The lady with the green apples

I first met Mrs. Smith (not her real name) in a grocery line at a local farmers' market. She was in front of me, and her bag of green Granny Smith apples had just slipped out of her hands, sending them rolling down the smooth pavement. I helped her collect them, one by one, and while I was bent over, my face close to her ankles, I noticed that her ankles were swollen the size of the grapefruits that I was carrying in my own bag.

"Those ankles need to be looked at. "

Those eyes stared at me curiously as if trying to recognize a face. Then, as if in resignation, she shrugged and paid the cashier.

A SURPRISE VISIT

It was my first month in practice out of internal medicine residency. My husband and I were newlyweds, and we had just moved to a sunny northern California suburb. The area was affluent, surrounded by renowned university hospitals such as Stanford, and I wondered how long it would take me to get busy enough to make a salary to help support our new mortgage.

I looked out in my waiting room, which was empty except for one patient. It was the lady with the green apples.

"Her name is Mrs. Smith," my secretary informed me in a brisk voice. "She has not had a doctor in several years."

Mrs. Smith had found me through my photo advertisement in the town newspaper. She had recognized me from the farmers' market.

Now 75 years old, she had not seen a doctor since her husband died 10 years prior from metastatic colon cancer. She was disillusioned with the medical system. Her husband's diagnosis had been delayed despite a series of complaints he had expressed about abdominal pain. He had waited a year for a CT scan, by which time it was too late.

The medical bills were astronomical because he had no secondary insurance to pick up what Medicare could not cover. They had no children, and there was no money left over to afford home healthcare, so she had to be his sole caregiver.

So now, Mrs. Smith, despite swollen legs and progressive shortness of breath, had refused to see a doctor. She had come that day only because I had seemed like a "nice young woman." But she really did not care for doctors. She just wanted to give me, in her own words, "a small chance."

AN APPARENT NIGHTMARE

This situation would be a nightmare to many doctors, and I was no exception.

Mrs. Smith appeared to be a nonadherent, stubborn patient on the verge of depression. But I was new to the world of medicine, and my enthusiasm not only was fresh but also was strong.

I plunged into performing a work-up. I ordered chest radiographs, an electrocardiogram, an echocardiogram, and lab tests, and I prescribed diuretics.

Mrs. Smith had congestive heart failure with an ejection fraction of 30% and aortic stenosis due to a bicuspid aortic valve. After much discussion, she agreed to take diuretics and aspirin. She refused to take digoxin or anti-depressants, or to see a cardiologist, or even to get a mammogram. Her mother had had an anaphylactic reaction to digoxin, and Mrs. Smith was certain this reaction was related to an allergy to the foxglove plant. She thought the mammogram would be too painful; she knew that breast cancer was even more painful but was willing to take that chance.