Elaine Huang ~
The first thing I notice are the dark circles under Mr. Jones's eyes.
It's 4:30 pm on a Wednesday during my third year of medical school. I'm in the fifth week of my family-medicine rotation, and we're deep into our daily routine: triage, history, physical examination, differential diagnosis, present the case to the attending physician, repeat.
Mr. Jones is a new patient. His face and belly are round, his arms and legs lanky. His unkempt facial hair and calloused hands reflect a life of physical labor that has worn him down. According to his chart, he's just started an office job. Slumped apathetically in a chair in the corner, he seems apprehensive and hesitant to talk to me. Understandably so: I'm a stranger with the word "student" attached to my name.
"I can’t remember how long it's been since I've seen a primary-care doctor," he begins.
"So tell me a little bit about what brought you in today," I say.
"Well...." he says, then delivers a series of disorganized phrases that I try to piece together into a coherent story.
He has type 2 diabetes, diagnosed in 2012--and had diabetes "for God knows how long" before that. He was started on two medications, but one was experimental and too expensive to take long-term. After two months, he stopped taking both medications.
"I have three kids," he says, starting to stumble over his words. "I felt that the money was better spent on them than on me." It has been seven years since he stopped taking his medications, and he's never followed up anywhere else. He's here today because he's been reading up on the complications of diabetes and is starting to get worried.
"I think I’m in trouble," he says.
He first noticed his toes: They're starting to feel numb. Over the past few months, his vision has gotten worse, and he's scared to drive. His headaches have been killing him. He's lost his sexual drive, which has put a strain on his marriage. His fatigue is worsening.
"Aren’t you glad that I’m your last patient of the day?" he asks. "I’m a fun one, aren’t I?" He smiles, but a palpable sense of anxiety and worry comes through.
His diagnosis back in 2012 came about only because he went to the hospital for help with his fatigue and frequent urination. At the time, his hemoglobin a1c, a test that measures your average blood-sugar levels over a three-month period, was more than 12 percent--very high.
My mind is swirling with thoughts and emotions: How could he have waited this long to come see us? Wasn’t that experience scary enough to make him realize the importance of managing his diabetes? Why didn’t anyone help him back then? I wish I could have....
"Oh wait, there’s more!" he says, with joking enthusiasm. A year ago, he had a bad foot infection.
"It started out as a blister, but I didn’t realize that I had a crater in my foot until my wife pointed it out. She cuts my toenails, because I have trouble feeling anything down there," he says wryly. "I’m a catch, aren’t I?"
I'm in awe of his humor and positive attitude. A few minutes ago we were strangers, but now we're talking like old friends.
"I was scared back then, but I’m really worried now," he confides. "This isn’t normal."
I proceed to the physical exam. His heart and lungs are normal, his abdomen is not tender, there's no swelling in his legs. But he has no sensation in three toes on each foot. On his heel there's a healing scar from his foot ulcer.
"The doctors told me that I'm lucky they caught it," he says. "It was days away from turning into a bone infection."
I feel frustrated and upset that he's let matters get this bad. I also feel sad and defeated, because I wish I could have helped him back in 2012.
One last time, I ask, "What made you wait seven years to see a doctor? Why did you stop taking your medications?"
At this point, I realize that I keep thinking I wish when, instead, I need to ask, What can I do for him now? He's a patient who is, after years of hiding, finally reaching out for help.
I let go of my questions and leave Mr. Jones in the exam room while I present his case to Dr. Clark, my attending physician.
Five minutes later, I return with Dr. Clark.
"I'm glad that you've come in," he tells Mr. Jones. "I’m here to help you to the best of my ability." They discuss Mr. Jones's concerns, and then Dr. Clark examines him.
As they're talking, I start to understand better why Mr. Jones waited so long to come here. He's a husband, a father and a household provider who puts his family's needs before his own. He's scared to hear the truth. Over the past decade, he's suffered from unstable employment, jumping from one odd job to the next--so he's lacked health insurance. He has resorted to emergency rooms or urgent-care clinics for all of his diabetes care, with no follow-up on any of it.
He's a reminder of what happens when patients don't have easy access to good primary care, and when financial and social stresses get in the way of their seeking that care.
Labs are ordered, and Mr. Jones is started on metformin, a medication that lowers blood sugar. He's scheduled for a follow-up visit in two weeks. I feel relieved and happy that he's finally getting the care he needs.
Studying Mr. Jones’s face, I'm struck anew by the dark circles under his eyes. They're just one of the many marks left by his struggles over the past ten years.
And he's only forty years old.
About the author:
Elaine Huang is a fourth-year medical student at the Herbert Wertheim College of Medicine, at Florida International University in Miami. She enjoys eating (a lot), traveling (to eat more), painting, journaling and spending time with her cat and dog. She is applying to residency programs in internal medicine, with thoughts of a future in cardiology and medical education. "When I was a kid, reading was my life. I spent most of my time at the library, borrowing book after book and constantly absorbed by stories about families and young adulthood, and by science fiction. I considered pursuing journalism or creative writing because I loved the process of shaping a story, drawing inspiration from real life and creating something that many people could relate to. After I realized that I wanted to pursue medicine as a career, writing became an avenue for self-reflection and a way of documenting my life experiences. I hope that Mr. Jones’s story will touch other people the way it touched me."