On the diagnostic trail of ‘dizzy and tired’ with Dr. Max and Dr. Min

Dr. Max and Dr. Min are conscientious, seasoned family doctors, experienced in the complexities of family medicine, responsive and well-liked by their patients. But they do their consults very differently.Today they see a 70-year-old lady, “Grandma,” coming in by bus, accompanied by her daughter who translates. (Note: Dr. Max and Dr. Min are NOT both in the room at the same time. In fact, you have to read the following story as if it occurred in a parallel universe): “She feels dizzy and tired . . .” Began her daughter. Not great historians, they waited for the doctor to respond.Dr. Max typed into his computer record “dizzy and tired,” populated his SOAP (Subjective/Objective/Assessment/Plan) template for 1) dizziness, and 2) fatigue. He anticipated the numerous differential diagnoses, methodically probing with a dozen questions to narrow down the possibilities.Dr. Min felt an odd curiosity, but not sure why. Maybe it's the way the daughter said it? She blurted, “what happened recently that made you decide to bring her in to see me?”But the daughter did not elaborate, simply reiterated “she's more dizzy and tired now.” Dr. Max and Dr. Min both then performed a thorough physical exam, which revealed: poor dentition, frailty and weight loss. Blood tests were ordered, showing . . . Low serum ferritin, mild anemia. Extremely low vitamin C and D levels.Dr. Max phoned them to probe the causes of anemia. He also advised supplementing iron, vitamin C and D, and to eat better generally. To fully investigate unexplained weight loss, he ordered chest x-ray, abdominal ultrasound, and arranged for stool occult blood testing. He thought of doing endoscopy to rule out malignancies, ulcers, and gluten enteropathy, but held back for now. Dr. Min simply asked the daughter, “how is she eating?” “She's not eating well,” stated the daughter. Dr. Min persisted, “Why is she not eating well?” pause, then the daughter finally admitted . . . “There is no food”The daughter explained that a big portion of their social assistance money went to pay rent, with little left for food . . . but the next cheque wouldn't arrive for another week.Dr. Max found this out too, after the chest x-ray, abdominal ultrasound and stool test came back normal. He made sure the daughter wrote down the locations of a few local food banks. She thanked him.Dr. Min learned, after some coaxing, that they used up the last of their monthly bus tickets to come to her, so could not even get to food banks. She promised to drop by the apartment after work, to bring some groceries. In the evening, when she helped the family carry up the food, she stared, with disbelief, into a completely empty fridge. Seeing bags of grocery they smiled, Grandma, the daughter, and her three little grandkidsDr. Max did not see the family for a while, assumed that things got better. When they did come in, he suggested a referral for endoscopy for completeness sake, but they politely declined. He asked them to measure Grandma's weight regularly and let him know if further loss. They thanked him. Dr. Min kept up a correspondence with the family's social worker, to obtain extra assistance, and occasionally discuss the grandkids' learning issues related to school. Part of receiving social assistance required the daughter to do temp work. This meant busing four transfers each way, consuming three hours daily, which could have been better spent caring for the Grandma and grandkids. So Dr. Min wrote more letters. And occasionally dug into her own purse. Many years passed . . . then one morning . . .“Grandma passed away last night”One of the grandkids, now an adult, left a voicemail for the office. She looked after her Grandma through the last years and final days of dementia, along with her mom (the daughter), tenderly attending to her at home. She also invited their doctor to join in the virtual memorial service.Dr. Max declined, citing his schedule conflict. He reasoned (to himself) the importance of that “professional distance,” to allow a family to grieve, or celebrate, without triggering painful memories of the illness and dealings with healthcare, which he believes he represents. Dr. Min logged in on the day of the service. She watched as the three adult grandkids tried outdoing one another on the podium paying loving tributes to their grandma. All relished those special potato pancakes grandma used to make for them as kids. Suddenly, and with a start Dr. Min realized . . . the true diagnosis of “dizzy and tired” from so many years ago was this . . .When the family was running low on food, Grandma starved herself to feed the grandkidsDr. Min marveled at the way this family pulled through those hard times. Perhaps even the family forgot this lovely woman saved her food portion for the grandkids, but in that sacred doctor-patient moment, Dr. Min paid a nod of respect. She felt grateful, and humbled, to witness this beautiful life, this amazing family.Dr. Max, too, despite missing out the service, was thinking about this family. He often got the sense that there was something more “psycho-social” going on. He wished he had a “team,” a social worker who could probe more, a nurse practitioner who could make house-calls. Dr. Max continued to refine his SOAP templates, hoping it would make his consults more efficient, his diagnoses more accurate. He also added disclaimers for virtual care, and many pertinent negatives to ensure that, if he ever gets audited by his college, or sued in court, those looking at his notes will conclude that he thought of everything possible. AfterwordWhile Dr. Min got to the root of the diagnosis and Dr. Max didn't, I wouldn't give Dr. Max a hard time. Both had been there for this family over the long haul. And if that's not good enough, I don't know what is.Dr. Adam Chen is from Oakville, Ont. He helps run a WhatsApp chat for OMA's Primary Care Solo Doctors Medical Interest Group, for collegial support and practice survival tips. Ontario family doctors can join by contacting adamchen@live.ca.

On the diagnostic trail of ‘dizzy and tired’ with Dr. Max and Dr. Min

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