Beyond the Numbers

They are largely forgotten. They sit forlornly at the end of the body, usually housed in cotton and leather and bathed in a distinctive aroma. Toenails. They are often unsightly and decidedly unglamorous. For that very reason, I think, toenail care can really make a patient feel loved.

Wanda (not her real name) is a lovable 85-year-old woman who has diabetes, hypertension, sassy wit, and charm to spare. She is as independent as they come. In her time, she raised six foster children, but now she lives alone in an apartment building. She has lots of concerned neighbors who want to check on her and help with the upkeep of her place, but, as she told me with a twinkle in her eye, “I tell ’em no because I don't need them nosing around my home.”

She looks “younger than stated age.” But that stock phrase doesn't quite capture Wanda. She is one of those amazing people who can get mistaken for being 30—even 40—years younger; she has a positively youthful glow about her. One day in clinic, she told me that a man who looked to be in his 40s or 50s had propositioned her on the bus. She couldn't help but laugh in his face and told him, “Sorry, but you should know that I have grandsons ’bout your age!”

That being said, she has 85 years' worth of arthritis in her knees, and her mobility is limited. She walks with a cane and can get around town only via Access bus. It's a lot of trouble for her to come to our clinic, so I try to address as many of her concerns as possible at each appointment.

At our most recent visit, Wanda was wearing her customary black beret and child-like smile. We spent 15 minutes talking about a rash on her face, recent laboratory work, her blood pressure . . . and her mother. Wanda loves to tell stories, and she always manages to regale me with at least one or two during each visit. Sometimes she makes me feel like I’m sitting on a sunny porch in the countryside instead of in a fluorescently sterile room. She told me how her mother lived to be 87 years old. Wanda was the baby of the family, but when her mother had a stroke, it was Wanda who drove her straight to the hospital. And when “Mama” was no longer able to take care of herself, it was Wanda who welcomed her into her home, already crowded with foster children. She said that her mother was fiercely independent even after her stroke and that it took a lot of persuasion before she would agree to move in with her.

I could see that Wanda had inherited her mother's independent streak. But she wasn't so independent that she’d refrain from asking her doctor for a little help. When she had wrapped up her story, I transitioned back to a discussion of her hypertension and the possibility of increasing her diuretic. She replied, “Doctor, we could do that, if you think we should. Now, I know you don't have much time . . . but can I mention my toenails? They are getting much too long. I can't bend over as well as I used to, so I can't clip them myself. Do you know where I can get them trimmed?”

I felt the sudden urge to look at my watch, and the words started to form: “We don't have anyone who does foot care here, but there are community centers that do . . . .” But then I thought about how difficult it was for her to travel, how she had no family in town to help her, and how she had selflessly cared for so many people in her life. So I answered, ambivalence undoubtedly coloring my words, “I could trim them now if I can find some toenail clippers. . . . ”

She said, “Oh, Doctor, I don't want to take up any more of your time.”

The voices of opposition were still clamoring in my head: “Got to stay on schedule.” “We need to focus on higher priorities.” “There's no credit for toenail clipping with performance measures or, for all practical purposes, pay.”

This internal debate, which lasted just moments, brought into striking relief the tension I feel as a primary care physician. Tracking numbers is all the rage today: there are numbers on patient satisfaction surveys and numbers on insurance company scorecards, as well as numbers of patient visits and numbers of RVUs, on which my salary—more numbers—depends. I realize that quantitative data can lead to accountability, and accountability is generally a good thing. But I think that, in many clinics and hospitals, the focus on numbers has become all-consuming. A system that overemphasizes statistics will inevitably produce physicians who become fixated on the same, to the detriment of both physician and patient alike.

One potential casualty is the patient-physician relationship, a relationship that is built on so many unquantifiable actions: listening to a patient's story, conversing about family, walking an elderly patient to the lab, calling Medicaid on behalf of an ESL patient, and yes, clipping toenails. On examining my own practice, I can see that these mostly unseen human touches are falling by the wayside because I have internalized the values of today's system. I hope the pendulum swings back a few degrees—both in the system and in my mind-set—and soon.

As for Wanda, I excused myself, then returned with clippers in hand and placed a towel under her feet. “Doctor, I’d feel real bad if you had to get down on the floor to cut my nails,” she protested.

“Don't be silly,” I replied. “This is what I’m here for.” And, in an all-too-rare moment of clarity, I meant it.