Listening with the heart: Sometimes you really have to see patients to hear them

Important lessons in the life of a physician often come in a whisper. But one must have ears to hear. For me, such a lesson came fairly early on in my career, in the form of a petite, 36-year-old somewhat anxious mother of two, who worked as a municipal clerk.

I vividly remember Mrs. Sarah Franklin's (name changed) first visit to our office. She was well-groomed and very nervous. Although her speech was a little pressured, she was articulate and appropriate. As she gingerly made eye contact, I remember thinking she must be a little shy.

Mrs. Franklin said that her last doctor diagnosed her with high blood pressure and had started her on a calcium channel blocker. After several visits, she said he reassured her that the drug was working fine. She denied having any side effects. But she admitted to stopping her medication a few weeks prior to our visit because she did not think it was helping her. After further questioning, she shrugged her dissatisfaction, saying, "He was always in a hurry." Okay, I had been put on notice.

Ultimately, we decided to have her continue with the daily self-monitoring off medication. She was to have an ECG and some lab work. She agreed to see me in 4 weeks with a new log, and she was given instructions to call immediately if her blood pressure read a predetermined panic value.

She expressed her appreciation of the amount of time I spent with her. I thanked her and assured her that I would do my best to help her maintain good health. Sure enough, 4 weeks later Mrs. Franklin arrived, blood pressure readings in hand, all of which were normal, and so were all of her tests. We were both smiling when she left, with a follow-up appointment scheduled in 3 months. I did not know it at the time, but that pleasant moment marked the end of the honeymoon phase.

PUZZLING SITUATION

Over the next 2 years, Mrs. Franklin visited our office more than 20 times. Usually, it was a same-day appointment for what she perceived to be an urgent problem. Initially, she would worry about her blood pressure, despite my futile reassurances that it was normal. But soon I suspected that there was an underlying reason for her frequent visits.

She reported being happily married with two "good" kids and an enjoyable job. Perhaps she was just distrustful of doctors in general or me in particular, or maybe my assumption that she had sufficient knowledge about hypertension was incorrect. I had reviewed the records from her prior physician. She had no history of mental illness nor did anyone in her family. She did have elevated blood pressures early on, but the readings normalized quickly on almost a placebo dose of medication.

Then, a revelation hit me. Could she be harboring the fear that she would die of a stroke as her father had several years ago because of his noncompliance with his blood pressure medication? In my best nonjudgmental tone, I raised this possibility, which Mrs. Franklin considered, then dismissed. So much for my insightfulness.

Over time, the focus of her visits turned to concern about upper respiratory infections. Again, Mrs. Franklin would have minimal, if any, physical findings of real disease. I would repeatedly deflect her request for antibiotics. She would seem satisfied with my recommendation-until the next visit. My staff became increasingly frustrated accommodating Mrs. Franklin's predictable "emergency appointments" and her frequent "no-show" status for those visits.