end up in jail, or take a cross-country trip that has family and friends worried sick about her. These things will happen. 

I will still see them when they come back, get them back on track with a reasonable treatment plan, write the prescriptions for medications that should help them, and schedule them to come back to see me the next time, wanting to believe that this orderly way of doing things will keep the disorderly conduct of illness and infirmity at bay for just a little longer. 

In this new year, I hope that Dr. Grumet and I, and all of our colleagues, are successful at doing just that. 

5 thoughts on “Disorderly Conduct

  1. That is my hope and prayer for you, Jordan, and other doctors who so keenly understand the need for patient-practitioner dialogue and collaboration. Thanks to the Holy Spirit and technology, I’m reading your post and his on a morning where there’s absolutely no way I can go to church because I just don’t have the physical wherewithal and probably won’t be able to tolerate much auditory anything thanks to today’s fibro flare-up.

    I mention this not as an invitation to my Pity Party but because one of my goals for 2014 includes getting back into the #epatient conversation more publicly than I have in the past year or so. Your post here (3rd grandchild??? 3rd??? Wow!) and his are valuable reminders of the human element in the world of healthcare. I’ve been watching how the term “Evil Empire” has expanded beyond Big Pharma to include physicians and while I certainly have my own horror stories about insensitive and downright ignorant doctors, they are not the ruling majority.

    Planning to share your post and Jordan’s widely and to cite them when I get back to writing on this topic. Not today, but soon!

  2. Meredith, thank you for being a faithful reader and commenter over quite a long time now. Your insights are invaluable to me, and your pointers are always on target. I am glad to be able to provide some grist for your mill at times if I can. I hope you feel much better soon. Please feel free to use my posts or ideas as you wish. I would be honored.

  3. “The patient with schizophrenia may not live as long a life as I wish he would live, since he does not take care of his diabetes, he drinks too much and he goes off his medications every few months.”

    But do those medications shorten the schizophrenic’s life rather than prolonging it? Robert Whitaker’s recent book brings together what looks like compelling, though indirect, evidence that antipsychotic drugs are responsible for the decreasing life expectancies of America’s schizophrenics. Recent research by Nancy Andreasen and her colleagues appears to indicate that antipsychotics cause brain shrinkage. I have seen no substantive criticism of Whitaker’s analysis or of the Andreasen, et al. research. Have you?

    Edward Opton
    eopton@youthlaw.org

  4. Edward,

    Excellent points both.

    This is a very mixed bag from what I read, sometimes seeing that these factors lead to higher mortality and other papers stating that they may be in some ways protective in the patient with schizophrenia. As to specific critiques of the sources you voted, no I have not.

    This article may address some of what is relevant here:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951588/

    Thanks very much for reading and for your comment.

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