“I don’t want to bother my doctor”

The fourth year of medical school provides a little extra time for catching up with loved ones. I’ve been traveling during the holiday season, and I’ve been fortunate to spend a lot of time with family this year. We carve turkeys, swap stories, and count our blessings. My little brother got married. My sister-in-law is pregnant. Grandma just turned 85. Frequently, I get asked a few medical questions over dessert. “I’ve been coughing in the mornings … my doctor said my blood pressure is still too high … do you think I should be worried? … I don’t want to bother my doctor with this, it’s probably nothing.”

It’s that last statement that sticks with me. “I don’t want to bother my doctor.” We’re going into medicine so we can answer patients’ health questions, address their concerns, and help them make treatment decisions. We’ve spent time acquiring knowledge so we can share it with people who are sick, scared, and hopeful that we have answers. So why do my family members hesitate about their health issues? Why wait for an infrequent, informal meeting with a family member who is a medical student instead of scheduling an appointment with a physician? I suppose there’s the advantage of my being immediately available at the dinner table – no scheduling, no driving, and no waiting room. A lot of the problems they mention, however, aren’t new. My loved ones describe chronic symptoms that they struggle to minimize rather than asking doctors for help. I wonder how often my clinic patients minimize their own symptoms. I think about times I’ve interrupted, rushed a personal story, or shelved a patient’s concerns “for a follow up appointment.” How often do my patients avoid making these appointments because I’ve made them feel like they’re bothering me?

In 2016 I’m going to try to be more approachable in my patient interactions. If I listen first and make patients’ perspective a priority, then maybe visiting the clinic can feel more like a comfortable dinner conversation. Ultimately, it’s about lowering the barrier to picking up the phone and finally making that appointment.

“Your patient wants to leave against medical advice”

We realized that it was our patient’s 38th birthday during morning rounds. She had a history of drug and tobacco use and poorly controlled blood pressure. She had already had a heart attack and stroke in her twenties. She had come in with slurred speech and right leg weakness and was found to have an intracranial hemorrhage and a blood pressure that was through the roof. She had not been taking her blood pressure medications. She was a single mom with three boys aged 4, 8, and 11. The 11 year old was severely autistic. She was admitted early morning to the ICU for blood pressure medication and close monitoring.

After lunch, our senior resident made a quick trip out to a nearby bakery to buy birthday cupcakes and candles for the patient. Although the ICU staff vetoed the candles, the ICU nurses, residents, and students gathered to sing “Happy Birthday” to our patient and enjoy bites of cupcake. She was moved to tears by the gesture and eagerly showed us pictures of her three sons on her iPhone. “I’ve only been here 10 hours, but I miss my boys already,” she said. “Nobody wants to spend their birthday in the ICU,” said the senior resident.

Several hours passed. We had admitted another patient and completed our floor work when we got a page from the ICU. “Your patient wants to leave against medical advice because Child Protective Services wants to send her kids to Polinsky while she’s in the ICU,” explained the ICU nurse. Our senior resident found a note in the medical record from the social worker elaborating on the story. Two days prior to coming in to the hospital, she had brought her children to work and school staff suspected that she was drunk based on her slurred speech. When her three children did not show up at school the next day because she sought medical attention, the school filed a CPS report. She had not had any open CPS reports previously.

She had found a friend to take care of the youngest child while she was there, but a neighbor was only able to watch the two other boys until the late afternoon. The social worker found temporary placement for the boys at Polinsky, a shelter for children in emergency situations. However, our patient had apparently spent time in the shelter herself as a youth after significant abuse by her father. She was fearful that her children would be taken from her permanently if she did not get back home. She was anxious and wanted to leave against medical advice to take care of her boys. During all of this, her blood pressure, which had been stabilized, began to climb again and put her at risk for worsening hemorrhagic stroke.

Sensing her desperation and knowing the ramifications of her leaving in this condition, our senior resident started making phone calls. He called the social worker, who was on his way to our patient’s home to check on the children. There was no answer. He called the social worker’s manager and that person’s manager, hoping to find any way that someone could watch over her children. They stated again and again that Polinsky was the only option unless she had family that could watch them. The patient grew more and more anxious, her blood pressure was rising, and she was demanding to have her IVs removed and to obtain AMA forms so that she could leave to take care of her children.
The resident pleaded with her to stay, carefully reiterating the danger that she might be in if she left with poor blood pressure control: worsening hemorrhagic stroke and death. She indicated that she understood and was adamant about going back home to her children. She promised to take her blood pressure medications and return in the morning to the ED. She signed the AMA form and walked out of the ICU. I followed, attempting to dissuade her from leaving, while the resident tried one more time to talk the social worker into finding a neighbor or anyone else to watch the children. Despite our words and efforts, she found the exit and walked out of the hospital.

The senior resident was devastated. He had been giddy at the thought of bringing her cupcakes for her birthday early that day. He was terrified that she felt like she had no other option but to leave against medical advice to save her children from the experience of a temporary shelter. I was impressed by my resident’s persistence in attempting to find a compromise and by the social worker’s efforts to visit the home outside of work hours to make sure that the children were safe. It was a difficult reminder of the importance of understanding a patient’s social support system and its profound impact on treatment.

Long Distance

The distance between medicine and humanity, no matter how far we try and convince ourselves otherwise, is quite small.

After several small strokes and repeated infections, my grandfather was receiving care at a skilled nursing facility as his ability to speak and safely eat were no longer within reach. Such an image was one that was hard to imagine of a proud ex-marine that I had always perceived as invincible. Growing up with several thousand miles between me and extended family, I have grown accustomed to receiving text message updates or short calls with family happenings, and with illness such communication became more frequent. Texts would be brief, requiring careful interpretation and conveying much emotion like a modern telegram; “Gpa has started another round of antibiotics. Not sure what is going on,” or “just visited gpa, still unable to talk. He is getting quite frustrated.”

About two weeks ago, I got another message that seemed similar to previous ones; “Grandpa’s heart is racing, nursing home is taking him to ER now. Will update when I hear more.” My grandfather passed away shortly after being place on hospice several days following that text message. He was surrounded by those he loved for the last moments of a life well lived.

The cycle of ED visits, admissions, and subsequent discharge planning he experienced was something I understood, at least logistically, from my experiences in medical school. Although I had helped take care of many older patients nearing the end of their lives (even some whose wit reminded me of my grandpa), I had never really been privy to the raw emotion and fear of being a family member. Every word and gesture of those caring for a loved one mattered. I was instantly embarrassed about how I had emotionally distanced myself from previous patients in similar situations and will likely encounter again in my career as an emergency physician. With my grandpa, it was no longer an “older gentleman who was brought in from a SNF for tachycardia,” but rather a man I loved and whose fragile state caused my fathers voice to quiver when he spoke.

May we always remember as health care providers the necessity of compassionate care. Sometimes that may mean reminding ourselves that although our individual encounters with a patient and their families may be brief, each interaction fits into a narrative that is much bigger and messier than the precise clinical situation or chief complaint.

by Chris Evans, MS4