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Journal of the American Academy of Physician Assistants:
doi: 10.1097/01.JAA.0000437816.23161.57
The Art of Medicine

The end of something: When convenience trumps care

Maurer, Brian T. PA-C

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Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com.

Tanya Gregory, PhD, department editor

Four-year-old Jonah is here to have five staples removed from his head. They were put in place 10 days ago to close a scalp laceration incurred when he and his parents were visiting family out of state.

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“Where did you take him for care?” I ask his mother.

“To the pediatric practice where his cousins go,” she says. “They were very good. Jonah did well there, didn't you, Jonah?”

Jonah nods his head. He says nothing. Historically, he has been a quiet child. I've taken care of Jonah since he was a newborn. I've never seen him kick up a fuss, not even when he had to have his blood drawn time and time again.

“Let's have a look at those staples,” I say. Immediately, Jonah drops his chin so I can see the back of his head.

There they are, five stainless steel staples all in a row, straddling the remnants of a 3-cm gash. The wound appears clean and dry; there is no drainage. It looks good.

“I'm going to clean the area with some alcohol, Jonah,” I say. “It will feel cold, but it shouldn't hurt.”

Jonah holds his head still while I dab the wound. He doesn't budge; he doesn't cry out. Jonah is a good patient.

I recall the day when Jonah's father brought him to see me for another bout of croup. Over the years, Jonah has had many episodes of croup.

“My wife would like to have a blood test,” Jonah's father explained. “She's worried because he seems to get sick so much.”

“A lot of children Jonah's age get frequent coughs and colds. They're exposed to a ton of viruses at daycare. They have to be challenged with a bug to build up immunity to it. There are literally hundreds of these viruses out there, so they get sick a lot. The good news is that the frequency of these sicknesses drops off considerably as they get older.”

“My wife would still like to have a blood test,” Jonah's father said.

I gave him an order for a simple CBC. “We'll check—just to be sure,” I said. “It will probably come back fine.”

With the exception of a low WBC count, Jonah's blood test was normal. His ANC—absolute neutrophil count—was low as well, just a tad worrisome. “Let's repeat it in a month,” I told his father. “It should be normal by then.”

We did, and it wasn't. Jonah's WBC count had dropped even lower, and his ANC came back zero.

This was shocking news. There was nothing for it but to send Jonah to see the pediatric hematologist-oncologist. Eventually, Jonah was diagnosed with autoimmune neutropenia. His body was producing antibodies against his own WBCs. Extremely low counts predisposed Jonah to overwhelming infection. Yet Jonah continued to look perfectly well.

“We have to be proactive if Jonah develops a fever,” I told his parents. “He needs to be evaluated right away and have his blood drawn so we know where we stand with his WBCs.”

Jonah's parents said they would follow the recommendations. But when Jonah developed significant fever while they were away on vacation, they treated him with acetaminophen and waited. “He got better on his own,” his father told me. Once again I explained the need to be extra vigilant when Jonah got a fever. Once again the parents said they would comply. Slowly, Jonah's WBC counts crept back toward the normal range. His ANC remained borderline low. More importantly, his health continued to be good.

“Now hold still,” I say, as I slip the jaws of the staple remover underneath the first staple in the back of Jonah's head. Deftly, I extract the staple from Jonah's scalp. “Good—one down, four to go.” The remaining staples pop out in a jiffy. “How's that? Want to see the staples?”

Jonah shakes his head, but he looks anyway. Jonah's parents seem pleased. Everything has worked out well. “You are my best patient,” I tell Jonah. His parents beam twin smiles.

I retreat to my office, pleased that I have been able to help and support this young family over the past 4 years. They are good people. Jonah is one of those patients I look forward to seeing whenever he comes to the office.

I jot a note and return Jonah's chart to the bin. My eyes glimpse a paper lying in the basket: a transfer request signed by Jonah's parents, dated today. Under “Reason for Leaving” the words appear: “Would like a doctor closer to home.”

There you have it, I think. Convenience trumps quality of care. Somehow I always thought it was the other way round.

© 2013 American Academy of Physician Assistants.

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