It’s not my fault

It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

Doctor, no offense but I don’t want to see you

Doctor, no offense but I don’t want to see you

It was already close to the end of the workday in my clinic but there was still a new consult to see. It was the usual – a recent heart attack with diabetes, metabolic syndrome and hypertension. Pardon me, I meant to say – there was a new patient named Mr Lowry with the above-mentioned medical conditions.

I went through the chart quickly – some of the medications could be further optimized, blood pressure could be better controlled, the weight would have to come down. I asked the patient the usual questions – no, no recent chest pain; yes, he can walk for couple of blocks until his knees start hurting; yes, he quit smoking; no, he has not been able to lose weight. Mr Lowry answered the questions readily enough though he did not offer additional information or ask questions.

I asked him to take off his jacket and get on the exam table for a quick physical. As I leaned closer to help him push the T shirt up to listen to his heart, I could see there was writing on the shirt. I could only make out the word “today” as the shirt was riding up on Mr Lowry’s generously sized belly. “What’s written on the shirt?” I asked, curious. I received the first smile of the visit, and Mr Lowry pulled the shirt down so I could see. I DIDN’T WANT TO BE HERE TODAY, the shirt read. As I puzzled, my patient burst out laughing. “This is my hospital shirt”, he explained. “I wear this to all my doctor visits. My wife knows that it needs to be washed every time I have an appointment”.

The smug joke masked a deeper truth – my patient was trying to set his own narrative for his medical appointments. He didn’t want to be “recent non-ST-elevation MI, diabetes, obesity”. He was “Mr Lowry who doesn’t want to be sick”.

There is something freeing in naming the negative emotion. It is now out there and identified. In regards to Mr Lowry, it made it easier for me to find the motivation for lifestyle change – “you need to take your medications, lose weight, etc – so that you don’t have to see me anymore”.

Over the next day, I kept going back to the shirt. Is it somehow more powerful to elicit a negative emotion rather than positive one? Politicians certainly know that fear moves people to vote more than a desire for a positive change. The generic “you should exercise to be healthy” is less motivating than “you should exercise so that you wouldn’t get a heart attack”. It is especially motivating if the heart attack has already happened once – now the fear has teeth. When I ask my patients what is the most important thing I can do to help them, the answer often comes in negatives: “I don’t want to be short of breath”, “I don’t want to be tired after walking 10 steps”, “I don’t want to be in the hospital”, “I don’t like the hospital food”.

Few weeks ago, Mr Herkel was admitted to my hospital service. He was an epitome of a healthy 53-year old – slim, fit, didn’t smoke, exercised regularly. Part of the reason he had kept himself healthy was his bad genetic lottery – most of the men on his father’s side of the family had already had heart attacks or died by his age. And now, when he had developed chest pain that refused to go away, he anxiously checked himself into the emergency room. The type of chest pain he had was not especially worrisome – but due to the significant family history, we did a thorough workup nevertheless. His careful lifestyle had counteracted his genetics – the tests showed no heart disease. Mr Herkel’s relief was palpable. “No offense, doctor,” were his parting words, “but I sure hope I will never have to see you again!”

As for Mr Lowry, I am waiting for him to come back one day with a different T-shirt. The one that says, I DIDN’T NEED TO BE HERE TODAY.

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Self-care tip: Sometimes, a powerful negative emotion may be a motivation for positive changes in your life. But you have to name the emotion first and evaluate it. Be smart.

Question: Have you had a negative emotion change your life for the better?  Tell us your story.