The Big Picture

Her eyes were bloodshot.  She responded to my casual greeting of \”How are you?\” with a sigh.
\”How am I?  I\’m alive; I can tell you that much for sure.\”

She went on to describe a situation with her adult son who is in a bad marriage and has struggled with addiction.  She sighed again, \”I feel weak.  I don\’t know if I can deal with this one.  I\’ve had so many hard things in my life already.  When will it stop?\”

Many hard things.  Yes, I agree with that assessment.  She\’s been my patient for more than a decade, and I\’ve had a front row seat to her life.  Her husband died a few years ago (while in his 40\’s) of a longstanding chronic disease.  Her daughter also has this disease, and has been slowly declining over time.  I\’ve watched her bear that burden, and have actually shared some in that load, being the doctor for the whole family.

I\’ve also taken care of her parents, who had their own psychological problems.  They were difficult patients for me to manage, and they had died long enough ago that I had forgotten that difficult chapter of her life.

I\’ve helped her with her emotional struggle from all of this.  It was hard, but she hung on as best as she could.  I know.  I was there when it was happening.

To me, this is the biggest benefit of primary care.   Yes, it\’s nice to have a doctor who knows what\’s going on with all of your other doctors.  It\’s good to have a doctor you are comfortable talking with about anything.  It\’s good to have someone without a financial stake in doing surgery, performing procedures, or ordering tests.  But the unique benefit a long-term relationship with a PCP is the amazing big picture view they have.

I had a man come into my office with his daughter, who was struggling with emotional problems.  We discussed the situation for a while, and the subject of extended family came up.  When he reminded me who the girl\’s grandparents were, I laughed out loud.  They saw my moment of insight as to how the grandparents might be influencing this problem, and they both started laughing with me.  Nobody had to explain anything.  Nobody even said anything about the grandparents.  He just reminded me who they were, and I already knew more than enough.

I have now been practicing for more than 15 years, and have a longstanding relationship with a lot of people.  When they come in to see me, it isn\’t just for my expertise, knowledge, or to listen to my jokes; they come for my perspective.  They come because they know that I know them like no one else.  I have spent years gathering information from this visit.  I saw them when they were depressed.  I took care of their dying child.  I broke the news of their spouse\’s cancer.  My care for them is not just an office visit, it is a legacy.

When she stopped explaining her present situation to me, she let out another sigh, deeper than the rest.  \”Can you help me?\” she asked.

\”Sure, I can help you,\” I responded.  \”But let me reassure you that you are not weak.  I\’ve seen you weather the storms in your life and have been impressed by your strength.  Sometimes when you are being crushed by a weight, it isn\’t that you are weak, it\’s that the weight is too heavy.  I\’ve seen you carry heavier weights than most people could carry.  I\’ll do what I can to help you, but don\’t get discouraged with yourself.  You aren\’t weak.\”

She paused in thought – thinking about all I have seen of her life and my qualification to make this pronouncement.  She sighed, then nodded.

She knew that I knew.

As always, I have changed details about both of these situations to protect the identity of these patients.

10 thoughts on “The Big Picture”

  1. Thank you for this wonderful post. Your patients are lucky to have you. I’m lucky too–my husband and I have been seeing our PC doc for more than 15 years and trust him completely. He helped me navigate breast cancer tx with three specialists & put up with my emotions sometimes running high. He also saved mobility in my husband’s foot after an emergency room doc stitched the skin shut over a deep tendon cut. Our doc happened to run into my husband, made him walk for him (he couldn’t walk right because his big toe was flopping) and got him booked with an orthopedic surgeon stat. I hope healthcare reform/ACOs etc. don’t erode our ability to form these kinds of relationships.

  2. I have never been lucky enough to have this type of trust with a Doctor and I have never had a Doctor that “got it”.I wish I had, it would have made so much in my life so much easier.My experiences with Doctors have been negative.I envy your patients! I doubt I will trust a Doctor again with “me”,they might get my broken bones,but I will never “open up” to a Doctor again.

  3. I agree. I think you primary care folks have us specialists beat on this one. You guys really have the context.

  4. I’d love to have ONE doctor I could see. Instead, I deal with a rotation of residents and attendings who leave within a few years. I’m always breaking someone in.

  5. I’m just curious. With what percentage of your patients do you feel you have a relationship? I think my PCP is good but there is no relationship between us at all. When I go in, I usually wait for 30-60 min. in the waiting room and another 20-45 min. in the exam room. When I watch all the people going in and out, I think that there is no way she could remember more than a few of us even exist, much less have time to create relationships. When I hear that everyone should have a PCP because we need someone who knows us, it always puzzles me a little.

  6. As many as possible. Hard to say what my actual % is. I try to have some sort of relationship with all of my patients, but patients are not always open (and some come in to be seen rarely). To me it is part of what it means to be someone’s PCP. Not getting to know my patients is like not knowing what medications they take or not knowing medical facts. It is a very important part of me doing my job as well as possible. Docs doing otherwise are not doing their job.
    It’s a big bonus to me that I enjoy that aspect.

  7. I guess things must be different in the south. No one around here who I asked felt like they had any sort of relationship with their doctor. Several of them have had the same PCP for several years. Kind of sad.

  8. You wouldn’t like to move to Wales, UK, would you? We could do with a doctor like you. Hell, most of the world could probably do with a doctor like you. What I can’t figure out is how someone of your age gets to have the sort of personality and perspective of an old-style doc. My dad was like you are, but I’ve met very very other docs who are. He had a colleague who wasn’t in actuality a family doctor, but a specialist, who voluntarily took on his care when dad was dying because dad wouldn’t see his own doctor (that probably says it all, doesn’t it?) and this guy had also nursed my mum through many of her illnesses and, when dad was diagnosed with his final illness (a brain tumour), I started falling apart and he helped me too.
    Don’t underestimate the fact that you’re rare gold, Dr Rob. ‘Cos you obviously are. Keep on truckin’!

  9. My family are patients of Dr Rob are we very lucky to have a special doctor like him, He takes care all of us ages 2 to 64. He knows all our family and all we have been through, and we feel lucky to have him not only as our doctor but also as our our friend.

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