Lee A. Resnick, MD, FAAFP
Nothing represents the breadth and scope of medicine quite like urgent care.
The variety of complaints is daunting and requires a lifelong commitment to learning. Specialist back-up is scarce and diagnostics limited. Ultimately, the best care stems from a passion for examining the layers of each story, watching, listening, and compiling.
Cultural, gender, and age biases can serve to guide our investigations or derail them:
- Where is this patient coming from?
- How are they interacting with others in the room?
- What do they think is wrong with them?
- What do they think will help them?
- What are their misconceptions of medicine?
If we don’t take the time to reflect on the subtle clues our patients are giving us, we stand to miss the one opportunity we have to help them.
Consider the following:
20-year-old female with shortness of breath and dizziness Severe underlying depression for years, as of yet undiagnosed and untreated. Drinks 10 Diet Cokes per day, frequently skips breakfast, and smokes a pack of cigarettes per day. No other findings of organic illness. Diagnoses:
- Panic attacks
- Major depressive disorder
- Caffeine and nicotine dependence
The patient is shocked that we can actually help her; she never knew how her lifestyle and depression could contribute to such disabling physical symptoms. On the way out, she comments that she feels hopeful for the first time in years.
34-year-old male with shortness of breath and dizziness
History reveals a physically active male with no medical problems but whose father died “naturally” in his 40’s. The patient denies chest pain and has a normal EKG. Initial cardiac enzymes negative. Nonetheless, he is admitted to hospital on suspicion of coronary artery disease. Catheterization reveals extensive three-vessel disease.
The patient undergoes coronary bypass surgery, and maintains a physically active life without any complication.
80-year-old male with shortness of breath and dizziness
On multiple medications for blood pressure, all of which he believes he is taking appropriately. Exam reveals a pulse of 38 bpm. The patient is later found to have taken too much Lopressor.
70-year-old widow with shortness of breath and dizziness Extensive history and physical reveal no clear underlying cause. She spends most of our encounter sharing stories of her late hus- band, asking if I am married (which I am) or if I am related to any of the “other” Resnicks in Cleveland (which invariably I am not).
There is no diagnosis. There has been no recurrence, to date. But she does drop off a box of chocolates for all my “fine work.”
Four patients with the same complaint, but wildly different causes.
This is urgent care, the ultimate in investigative medicine: gathering evidence, evaluating clues, trusting your gut, posing hypotheses….
Every complaint, no matter how benign, represents a potential life-changing event for patients and physicians alike. We are at the front lines.
If we are right, we can be the hero. If we are wrong, the goat. We have the nearly impossible task of establishing the trust of a complete stranger, identifying their agenda, evaluating their problem, and curing what ails them (or explaining why we can’t) all in about 10 minutes.
This is what keeps me up at night, yet, keeps me going. This is the challenge and joy of urgent care. There is nothing else like it in medicine.
