Two Patients

So, on Tuesday I had a busy day. Two cases – that is, two people, two patients – stand out.

Patient #1 was a prepubescent boy who complained about an instance of burning when he urinated. A urinalysis was normal, and my exam was normal – uncircumcised male (we wouldn't have such a complaint with a circumcised male, by the way) with partially adherent foreskin to the glans penis, which is not a problem. I could have said “it's nothing” and let him and his father go with reassurance and telling him to drink more water, but I thought I would take a minute and take advantage of the situation.

So I told him that I was glad that he had said something about the burning, because many kids are too shy about talking about their penis, and it's good that he spoke up. Then I said, “You know, you haven't started puberty yet, but you will pretty soon, and you'll notice first that you testicles (your balls) will start to get bigger, and your scrotum (the sack) will stop being so smooth and will develop ridges, which we call rugated.”

He was looking down at his shoes, occasionally glancing up at me.

“And get hair,” he said softly.

“Right,” I said. “And then your penis will get bigger.”

His eyes opened wide, then he looked down again.

“We've all been, through it,” I said. I nodded over to his father. “He's been through it, and I've been through it. It happens to all of us.”

“And not only that, you'll start thinking about girls differently, probably. And sometimes your penis will get hard, even when you don't want it to.”

With this he put his face in both hands and bent over as I talked, completely embarrassed, but I kept talking.

“It might get hard at embarrassing times, and you'll turn away so no one will see, if you can. Once, when I was in high school, one kid was in the Senior Play, and he had to come on the stage in tights. So he came on, and he had to stay there, and his penis got hard, and everyone in the whole audience could see. We were real quiet, except for one of my friends, who said 'Look at Roger!!'”

Laughter, all three of us in the exam room. Commiserating.

“So, these things happen. It's good for you to talk to your Dad about whatever you want to, about your penis. I'm glad you said something to him today about how you felt the burning. It's important to talk and not feel embarrassed.”

“Actually,” he said, “I told my Mom.”

“Well,” I said, “that's good, too.”

I figured I had done some good; I hoped so. I was back in the office I share with Mary, our office manager, and she came back and said, “That patient you just saw? His father just asked if they could come back and see you regularly.”

Mary is so proud of me. I like that. Of course, with my schedule, one half-day a week, it'll be hard for them to see me, but I think I did them some good. Hopefully. Nice family. Nice kid.

Then later in the day I saw a 15 year old boy who used to be with Kaiser and now came in for his first physical with our office, this patient also with his father. Again, I was able to take some time and the later patients understood when I was a little late with them. With these patients I know I can't check everything, especially the first time, so I try to zero in on what's meaningful to them and what I maybe can help a little. I want them to leave the office somehow better off, in some way. Getting to a significant issue is helped by having them fill out questionnaires, but truthfully, I've been doing this a long time, and it's that experience that really helps find the soft spot. So with this patient just going into his junior year of high school, I soon discovered that it was school performance that was the problem. He had a sensitive and nice father with him who suggested that he excuse himself while I talked to the boy, which is what I normally do anyway, but it's nice when the parent suggests it, which they do with some frequency, it turns out.

It's kind of complicated with this kid. He's obviously a smart kid, just from talking to him, or smart enough, anyway. He's tall if not heavy, and he plays cornerback for his team, but he's not a macho kid. I asked him what his GPA was last semester, and surprisingly to me, it was below 2. How it got there I'm not sure, but it used to be higher. No drugs, no alcohol, no big problems I could find. In fact, it turns out he loves history, of all things. But he says, basically, he thinks there's no future in history. I think that's because we all hear about needing math and science and engineering, but this kid loves history. He also likes science, and as luck would have it, I'm a history and science guy, too. So I was able to connect with him on that, strongly, and tell him that he was lucky to have such a great focus, and that history is the mother of all study, in my book. Don't think it's useless! It will lead somewhere good. He even told me with pride of things he knew in class that no one else knew. How, I wondered, is this kid not doing well?

Turns out that he lives one week with his father and one week with his mother. It's not so great to go between two houses. I almost told him that that was what I made my first two kids do, but resisted this time, for the sake of time. Both parents try to help him, but his mother is angry with him a lot – I didn't have time to figure this out, but lots of times parents get very afraid for their kids when they aren't doing well, and they get angry at them as a result, fearing for their failure in life. Didn't have time to go into that; I had patients waiting.

He said that what he needs is someone just to set him on task, to say, basically, OK, time to study now, and then leave him alone. I also asked about help at school, and he said his counselor is good, but it seemed that she couldn't help him with his problem. His problem seemed to be, and he was amazingly self-analytical about this, that when he gets stymied about something, he just stops and gives up, and he should persist. He started out well in the year but got behind and couldn't catch up. I thought that I wished he could get some tutoring about this, but I doubt that his family had the resources.

We talked about college and the need to get ahead. He hoped that his football would get him in somewhere, and somehow he had heard from a coach that football was the important thing, and that when he gets to college the studies will be helped by the coach, or something like that. Sounded bad to me and I tried to set him straight.

I kind of got caught here. What more could I do? I probably should have urged him to come back, and talk more with his father about this issue. Maybe I should call him back, or talk to his father and see how he's doing and what more I could do in directing them for help. I did give him a talk about studying being a marathon, and you just have to keeping training yourself and go farther each time. But I don't think that's enough help to give him. I'll need to do more.

Is this medicine? Well, it's his most important problem. At the end he said his father wanted to talk more about nutrition because he doesn't eat red meat or fish, but he does eat chicken, so I told him that's fine and make sure he gets fruits and vegetables. So I did some minor medicine. But I can't help thinking that I should be doing more with him, at least get him and his parents talking more about it. I think I'll try giving them a call next week. I keep thinking that someone else would have done it better.

Now, one small reflection for a recurrent concern of this blog. Look at what I did with these two patients. How could one ever detect the quality of these visits? Quality assessment is an area of immense concern in medicine, and the scientific approach they have taken is to survey what questions have been asked, what shots have been given, what fields have been “covered.” That's fine as far as it goes, shots are important, talking about nutrition is important, talking about sex and drugs is important, God knows; it should all be done. But if you think about these two visits, doesn't the quality of the care rest with making real, personal, concerned contact with the patient, finding out what the issues are, and seeing what can be done to help? It's just so personal.

The problem with assessing quality of care as we are now doing it is that, if you were going to assess these visits for quality, the most important things I did would be entirely overlooked. Moreover, if they were to assess my quality continually, they would be giving me all kinds of incentives not to take the visits in the directions I did, but in the first case just to say “you don't have an infection, drink more water,” and in the second case, to give detailed instructions about nutrition and to refer the patient for counseling at school for school failure, and onto the next patient.

On our fabled American Academy of Pediatrics Section on Administration and Practice Management (SOAPM) listserve, we call that LUC – the Law of Unintended Consequences. The problem with quality assessment is just that – you think you are doing good by measuring the hell out of things, but in fact, LUC takes over, and you take the humanity out of what needs to be a humanitarian science.

I think I'll call that kid and his father next week, see what I can do. I hope they don't have a high deductible health plan, which would make any further visits unaffordable for them. Maybe they have Medicaid....

Budd Shenkin