The House Special
During the past several weeks, I have diagnosed several patients with novel H1N1 influenza infection with my diagnostic opinion occasionally backed by a positive flu swab. When my wife, an ER doctor, fell ill I suggested she had novel H1N1 infection and went on to advise some of my family, friends, and neighbors of the likelihood that they too had H1N1. Yet when it was my turn to suffer with fever, body aches, headache, sore throat, and malaise one word seemed best able to convey how I really felt: swine.
My symptoms began four days after having the H1N1 shot and almost immediately after putting my children to bed following a fun but rainy Halloween night. It would have been nice to blame the rain or the flu shot for my suffering but I knew better. Unable to sleep I found myself ruminating over an aphorism I first heard as a third year medical student, spoken by a man who lives in my heart as my mentor.
“Some days the sickest patient you’ll see … is yourself.”
When I was in medical school, my alma mater, the University of Tennessee, offered third year students $100 a week to study Family Practice in an underserved rural area for six weeks hoping to encourage medical students to choose a career in primary care medicine. I accepted, valuing a chance to go home, eat some home cooked meals, and temporarily escape life on the bottom rung of the medical hierarchy. Fortunately, I was assigned to the most respected and, consequently, the busiest physician in town, Dr. B., with no idea of the invaluable life-changing experience ahead of me.
This experienced doctor shared many aphorisms and anecdotes over those six weeks that continue to guide me in my practice today including such topics as health care reform, the role of government in the patient-doctor relationship, medical ethics, and simple human decency. Whenever I feel ill the above aphorism fuels my responsibility to still care for my patients, despite my own illness, but he had much more to teach than personal accountability and toughness.
He was the only teacher to shed light on the combination of psychology and business in primary care medicine with a lesson I remember as “The House Special:”
Dr. B’s House Special - 1cc each Celestone, ND-Stat, and Gomenol given IM
One of the first of his first patients who I saw told me she was sick and needed “The House Special” because she had work to get done. Thinking this patient likely had a viral infection and confused by her request, I repeated it to Dr. B. A wry smile crossed his face as he shut his office door and patiently explained.
When Dr. B graduated from medical school, physicians were permitted to write a prescription for placebo pills. The patient was unaware the prescribed treatment was a sham and pharmacists participated in the illusion. Since the patient was expected to benefit from the placebo effect, this approach initially was not considered unethical. Dr. B. went on to explain that a patient, given nothing for aches and pains but a lesson on the inability to treat a virus, more often than not will go doctor shopping until another physician, “gives her what she wants.”
For the doctor, this would be bad for two reasons: first, as a small business owner, a practitioner couldn’t afford to run off too many customers; and secondly, patients would often get something they don’t need (e.g. antibiotics) from someone else, who would then get to keep their future business. Looking back on that now I see it both as a medical rationalization and a fiscal reality and I am struck that doctors, today, remain unable to separate these two realities for many patients.
He had decided to give his patients his “House Special”, if requested, when they had a viral URI yet didn’t have to prescribe antibiotics nor worry that his patients would go elsewhere. He further advised that the “experts” — a word that derisively dripped off his tongue — would look down their noses at him but would go out of business if they left their protected academic world. I was not supposed to learn nor remember (too late) the exact formula of his shot but rather to understand that I would need to find the middle ground between my patients’ expectations and scientific reality if I were to succeed in my future.
Decades later, I practice medicine in the information age and struggle when some patients tell me what they want instead of asking me what they have, which leaves me feeling less like a physician and more like than a short-order cook. “May I have the Tamiflu Special with a side order of Zithromax? And I want to super-size my order with a note for work?” What would Dr. B say now that his House Special is off the menu? I can’t be sure, but with his sense of humor I imagine him asking, “Would you like fries with that?”
Until next week, I remain yours in primary care,
Steve Simmons, MD
So what’s the aphorism?