Medicine would love to be an exact science, but the science of patients can never be exact, as you will see from this small tale of an 81-year-old woman. As a medical student, I always feared presenting patients like her on rounds. When a patient keeps changing key details of the history, it makes the student look like an incompetent idiot in front of the entire team. The professor gets upset and may even demote the trainee to the remedial medical unit.
This woman came to see me because her left hip was hurting. I asked her how long her hip had been hurting, and she told me that it was more than 2 weeks. I examined her and found good range of motion in her hip, but tenderness over the side of her hip, consistent with trochanteric bursitis.
While I was pondering what to do for her painful hip, she mentioned that her family doctor had injected it with cortisone 3 weeks ago, but the injection had not helped. I am not fond of injecting hips, and this absolved me of trying that remedy. This procedure requires a long needle, and a strong determination, but the results are frequently disappointing.
Although I didn’t have to inject her hip, I would have to do something, so I studied her chart more carefully. She was frail, and her creatinine was elevated slightly, so NSAIDs were not an option. After much deliberation, I told her that I thought physical therapy was the best option.
"I’ve been going to therapy twice a week for the last month, and it hasn’t helped." The problem just kept getting longer and longer like one of those silk scarves that stage magicians pull out of their hat. "Would you make up your mind," I thought to myself with some irritation, but I remained composed and I reminded myself that it would be unseemly for me to act petulantly with an elderly patient.
After one last round of mental effort, I told her that I would put her on prednisone for a few days. If that didn’t work, I told her I could refer her to an orthopedist, although I knew the orthopedist would be reluctant to suggest surgery for her bursitis and would be left with the same paltry treatment options that I had at my disposal.
I felt relieved when she finally toddled out of the office pleased with my sagacious advice and treatment. My relief was interrupted that afternoon by a phone call from the pharmacy. According to their records, my patient was allergic to prednisone. They didn’t have any details about this allergy, and the patient couldn’t remember anything about it either. Problems concerning this woman kept popping up, despite my best attempts to escape to the next patient. I rummaged through her old chart and told the pharmacy to dispense the medication. She had been on prednisone in 2005 without any problem. Mother had warned me there would be days like this. Medicine is more art than science, and that art calls for finesse, negotiation, and lots of patience.