AMSA's 2015 Annual Convention
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February 26 - March 1, 2015 

Patients and Doctors

PHYSICIANS TELL OF THEIR MOST MEMORABLE PATIENT ENCOUNTERS.

The New Physician November 2000
What makes a physician remember a particular patient? Was a life saved? Lost? Or was the physician-patient visit less dramatic? Perhaps it’s not really the patient at all. Perhaps it’s the physician.


She’s new to medicine, or she may be an experienced doctor learning something new with her patient.


Or it could be that the patient’s visit was just too beautiful to forget.


The following three short stories authored by physicians highlight the range of reasons for what makes a patient so memorable. The tales have been excerpted
from Patients and Doctors: Life-Changing Stories from Primary Care.


THE NEXT GENERATION

by Dr. Stanley G. Smith - Saskatoon, Saskatchewan


The phone rang intrusively as I sat at my desk writing notes on the patient I had just seen. I picked it up.

“Dr. Smith?” A female voice.

“Yes,” I said.

“Could you come out to the house and check the baby?” The voice had a dullness, an indifference, that a more experienced physician might have recognized as a warning sign. It was 10 in the morning, I was running late, and four patients sat in my waiting room. It was my first week in practice, and it was a new experience to be solely responsible for the patient’s care. I found it frightening to know, or at least to think, that my every decision might be a life and death issue. Making quick decisions was difficult; medical school and internship had not taught me how to handle simple nonmedical issues.

“What seems to be wrong?” I asked.

“The baby has diarrhea,” Mrs. Y answered tersely.

“How bad is it? How many times a day?”

“Oh, I don’t know; he just seems sick. Are you coming out?” she asked.

“Yes,” I said, “I’ll be out as soon as I’ve finished seeing my patients in an hour or so.”

“OK,” she said, gave me the address, and hung up.


It was one of those bright, hot prairie days, under a radiant blue sky. It was about two hours after the phone call as I drove northward through the city, into progressively seedier neighborhoods. I finally identified the house. It was a small, wood frame house that had once been green. That much could be deduced from the occasional green chip of paint that still adhered to the wood. The small front yard was overgrown with weeds and strewn with garbage. The front door was slightly open, and when I tried to ring the doorbell there was no sound. I could hear a baby crying inside the house. I tried rapping on the door with my knuckles, but still no response. I pushed the door open and walked inside.


The stench was unbelievable. The house was strewn with every type of litter imaginable: crusts of bread, paper, dirty clothes, unwashed dishes, toys and garbage, in addition to dirt in every corner. I assumed the crying baby was my patient. I worked my way toward the kitchen and opened the door. Inside, a 4- or 5-year-old boy had opened the refrigerator and seemed to be eating at random. He looked grubby, his face smeared with food, and a purulent discharge was running from his nose. A dirty little girl was trying to drag him over to the table to no avail.


A door opened and a fat, unkempt young woman with greasy-looking hair slouched into the room. “He’s in there,” Mrs. Y said, pointing to another room.


I felt anxious for a moment. I had expected to be directed toward the room where I had heard the crying. Even though I had visited slums before, and as a student completed many home deliveries in the slums of Dublin, I felt peculiarly uncomfortable. I walked into the room she pointed to, which was as grubby as the rest of the house. She pointed to a crib in the middle of the room. Under a pile of dirty covers lay a small body, white, with a sort of yellowish tinge to its waxy skin. The child was motionless, its limp form not much bigger than a ragged doll at the bottom of the crib. I pulled back the covers, horrified. Could the baby really be dead? Surely not in this day and age. How could this have happened? Was it my fault? Maybe if I had dropped everything and come to the house as soon as she phoned, I could have saved this little life.


Although the baby was obviously dead, I senselessly went through the ritual of performing a physical examination on the little body. Perhaps it was not senseless, for ritual does provide an opportunity to reflect on the present situation and give one an opportunity to collect one’s thoughts.


“I’m very sorry to have to tell you the baby is dead,” I said.


“Oh,” she said, as though all this had nothing to do with her. “What do I do now?”


This was my first week in practice. Nobody in medical school had taught me what to do about anything like this. After all, medicine is all about saving lives and relieving pain and suffering, not disposing of dead babies. I knew enough to know that unexplained deaths had to be reported to the coroner. From the next room I heard the sister call to the small boy, “Get away from the fridge, Gary, you can’t just keep taking food any time you want.”


“I have to call the coroner,” I said, embarrassed to have to mention such a thing. “I think there will have to be an autopsy, so you will have to bring him down to the hospital.”


She didn’t seem unduly perturbed, as though nothing had registered at all.


As I walked out of the house, I glanced back. My last glimpse was of little Gary, being pulled away from the fridge by his sister, twin tracks of yellow-green snot running down his upper lip, delicately poised at the slightly upward incline, where the white skin met the pink.


Doctors have been trained to take a lot of responsibility, even for things they are not responsible for. As I drove back to the office that afternoon I felt, quite unrealistically, that perhaps, if I had only dropped everything and run straight out there, maybe I could have saved that baby. As I walked up to my office I stopped at the office of one of my senior colleagues, whom I had adopted as a mentor.


“What are you looking so grim about?” he asked me.


Jamie was a wiry, lean guy. He was kind, but with a short temper that went well with his clipped Canadian accent. He had been a fighter pilot in World War II, and somehow he looked it. He usually had a carton of cigarettes on his desk and a lit cigarette in his hand. When he had his heart attack a few years later, he got into his car, drove down to the emergency room and walked in saying, “I’m having a heart attack, someone better do an EKG.” He was right, he was having a heart attack.


“I just made a house call on a dead baby,” I said. “If I had just run straight out when I got the call, maybe I could have got the kid into the hospital and we could have gotten some fluids into him and saved his life, but the mother didn’t sound that concerned over the phone.”


“How long was it between the phone call and the time you got out there?” he asked.


“A couple of hours,” I said.


“Perfectly reasonable,” he stated. “You know perfectly well there was nothing you could have done. You responded perfectly reasonably. Why don’t I give the coroner a call on your behalf. I know the routine.”


Although I never had a chance to repay Jamie for his kindness and support, I hope I have passed on the kindness and support he showed me to some of the young physicians I have worked with over the years. He called the coroner and put me in touch with the appropriate social services, who went out and visited the home. Not surprisingly, they decided the parents did not have the skills necessary to look after children. They were not deliberately cruel to the children; they merely lacked the capability to raise a child properly. The children were placed in a foster home, I was informed later. From time to time I thought of little Gary, who had no regular eating hours and would just forage through the fridge whenever he felt hungry. My thoughts turn to that last glimpse I had of him, with the snot running down his nose, and to his sister, not much older, looking after him.


Many years later, one of my duties was as medical officer for a high-security psychiatric prison. One morning, I was seeing patients regarding their general medical condition, when a polite young man came in to see me. He looked vaguely familiar. I picked up his chart and read his name. It was Gary Y. The same Gary Y I had last seen in that squalid house when I had attended his long-dead brother.


SHE LAUGHED

by Dr. Perle Feldman - Montreal, Quebec


Sue Jong was a young Chinese commercial artist born in Hong Kong. She had been living in Canada for quite some time. Her English was good but her husband’s was less so. When she was in her 36th week of pregnancy she told me that her mother was coming from Hong Kong to be with her at the time of birth and to help her with the baby.


“She wants to bring me all kinds of Chinese medicines, but I know I can’t take those,” Sue said sadly.

“Do you want to take them?” I asked. Shyly, she nodded. “Then why not?”

Sue then explained to me that she thought I would disapprove of her using Chinese traditional medicines, and she did not want me to be angry. I explained to her that I had a lot of respect for the thousands of years of tradition behind Chinese herbal medicine; as long as it did not interfere with the stuff I was doing, I did not mind at all.


When the time of the birth came, Sue had a long, slow labor. Steven Tsui, the resident, spoke Cantonese well enough to communicate with the husband and the patient’s mother. We called for an epidural and William Khazzar, one of my first clinical teachers, came to administer it. I was pleased and surprised to see him, since he had just moved to this hospital. Dr. Khazzar always combined a real concern for both students and patients with a low-key, incisive humor. The epidural he inserted was a dream. It relieved the pain while still allowing the patient to move around and push effectively.


She was fully dilated an hour later. When her pain was relieved, Steve asked her about the medicines her mother had brought from Hong Kong. Sue told us that her mother had brought a special Korean ginseng wine, which was supposed to be taken just as the head was crowning. Steven was impressed: “Wow—real Korean ginseng.” We assured Sue that we would try and help her take it at just the right time. She soon began to push, as her husband supported her. The chemistry in the room was happy and positive, not too much noise. She pushed the head down to the perineum and soon it began to crown. I waited. The head crowned a bit more, but still I waited.


“Aren’t you going to cut an episiotomy?” Marie-Elana, the nurse, asked me.


“Nope,” I said. Even though the head, which was still crowning, had been stretching Sue’s perineum for more than 10 minutes, the patient had experienced no pain. Her perineum was long and tough, and the baby’s heartbeat was fine. I wanted to wait.


“Tch! You’ll never get it out without a tear,” Marie-Elana stated emphatically, making a sound West Indians use to express disbelief.

“Is that a bet?” I asked.

“You’re on,” said Marie-Elana.

“Move over,” I said to Steven, “I’m afraid I have to do this one.” At the same time I sent up a little silent prayer, “Please, please don’t let me get into trouble for showing off.” My patient thought this whole interchange was funny; she started to giggle. Her husband whispered something into her ear. She started to laugh out loud. Somehow that laughter produced the right combination of pressure and relaxation. The baby’s brow began to slip over the edge of the perineum.


“Quick, take your ginseng,” I said, “and keep laughing.” This must have sounded really silly; both the patient and her husband burst into laughter. It was infectious. Soon we were all laughing and giggling helplessly, while the baby’s head slipped gently over the perineum as I guided and slowed it. This child was born as every person in the room was laughing. He cried briefly and reassuringly, turning pink and rosy.


“So?” Marie-Elana said to me. I inspected the patient’s perineum as Sue inspected her baby’s fingers and toes. I grinned in triumph.

“Not a scratch.”

Afterwards, as we were doing the paperwork, Marie-Elana approached me. “You know, that was a beautiful delivery.”

“Yes,” said Steven. “I’m going to remember this one.”

“So will I,” I said.


EPILOGUE


For me, the best deliveries are those where “nothing happens.” Unlike many of my obstetrical colleagues, I am not thrilled by difficult and complicated cases. What interests me are people’s lives and how they deal with what is happening to them. The most uneventful births can sometimes be the most satisfying. I remember this birth because I had such a good time doing it.



CYBER-FAMILY PRACTICE: A STORY IN THREE PARTS

by Dr. Robert C. Like - New Brunswick, New Jersey


“Clinical Encounter” on the Internet
It is approximately five o’clock on a hot July afternoon. I have just returned to my medical school office after a busy and tiring day seeing patients at our Family Practice Center. I check my phone messages, mail and calendar. A list of academic tasks await me—committee meetings, student advising, lectures to the residents and medical students, a letter of recommendation that needs to be written, a journal manuscript to review. Multiple competing obligations comprise the life of an academic family physician. Fortunately there are no emergencies, and it looks as if I will be able to go home a little earlier tonight.


It occurs to me that I last checked my e-mail about a week ago. I am still fairly new to the Internet and do not yet make routine use of the information highway for communication purposes. Eventually I may become more comfortable with cyberspace. “How wonderful it is to be connected to people throughout the world,” I muse to myself. I turn on my computer, get into my electronic mailbox, and discover the following three-day-old e-mail message:


Hello! Was just snooping around the hostname files on my server and came across “rwja.umdnj.edu” and “njmsa. umdnj.edu” so I thought I would see if I could find your user id. Now you have my address, as well as my Web page address.


Actually, while I’m here I hate to bother you with a professional question, but at least this way you can answer when you have the chance. I’ve been on and off depressed (more on than off for several years now). I first saw a psychotherapist several years ago during my freshman year of college, after finding myself spellchecking a suicide note at three am [sic] one Saturday night. I felt better after several sessions with her, but my troubles were not over. As soon as something would go wrong, as soon as the stress would go up, the depression would return, along with thoughts of suicide. My mother knows about that first suicidal time, but not any of the others, and my dad doesn’t know any more than [sic] I am periodically depressed. Psychotherapy seems to work only temporarily, which is why a friend of mine, who is on Prozac herself, suggested that maybe I needed something like Prozac or other antidepressant drugs to cure me of this before I do go too far one night. I was just curious as to how expensive such drugs are, what is involved in determining if I do indeed need anything like that and what is involved in obtaining whatever is necessary. I assume that since I first sought help three years ago, under a different insurance company/plan, that it would be labeled as “preexisting condition” and therefore not be covered. But if it’s at all possible for me to do it, I think it’s worth it. Not sure how to tell my parents, or even if I should, but I guess that’s something to consider later on. Thank you for any help/information/advice you can give me.


Sam (pseudonym)


I sit back in my chair and sigh deeply. I know this person. His family comes to our Family Practice Center. What a dilemma. What do I do now?


Personal Introspection and the Auto-BATHE


It has been said that before acting, one should always “take one’s own pulse” first. I take a deep breath and fortunately remember a helpful interviewing technique known as the BATHE, which we teach our residents and medical students to use in caring for patients. Well, it’s time to BATHE myself (i.e., perform an “Auto-BATHE”). I ask myself the following series of questions:


B. Background: What’s going on? Sam has reached out to me for help via e-mail. He is depressed and has gone for individual counseling in the past. He is concerned that he may have a more serious depression requiring medication. He has contemplated suicide in the past. He is also not sure whether or what to tell his family about his condition. He is looking for information, support and professional guidance.


A. Affect: How do I feel about it? I experience a mixture of emotions including surprise, shock and dismay. My day was exhausting enough and the last thing I needed was a new and complex situation such as this to deal with. However, a person is in distress and a life is potentially at risk. This must take precedence.


T. Trouble: What troubles me the most? I am worried, of course, about Sam’s depression. How serious is the suicide threat? How can I best assess the situation in order to provide assistance? I also am concerned about the best way to interact with Sam and his family since we all live in the same community. What is the right thing to do clinically, ethically and legally?


H. Handle: How should I handle the situation? A variety of practical questions go through my mind. Do I need to deal with this situation now or can it wait till tomorrow? Should I send an e-mail response? Should I send a certified letter? Should I try to telephone Sam (presuming I can locate his phone number)? Should I speak with Sam’s parents? Should I contact one of my psychiatric colleagues for advice? Does Sam have his own personal physician and if so, should I contact him or her? Does this e-mail communication constitute a “clinical encounter?” Does this encounter need to be documented in the medical record, and if so, how? The questions go on and on.


E. Empathy: A little bit of self-empathy. I force myself to stop thinking and try to give myself a “mental pat on the back.” I will try the best I can and hope everything will work out. So much for a quiet night at home.


Patient- and Family-Centered Clinical Praxis
I decide that I will try first to locate Sam’s phone number as his e-mail appears to have been sent from his college. I make a long-distance call to the campus operator only to learn that Sam is not registered there for this summer. No luck. I drive home and tell my wife that I have a “clinical emergency” that needs to be dealt with. She is a nurse and is understanding as always.


Sam’s family lives in the community and perhaps I can find out where he is. I go over to his house and ring the bell. Much to my surprise and relief, Sam answers the door himself. He is at home with the rest of his family. As he is an adult and has sent me a confidential and personal communication, I invite him over to my home saying, “I received your e-mail. Would you like to come speak with me about the information you requested?” He agrees and his family does not seem to suspect that anything is wrong.


My wife needs to run some errands; she leaves me with our 2-year-old son, who is happily playing with his trains. Sam and I sit in the living room. I thank him for his e-mail message and over the next 15 minutes learn more about what has been going on in his life. We discuss the duration, frequency and severity of his depressive symptoms, what he has told his family so far, and what types of help he has sought. Clinically, I conclude that he is not actively suicidal but does indeed have a major depressive disorder which will require antidepressant medications. I discuss this with Sam and ask him if he would like to have a family meeting where we can share his e-mail communication and discuss potential treatment options with his parents. He agrees to this and internally I heave an inaudible sigh of relief. Sam goes home, and both he and his parents return 15 minutes later. Over the next half hour, we discuss my clinical findings and treatment recommendations. I commend Sam for his courage and willingness to obtain help. His parents fortunately are very supportive and understanding, and a referral to a psychiatrist is accepted. Everyone smiles and shakes hands. The genie is out of the bottle.


After Sam and his family leave, I reflect further on what has transpired this evening. A powerful personal learning experience. A gratifying clinical encounter. A ratification of the family systems paradigm of health care. I believe that all will work out for the best. I return to playing with my son and his trains. My wife comes home and asks how my day has been....


Yes, the Internet is indeed a wondrous creation of technology and is enabling us to become an interconnected global community. As we increasingly travel on the many byways of the electronic information highway, I wonder what new challenges await us and what the impact will be on the doctor–patient relationship and the practice of medicine.
Short stories included in this feature have been excerpted from Patients and Doctors: Life-Changing Stories from Primary Care, edited by Drs. Jeffrey M. Borkan, Shmuel Reis, Jack H. Medalie and Dov Steinmetz ©1999. Reprinted with permission from the University of Wisconsin Press, www. wisc.edu/wisconsinpress.