Patient by Patient is the memoir of a young doctor, fresh from residency, as she explores the joys and frustrations of beginning her medical practice. As she strives to help her patients face a range of challenges from the humorous to the profoundly devastating she learns that while medical school gave her an M.D., treating patients has made her a doctor.
At the same time she is working with her patients she is also struggling with illness in her own family. Through her shifting perspectives of doctor, daughter, and granddaughter, she contents with the process of dying, the experience of grief, and the buoyancy of the human spirit.
Dr. Transue began chronicling her experiences in her memoir of residency, On Call, and she continues her education here but the source of her knowledge about love, loss, hope and healing are not medical texts or professors but the patients she treats and gets to know – those she helps to wellness and those she must let go.
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Emily R. Transue, MD, author of On Call, is a native of Toledo, Ohio, and a graduate of Yale College and Dartmouth Medical School. She did her residency and chief residency in Internal Medicine at the University of Washington, Seattle. She works as a general internist at a multispecialty group in Seattle, and is a clinical Assistant Professor at the University of Washington. She received the Providence-Seattle Medical Center Outstanding Educator of the Year award in 2003, and is a Fellow of the American College of Physicians. She has also published stories and poems in JAMA, Dartmouth Medicine, and elsewhere.Excerpt. © Reprinted by permission. All rights reserved.:
Patient By Patient
BEGINNINGS1. ANOTHER BEGINNINGAs I pressed my new parking sticker carefully onto my windshield, I paused to consider the enormity of what the small sliver of plastic represented. At the age of twenty-nine, with twenty-four continuous years of education under my belt, I was about to begin what could be called my first real job. My new business card burned in my pocket: "Emily R. Transue, MD, General Internal Medicine." I was starting practice as a primary care physician.With a laugh, I thought back to the day I'd decided to go to medical school. It was early in my senior year in college; I'd been a biology major, scrambling for a new career path after realizing I didn't want to spend my life at a lab bench. I'd done Parkinson's research with primates, and reasoned that if monkeys were interesting, people must be even more so. I called my grandparents to announce my momentous decision."But we hate doctors," my grandmother protested.Through all my years of medical training, whenever a physician amputated the wrong leg, administered the wrong medication, or made some other terrible mistake, my grandmother would send me a news clipping. I was never sure if these were warnings about what might occur if I applied myself inadequately, or simply further evidence forthe argument that physicians were an untrustworthy lot. During my second year of medical school, she called to tell me that my grandfather had developed atrial fibrillation, an irregular heart rhythm. It's usually treated with blood thinners, to reduce the risk of a clot forming in the heart and traveling to the brain, and cardioversion, a brief electrical shock to restore the heart rhythm. "They're giving your grandfather rat poison," my grandmother declared. Rat poison is made from warfarin, the same compound used medicinally to thin blood. "Then they're going to electrocute him."I had to admit that these were precisely the kinds of barbaric things that people in my chosen profession did.
Still, here I was. Absurdly, the parking sticker brought home what my contract, my application for hospital privileges, the ordering of office letterhead and exam room supplies, and all the other events of the past weeks had not. In the eight years since I had started medical school, everything I had done had been temporary. Student clerkships lasted four to eight weeks, residency rotations a month. My year as a chief resident, teaching and helping run the program I had finished the year before, was the longest I had spent in any single role, and even that was clearly defined as transient; my successor was chosen before I'd even started. In all that time I had hung temporary parking placards from my rearview mirror. The sticky teal rectangle on my front window seemed to symbolize the end to transience and the unfamiliar permanence I was entering. After eight years of working toward this role, I had arrived.A few weeks before, the ink barely dry on my employment contract, I had signed another sheaf of papers, buying a house with my sweetheart, also a doctor starting his first job. Our possessions were still in boxes, the wonder of owning a piece of land and the home that sat on it still fresh. As I finished affixing the parking sticker and walked into the angular brick and glass building of the clinic, I was bursting with the richness and strangeness of my new life. I had ahouse, a job, a piano, two cats, a life partner. I was a long way from Ohio, where I grew up, and from New Hampshire, where I went to medical school. I was far from my family. My brother was doing computer work in Boston; my mother had left her college professor position in Ohio to go to law school in Washington, D.C. Most acutely, I felt my distance from the ones who weren't well: my father, who recently had moved into a nursing home in California, and his parents--the ones who hated doctors--who were close to ninety but still living independently in Pennsylvania in the house where my grandfather grew up.Nonetheless, I had laid down my roots here, in Seattle. I could feel them in the earth under the maple tree in my new front yard, and even in the glue of the parking sticker. I was about to walk into the clinic and begin to grow roots of another kind, putting on my white coat and meeting strangers who would become my patients, as I grew into my role as their doctor.I felt the joint tug of responsibility to the people I loved and to the patients I would begin caring for today. I had finished the hard years of residency, the hundred-hour weeks and thirty-six-hour shifts, the drama of the hospital and the emergency room. I had seen a lot of people die or nearly die in those years, and I thought I knew plenty about grief and loss and healing. I little imagined how much more and how differently I would learn in the coming years. Much of this would come from the patients I would care for, not just in the episodic crises of the hospital but in the slower, richer arc of sickness and health that a primary care doctor sees. In parallel, my first years in practice would be tumultuous ones for the people in the world I loved most, and I would see more than I ever had of medicine from the other side.I could only begin to glimpse all this, as the sliding doors opened to admit me to the cool, quiet air of the clinic. My heart sped with a mix of anxiety and excitement as I stepped inside, savoring the newness, and looking forward to a time when I could savor familiarity instead.2. FIRST DAYSThe first patient I saw, that first September morning, was a young woman with sciatic back pain. "I bent over to pick up a pile of books and there was this sudden, terrible pain in my back. It shoots down my leg all the way to my foot."She was uncomfortable, but not in crisis. It was a simple problem; a medical student would have known what to do. I gave her medication to reduce the inflammation and to quiet her pain. I told her which activities she should and shouldn't do, when to expect the pain to get better, and when to call me if it didn't. The interaction went just fine, but I don't know that I had ever been as nervous managing a heart attack or massive stroke as I was with that young woman's sore back. I schooled my voice carefully to keep it from trembling. I double-checked the details of the prescriptions I had written, which looked oddly unfamiliar on the fresh pad printed with my name. The question kept popping into my mind: What if what I'm telling her isn't right? I had to keep reminding myself that it was, that I did know how to do this. I'd had similar conversations many times in training, but afterward I had always gone to present my findings to my supervisor, gotten advice or a stamp of approval. From here on, though I could and often would ask advice of my colleagues, there would be nobody above me. I was on my own. With that first patient, that fact in itself was terrifying.My second patient had a urinary tract infection, and was a little easier. The third was in for a physical exam, and soon I was so caught up in learning about her history and her concerns that I didn't think to be nervous. By the end of the day the fact that I didn't have to run things by anyone didn't seem so strange. By the end of the first week I had stopped thinking about it.
My clinic is a large, doctor-owned group, which represents almost all the medical specialties. I chose it partly for this, knowing I would have colleagues to talk to, to ask questions of, to learn from. I had completed four years of residency training on top of the four years of medical school. I had passed my specialty boards in Internal Medicine. "It's like being a pediatrician for adults," I explained to friends who didn't know what an internist was. "No kids, no OB, no surgery, but pretty much everything else." I had the tools I needed, but there was lots of practical, day-to-day knowledge I had yet to learn. They call it "practice" for a reason, I reminded myself.The clinic building was yellow brick and glass, with several wings built at different times. Medical buildings, ever-expanding according to need, have always reminded me of swallows' nests, the structures of one era tacked onto those of the age before. My office was on the second floor in the older part of the building, its window looking out onto a quiet street and the steeple of a nearby church. I had my own medical assistant and would soon hire a receptionist (the title would later change to "patient service representative," roles shifting and evolving like the building, like medicine itself). I had two examination rooms, small and neat but a little dark. After years of rotating through rooms in the resident clinic, I realized to my great delight that these rooms were mine to set up as I chose. I replaced the ugly, industrial mirror in each room with a pretty, modern one, and added a floor lamp. Suddenly the rooms seemed brighter and the note of dinginess was gone. I began to fill the walls with photographs, the plain yellow paint giving way to scenes of mountains and wildflowers. I put fuzzy covers on the cold metal stirrups of my exam tables. After a few weeks I realized that the rooms no longer felt like just exam rooms: they felt like my exam rooms. It was a subtle difference but a transforming one.As I rearranged and settled into my office and my newly boughthouse, I felt that I was building a home of sorts in both spaces. My new life was beginning to take shape.
The saving grace of starting practice was that I had friends from residency going through the same thing. Periodically we would gather to debrief about the strangeness of this new world."I saw this guy in coverage today that I wanted to steal from his regular doctor.""Steal?""To have him come to me for primary care. You know? He was just such a nice guy, we had a great chat. If all your patients were that nice, it'd be the perfect job."I laughed. "I've had people like that. You think, I would smile every time I saw you were coming in." I thought of a sweet seventy-year-old I had seen that day with nosebleeds, anxious to have them stop before she went to Europe with her son. We'd talked about my trips to Europe with my mother, about Italy, about grown children traveling with their mothers. She'd smiled, and as she was leaving she said shyly, "You're nice--" In that moment all the years of work I'd done to get to this job felt worth it."It's so weird having such an open schedule. We didn't have this much time for new patients when we were residents, even.""I know. It's neat, you feel like you really have time to talk.""Sure. But I find myself doing these ridiculous things, just because I have the time. I feel like I need to do all the health care that people haven't had in the last five years. Someone comes in for sinusitis and I have an empty schedule so suddenly I'm reviewing their whole family history and giving them a tetanus shot and trying to check their prostate. They're like, 'I just wanted antibiotics!'"I nodded. "I did a Pap smear yesterday on someone who came in with an earache."He giggled. "Poor people ... .""It's kind of like an assault.""'Leave me alone! I felt bad enough when I came in here.'"
Meantime, I was learning a new kind of medicine. Residency had trained me brilliantly to think of things to worry about; I was not so adept at deciding which of those I needed to take seriously. Much of my training had been in the hospital, where we were dealing with urgent issues and often doing lots of tests at once. The rhythm of clinic medicine was different; few problems were emergencies, and it was usually better to approach the evaluation one step at a time. Furthermore, in contrast to the hospital where almost everyone had something seriously wrong, in clinic half the challenge was figuring out who wasn't sick. The hardest part was often reassuring people that their bodies just needed time to heal on their own.Though the approach was different, the learning curve was as steep as it had been in residency, those packed years of specialty training after medical school. A lot of the time I felt like I had then: excited, and exhausted, and thrilled to be finally doing something that I'd been training for so long. I wasn't yet efficient at clinic medicine, so the difference between a too-quiet schedule and a too-busy one was only a few patients. I could turn on a dime from feeling restless to feeling overwhelmed. My practice grew quickly, though, and my skills grew with it. I was startled to realize one afternoon that I had comfortably seen more patients in half a day than I had in my entire first week.
Some weeks after that first day, a young woman who looked vaguely familiar came in to have a physical exam. She smiled brightly and told me that her back pain had gone away just when I had said it would. Glancing down at her chart, I realized that she had been my very first patient from my very first day. It seemed much longer ago than it was; I couldn't imagine having been quite so nervous over a simple problem just a month or two earlier. She looked around the room and admired a photograph of a rose from my front yard."Looks like you've settled in," she said."I have."3. CODING AND COMPLIANCESeeing patients was easy to get used to, but the financial and administrative side of medicine was considerably more challenging. During my first week I had a long and baffling meeting with the people from a department I had never previously heard of: Coding and Compliance. The Coding and Compliance staff had the unenviable task of teaching me in a few hours how to bill for the work I do. This had barely been addressed in my four years of post-graduate specialty training, much less in medical school. I'd had eight years of medical training, and nobody had acknowledged that this was a business as well as a calling.The medical billing process is based on codes that are marked down for each visit. There's one type of code for the visit itself, which depends on the visit's length and complexity. There are also codes for procedures: Everything from heart surgery to giving a shot has a distinct code. Each of these is then linked to a separate diagnosis code--what the visit or the procedure was for. This seemed simple enough. But when the Coding and Compliance specialists--Karen and Linda--started talking, nothing they said made sense. I flashed back to a time when I tried to speak French with someone who was Belgian; the words sounded right, but no actual communication occurred. I wondered if, as on that earlier occasion, it would be better to use mimes and hand gestures.Karen began. "You've got your basics, your E and M's and your preventatives." I took a breath to ask what these were, but she was already continuing. Somewhere I could remember having heard "E and M" before. Random paired letters flashed through my mind--A&P grocery stores, A&W Root Beer, B&O railroad--wait. I had it! "E and M" was "Evaluation and Management," the code for a visit about a problem. I struggled to catch up to what Karen had been saying in themeantime. "Remember that news are different than follow-ups, although if they've been seen by someone else in the clinic in three years they're not a new, unless it wasn't in your specialty. Remember if it's a consult you have to code a 9...
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