General Medicine: Swapping Zebras For Horses

Doreen is an 81-year-old lady referred to general medicine by the emergency department. She doesn't have a black and white diagnosis like 'right lower lobe pneumonia'. Our patients rarely do. She does have a cough, and a history of chronic obstructive pulmonary disease, but her chest X-Ray is non-specific and the respiratory team don't feel she is unwell enough for non-invasive ventilation or admission under their team.
Likewise, the cardiology team were unexcited by a mild troponin rise but agree she has an element of heart failure.
She is certainly in renal failure, but nephrology weren't even consulted because it's clear a moderate creatinine rise isn't her main issue.

Doreen, like many general medicine patients, has a little bit of everything. A mild of an exacerbation of her COPD, a bit of heart failure, and acute on chronic renal failure. She has a touch of diabetes, hypertension & cholesterol, pretty severe osteoarthritis and is falling more in the past 6 months. She's definitely anxious about those falls, and about being a 'burden' on her family.

It's 9pm on a Saturday night when I see Doreen. She's in her dressing gown in a cubicle in the chaotic emergency department. She's with her husband Louie, who is a bit hard of hearing and walks with a limp since a stroke 4 years ago.

Unlike the agitated patients around her, Doreen is delighted to see a doctor. I take a history and examine her, and think about what she really needs from this admission.


What she needs is a doctor who is realistic about her conditions and what can be achieved, but also what is worth achieving. Modern medicine does mean it's possible for her to have perfect blood pressure control but if 120/80 means she gets dizzy when she stands too, it's not the number to aim for.
She needs a doctor who'll explain things to her, honestly. Yes, her breathing will get worse over time with the COPD, and each chest infection lowers her baseline function a little but further.
She's needs to know that if her heart was to stop beating, doing 'everything we could' would not be in her best interests. Being intubated and attached to lots of machines in the ICU would be unlikely to help, and would prolong the inevitable at much emotional expense to her family.
She needs is a doctor who understands that death isn't a consequence to be avoided at all costs. Death is the natural progression of life and often a peaceful reward for a long and fulfilled life.

Doreen gets a short course of antibiotics, an increase in her fluid tablets and regular paracetamol. She'll get a bed on the medical ward, probably next to Maude with the cellulitis and unstable blood sugars.

She'll get a full allied health assessment. If she's lucky, she'll get my favourite physiotherapist Katharine, who'll realise Doreen's biggest issue isn't a 15 metre decrease in exercise tolerance, but anxiety about falling. She'll be able to give Doreen some techniques to feel more confident and maybe even convince her to use her 4 wheelie frame more often.

General medicine is full of patients like Doreen. It might not be as glamourous as what I imagined myself doing in medical school, but it's what I've fallen in love with. We don't get the Wegner's granulomatosis patients or the rare endocrinopathies or even most of the STEMIs. In fact, we don't get anything that would have excited me at the start of internship.

What excites me now though is managing these little old ladies with 10 comorbidities. Everything exists on a balance beam and if you treat their heart failure too aggressively, their kidneys will fail. If you fluid restrict them too carefully, they become hypotensive. How do we balance the risk of bleeding on anticoagulation against the risk of stroke? How far should we investigate their iron deficiency anaemia? Is there a point in doing a colonoscopy on a nonagenarian? And how do we deal with a family who refuse to accept their mum isn't coping at home, or worse, refuse to accept that mum is dying?

Our bodies are an incredibly complex interplay of systems that depend on and influence each other. The heart can't function without the kidneys, a failing heart affects the lungs. General medicine requires you to not only master each system, but manage all the systems simultaneously whilst taking into consideration the psychosocial context.

There's a famous quote:
The emergency doctor views the patient through a telescope
The speciality doctor views the patient through a microscope
The Medical Registrar views the patient in plain sight.

Furthermore, you can achieve perfect control of a patients ailments in hospital but if you send them back to an environment where they are too scared to mobilise, too forgetful to take their tablets or can't cook, they are no better off than when you met them.

We might cure their UTIs or this particular infection, but general medicine isn't really about cures. It's more like when you take your car in for a service and they replace the oil, fix that strange leak beside the radiator, align your wheels and give the inside a good vacuum. That's what general medicine is about - making the most of what a patient has. The end point isn't a cure. The end point is getting the patient to the best level of health we can then sending them home with enough supports to maintain this, or sending them to a place where they can get extra help.

Some people call medicine a 'dumping ground', as by the time they are referred to the med reg, several of the speciality units have usually said no. I think that downplays the work the unit does. We've all seen the orthopaedic team take excellent care of a #NOF, but not notice the patient slide into pulmonary oedema. Or the cardiology team that saves the patients life but doesn't realise her bigger issue is that she can't cope with the stairs at home.

The truth is, for patients like Doreen, general medicine is the best place for them. She needs 'big picture' medicine. Her creatinine clearance means much less than her ability to get out of bed in the morning.

Maybe I'm not as hardcore as I was in medschool, but these days an adorable geriatric with 4 vague symptoms, functional decline and 10 comorbidities makes me more excited than a zebra diagnosis.
And let's be honest, Doreen, Maude and more than likely your grandparents, need more doctors who like me want to do general medicine.

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