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The Art of Medicine

Empathetic medicine: What's bred in the bone

Maurer, Brian T. PA-C

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Journal of the American Academy of PAs: August 2013 - Volume 26 - Issue 8 - p 73
doi: 10.1097/01.JAA.0000432575.36936.6b
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Decades ago during my early years of practice, shortly after performing rescue breathing on a pallid, limp toddler, I contracted a nasty enteritis. It ran its course over a period of 10 days. At the time, sick as I was, I remember musing to a colleague that an occasional bout of illness permitted us clinicians to better empathize with patients in their time of distress. My colleague looked at me askance, unable to muster any meaningful response.

Twelve days ago, five screws and a plate were surgically removed from my right ankle. The wound is healing nicely. No discharge appears on the daily dressing; the incision remains clean and dry. My initial postoperative discomfort responded well to generic ibuprofen; there was no need to dip into the oxycodone I was given. Once again, I am back in harness, busy at the office.

As usual, this Monday is hectic. By mid-morning my schedule is full; now they are double-booking patients in the same time slot. I step in to see the latest addition to the roster, a 2-year-old previously diagnosed with shaken-baby syndrome. Her foster mother has brought her in with cough, cold, and fever.

“Her ears are congested,” I explain. “It looks like she's headed for her usual bout of ear infections.”

“What am I gonna do with you?” the foster mother coos to the limp bundle in her lap. The blind child can't see her face; still she smiles in response to the woman's voice.

“You'll be seeing my 15-year-old niece next,” the foster mother says. “She's in for her yearly checkup. She never gets sick, but I wanted to make sure you knew about her ankle. It's been bothering her since last summer. I told her she has to tell you about it. She's been blowing it off, but I know she's been going to see the school nurse for ibuprofen during the day. She doesn't want me in the room when you examine her, but I wanted to make sure you knew about the ankle.”

“I'll check it out and let you know,” I say, handing her the baby's prescription for an antibiotic.

The teenage girl is tall and thin. She's personable, with a ready smile. “Your aunt told me about your ankle. It's been giving you some grief?”

She looks down and swings the leg out from the table. We both stare at the right ankle. It's easy to see that it's puffy. Like a shoe salesman, I drop down on one knee and take her foot in my hand, steadying it as my fingers trace the contour of the swollen area. “How long has it been like this?” I ask.

“Since last summer,” she says.

“Did you roll it, hurt it in some way?”

She shakes her head. “It just started to swell. It's been hurting more lately.”

“Can you sleep at night with the pain?”

“It's not bad,” she says. “Ow!” She winces as I press hard along the thickened bone.

Slowly I rise to my feet, conscious of the dull ache in my own ankle. “We'll get an X-ray to check it out,” I tell her. “Now let's have a look at the rest of you.”

Afterwards, I speak to her aunt privately while the girl is getting dressed. “The ankle is swollen and tender,” I tell her. “I've ordered an X-ray and some bloodwork. I'll give you a call as soon as I have the results in hand.”

“What do you think is wrong?” the aunt asks.

“I'm not sure,” I say, clearing my throat. “We'll know more when the tests come in.”

I wade through the remainder of the patients on my morning schedule, and then retire to my desk to write my notes. I lean back and put my foot up. It's throbbing now, the result of running up and down the hallway from one exam room to another over the course of several hours.

The report from the radiologist comes in late that afternoon. There is a growth in the distal fibula. The overlying bone is markedly thickened. “It could be an osteochondroma or an aneurysmal bone cyst,” the radiologist says. “But we can't rule out a malignancy on this study.”

I punch in the number of the aunt's cell phone and identify myself when her voice answers. “We're still on the road, just about home,” she tells me. “Maybe I should pull over so we can talk?”

“That would be a good idea,” I say, and almost without thinking, I reach down and gently stroke my right ankle. I reflect that my own wound, not quite fully healed, is in the exact same anatomic place.

© 2013 American Academy of Physician Assistants.