Sixty-nine-year-old-Ruby came in for her annual pulmonary evaluation. Among other complaints, she was putting on weight. Her exam confirmed a 20-pound weight gain since her last evaluation. Ruby stated that the extra pounds were NOT from the food she was eating. “In fact,” she said, “I have to eat 5 or 6 times a day because otherwise I wouldn’t get enough.”
A 43 year old Pickwickian male with hypersomnolence and alveolar hypoventilation secondary to the 325 pound weight was being evaluated. I began a serious discussion on reducing his caloric intake, even if only 500 calories a day which would equal one pound per week. After a few minutes, I noted that his hand opposite from me was going back and forth with a 64-ounce plastic container with a cap and a straw–one of those 2,000-calorie fast food milk shakes. I asked him how many of these milk shakes he drank per day. He said, “About six. Aren’t we supposed to drink a lot of fluids?” This man drank 12,000 calories a day on his way to the table before he even counted the calories in his food.
When I was a resident in medicine at Wayne County General Hospital, we had a diabetic patient whose widely fluctuant blood sugars defied all attempts at dietary and insulin management. One day, while on staff rounds, the RN informed us that she had found several cartons of candy bars in this patient’s bedside table. When we confronted the patient, she readily admitted that every day she consumed two cartons of candy bars–that’s 24 candy bars in 24 hours. She then added, “Doesn’t everybody?” She didn’t start counting calories until after two cartons of candy.
A 5′ 2″, medium-framed, 43-year-old female patient weighing 285 pounds couldn’t understand why she was gaining weight. She assured me that she was only eating one bowl of peaches per day. I looked her in the eye and told her she had to reduce that to half a bowl and proceeded with my medical interview.
A woman with asthma refused to be weighed. My PFT tech said we needed a weight statistic to plug into the computer so it would read out the normals for the pulmonary function test. Still she refused–though she admitted to at least 350 pounds which we accepted since weight is a secondary factor in interpretation only. She said she had not eaten in days. But we noted that she required a 32 ounce soft drink from the coffee shop with at least 500 calories in it to get through the several breaths and 25 minutes required to obtain a complete PFT. Twenty calories per minute does add up.
And then it happened. A stout, forty-year-old woman who carried her 220 pounds well, tried to establish medical care in my office after six unsuccessful ventures with other physicians. Among other complaints she wanted some of her calories removed surgically. After an hour in my lab and an hour and a half with me–and still an incomplete history–I felt so sorry for her that I quickly completed four short appointments that followed her and continued with this desperate woman for another hour. At 5:30 I felt that I could perhaps accommodate her in her search for a sympathetic physician and help her in her medical confusion. Then I said, we’ve been here for 3-1/2 hours and I had to bring this medical evaluation to a close. She responded, “We have not yet even begun to scratched the surface of my medical problems.” She had no significant medical illnesses that I uncovered during those hours. I then closed the medical file, looked her in the eye and told her that there was no way that I or my office and staff would be able to meet her medical needs, and that I was sorry that I would be number seven in her quest, but she would have to call her HMO in the morning and get herself reassigned to another physician. However, I was unprepared to spend another eight hours in responding to her HMO, the Managed Care Organization, the Medical Society, and her numerous letters concerning the care she had received in my office. She stopped payment on the $10 co-payment check because the 3-1/2 hours had no value to her. My office manager put the check through again six months and one day later. It covered about 75ยข an hour of my $75 an hour office overhead. Despite this unfortunate incident, I believe we all must periodically try to help the desperate in order to maintain our perspective on the foibles of patient care.