The Second John McPhee Reader by John McPhee

Author:John McPhee
Language: eng
Format: epub
Publisher: Farrar, Straus and Giroux
Published: 2011-08-28T16:00:00+00:00

Referral is the fulcrum of the family practitioner’s craft. From case to case—situation to situation, medical topic to medical topic—the exact position of the fulcrum varies with the doctor. One who too readily refers patients to assorted specialists is suffering a loss of science—giving up one chance after another to add experience in manageable situations. An ideal family practitioner works not just within but also up to the limits of her competence, his competence—knowing precisely where those limits are. Forman says, “You try to make the right scientific diagnosis with the least steps, try to make a good quick history that doesn’t miss things. This is the real challenge of family practice. You know the health resources available to you. You don’t hold on to patients too long out of pride or ignorance. The talent is in knowing when to give them up.”

In some ways, a good family practitioner is not unlike a good bush pilot. There is no dearth of self-confident, highly skillful, bad bush pilots who cross the margins of heavy weather and whang into mountains. The good pilots know when to choose not to fly—know their own limitations and the limitations of their craft—and are unembarrassed by their decisions. “In the past year and a half, I have helped salvage six planes that were wrecked by one pilot,” a very good bush pilot once said to me. “Why do passengers go with such pilots? Would they go to the moon with an astronaut who did not have round-trip fuel? If you were in San Francisco and the boat to Maui was leaking and the rats were leaving, even if you had a ticket you would not go. Safety in the air is where you find it. Proper navigation helps, but proper judgment takes care of all conditions. You say to yourself, ‘I ain’t going to go today. The situation is too much for me.’ And you resist all pressure to the contrary.”

When outpatients appear in the F.M.I. with problems that are beyond the competence of the residents, they are routinely referred to specialists and subspecialists on the staffs of Kennebec Valley and other hospitals. They can be referred up the system to Portland and beyond. When something perplexing suggests neurology, however, the residents can step to an intercom and call upstairs, asking for their director, Alexander McPhedran.

Here, for example, Tim Clifford, a second-year resident, sees a patient whose name is Elaine Ladd. She is twenty-two years old, small, slim, light on her feet, with uncorrected teeth, a sweeping and engaging smile. She wears a print dress. Her blond hair is gathered in a band. She reports what Clifford records as a six-month history of right-leg weakness. As she got out of bed one day, she fell to the floor. Another day, she fell, unaccountably, on a flight of stairs. There have been similar occasions, in all of which, when the leg collapsed, the knee did not buckle. At these times, her right foot and leg felt heavy, her toes tingled, and the sole of her right foot was numb.

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