At first we thought it was funny when the doctor said, “Fatigue. That’s a tough one. At 75-years-young, your chronic conditions are catching up with you, sapping your energy.”
That was the end of exploring the presenting problem at my husband’s twice a year primary care visit.
On the way out to the parking lot, we said we’d like to be bugs on the wall when, 25 years from now, someone says that to our 50-ish year-old doctor.
Twenty-four hours later, the physician’s response to my husband’s question no longer amused us. Nothing happened during that brief visit that would shed light on the issue. Possibly nothing was missed by our doctor, but possibly something was.
Fatigue was not an invitation to limitless lab tests. Fatigue was an invitation to think about the patient’s history and some probabilities.
So, what chronic conditions excuse his fatigue?
His blood pressure, lipids and other vital signs would be the envy of a 40 year-old. His weight is within bounds, he doesn’t snore, but he is sleeping at least 10 hours/day. He has mild diabetes so well-controlled without medications it may not be diabetes. Thyroid disease is common with diabetes and is very prevalent in our part of the country. Perhaps thyroid testing is in order since it hasn’t ever been done before?
He has bone marrow dysfunction, monitored by a hematologist for the past two years. Do we need to move my husband’s appointment so he is seen sooner?
This is a sore point, but also instructive, at least to us. For twenty years, my husband took two medications, needed at the time, but never re-evaluated. Our primary care physician wrote prescriptions for these drugs for at least 8 years without the FDA-recommended bloodwork.
Our failure was not requesting monitoring or assessing whether these drugs were still needed.
Two years ago, a physician assistant at our primary care doctor”s office ordered a CBC to check out my husband’s fatigue and easy bruising when we made a sick call. The CBC results led us to the hematologist who told us that both of my husband’s medications can cause bone marrow depression. At the initial visit, my husband’s levels were close to necessitating a bone marrow biopsy and transfusions.
Furthermore, although my husband’s prescriptions might be responsible for his concerning lab results, there was no way to tell if in fact they were responsible unless he went off the drugs.
We got rid of the easier one first: a slow taper with no repercussions other than some uncomfortable nights. The next hematology appointment revealed a slight, but definite change for the better, sufficient to take a bone marrow biopsy off the table.
But, still far from okay.
The second medication has a notorious withdrawal profile. We began a very gradual taper.
More improvement. No repercussions. Two years later, we were at a half dose, probably below a clinical level, but certainly not below side effect level.
We did tell our primary care doctor that this medication, the only medication my husband is taking, possibly was doing more harm than good. He did not argue with the plan to eliminate it entirely.
It may take 6-12 months for us to do it. Periodic visits to the hematologist will be our safety net.
We are not physicians. We won’t know for months how much energy this man will have once he is off a medication we all agree is no longer needed.
We don’t know if his bone marrow changes will be reversed. We don’t know if there are other causes for these abnormalities, but we do know that other causes are difficult to detect as long as he is still on that medication.
Yes, we realize that we all die at some point. But we also know that older Americans tend to spend more years in poor health than older people in many other countries.
We do know we want to live as well as we can even if we are 75-years-old.
We would like our doctors to want this for us, too.
What does the doctor’s response to a 75 year-old’s question say about this doctor’s attitude toward his older patients?
And a note for patients of any age. Remember to ask whether you really need to be taking drugs that were prescribed for good reason at the time, but which may not be needed now.
Martha Deed is a retired psychologist and author of The Last Collaboration.