Putting Prevention Into Practice, Part 2

“Putting Prevention Into Practice” is a series that illuminates the realities of implementing evidence-based preventive medicine by recounting patient encounters from my general medicine practice. This is the second entry in the series.”

Mrs. GF is the kind of nightmare patient that sometimes keeps doctors up at night. It’s not her personality to be sure — she’s sweet, too sweet even, a fact that makes taking care of her even more difficult. And it’s not the complexity of her medical care, either. In fact, it’s the opposite — it’s the complete lack of medical care that makes her case so scary.

At 58 years young, Mrs. GF has not seen a primary care doctor – or a doctor of any kind — for over 20 years. 27 years to be exact. How does she remember that? Because that’s the age of her youngest son — the last time she saw a doctor was when she gave birth to him. To people outside of medicine that is an impressive track record — 27 years without any significant illness requiring medical care. But to doctors, especially those who are prevention-oriented like myself, it is also alarming. That’s 27 years without a physical exam, 27 years without a blood pressure measurement, and 27 years without a Pap smear. And given the guidelines for cancer screening, that’s also 18 years without a mammogram and 8 years without colon cancer screening.

But that’s all about to change. Over the next several months she will see a host of doctors including me, her new primary care doctor. Together we will make up for lost time and play catch up on her medical and preventive care, hoping at every step of the way that her lack of recent medical care has not resulted in any irreversible damage.

So what moved Mrs. GF to finally seek medical attention? What brought an end to her 27 year hiatus? It was a simple nosebleed. A week before we met in clinic, Mrs. GF’s nose started to bleed. Despite the usual maneuvers, it wouldn’t quit.  Concerned, her husband decided to rush her to the ER.  Within minutes of getting in the car the bleeding stopped, but her husband was undeterred. He wanted her to get checked out. In the ER, after a proper evaluation, doctors concluded that the nose bleed was nothing of concern. It was probably from a change in the weather. What was more concerning was her blood pressure. It was a whopping 206/110 (a healthy blood pressure is less than 120/80). She wasn’t having any symptoms from the high blood pressure, which suggested that it did not develop overnight. Her elevated blood pressure was a longstanding problem, but because she had not had a routine checkup in over 20 years, it was simply never recognized. After monitoring her for a few hours, they sent her home with a prescription for a blood pressure-lowering medication and an appointment to see me.

In clinic, I started by first getting to know Mrs. GF better. I was especially interested in getting a sense for why she had not seen a doctor in so many years. I learned that in many ways Mrs. GF is not the stereotypical patient without medical care. She is well-educated and raised three sons who graduated from college. She works in a medical office (though in a non-medical capacity). And she has great insurance — her husband is a maintenance engineer at the hospital where I work and so they are both covered under the same health plan that I am. In other ways she is typical — she is African American, female, and lives in a less affluent area of the city.

All these factors played into my mind as I decided how to best approach her care. Knowing that she voluntarily stayed away from the medical system for so many years, I was leery of overwhelming her. I resisted the urge to work up everything and schedule her for all the tests she was overdue for. But she surprised me with her acceptance of the situation. She knew that for many years her blood pressure was elevated. At work, she sometimes asked the nurses to take her blood pressure and it always came back elevated. At the same time, she was familiar with many of the tests she needed including cholesterol screening, mammograms, and Pap smears and was not surprised when I told her she was overdue for them. I wanted to ask her, “If you knew all this, why didn’t you come in sooner!?” But I resisted and focused instead on moving forward.

Despite the new medication, her blood pressure was still markedly elevated. I doubled the dose and added a second medication, making sure to pick medications that were dosed once a day. I also counseled her to change her diet and increase her exercise routine. Rather than inundating her with information, I tried to stick to a few key messages. But again, she was eager to learn more and frequently asked follow up questions. In counseling her about healthier eating, I gave her a list of food items to avoid because of their high salt content: fried chicken, canned soups, deli meats, hot sauce, frozen dinners. As I pointed out each item, she responded “Yes!” with increasing intensity. After I had finished, she exclaimed “Doctor! You just listed my whole diet!”

At the end of the visit my head was spinning. We had covered much ground yet there was much more to do. I still had to schedule her for colon cancer screening, for which she was 8 years overdue. I had yet to take a complete immunization history and had not assessed her alcohol use. At the same time, I was anxious about the results of her tests. After of years of untreated high blood pressure, what was her kidney function? Would her mammogram show an invasive cancer that we might have picked up sooner? Most of all, I was worried about how she would deal with the increased role of modern medicine in her life. Would she follow my advice? Would she take her medications? Would she even come back to see me? These thoughts enveloped my mind as she walked out of the examining room and said goodbye.

Halfway down the hall she turned and came back. “Dr. Nundy, you almost forgot.” I looked down to see her taking her prescriptions from my hand. As she walked away she said, “See you in two weeks.” After staring absentmindedly at my empty hand, I looked up to wave good-bye. As she turned the corner, I found myself saying quietly aloud, “Yes, see you in two weeks.”

- Shantanu Nundy, M.D.