My patient sat back in her chair, shoulders curled forward over her substantial belly, two canes leaning against the counter next to her. “No, doctor, I need you to say that you WILL make this happen, not that you will ‘try’. Can you say that?” It was an uncomfortable moment. As a physician I am not used to having my words dictated to me, and I did not take to it very well.
She was about to be released from rehabilitation, recovering from surgery. She usually lives in her own home, by herself, but with a support team due to her serious mental and physical illnesses. During her stay in rehabilitation her complex care nurse had been discontinued, and she had not yet met the replacement. She needed me to arrange house cleaners to clear a path from the front door to her bedroom, through the accumulated debris (and treasures) of her life. And to wipe the filth from her counter tops. And maybe someone to help her order food, since she did not want the meal delivery service any more. Visions of broken hips and an A1C levels rising faster than a comet played through my mind.
Then she spoke about her thickened ankles, and listed off (correctly) the last four serum calcium levels in her blood, saying that she thought the (slightly elevated) calcium was responsible for the swelling and could I please give her a medicine for that. She asked for me to renew prescriptions for five supplements that she likes to take, along with her approximately 18 prescription medications, to manage her many medical problems. Then she shared information about her fit-bit and all of the associated apps and computer programs that were going to help her get to a healthy weight and manage her blood sugar. She told me about the alarms on her computer that go off every 15 minutes or so, to remind her to take her medications, or drink water, or stand up and move around. She seemed tired but also determined as she gazed intently at me from beneath arched eyebrows, insisting that I help her.
In our era of patient centered medical home many things have changed. We have teams assembled to care for our patients, of which the clinician is no longer the sole driver, but rather one more person with a role to fulfill in the shared goal of meeting patient needs. We have nurse educators and complex care managers, and pharmacologists and a behavioral health team. Even with all of this, at least one thing should not – cannot- change if we are still to be successful in primary care. Clinicians still need to sit, with single-minded attention, and deeply listen to patients. While my patient shared her needs and concerns I stopped doing medication reconciliation. I stopped clicking boxes on her problem list. I took a break from hunting for which preventive measures were due, and left off my progress note in the EMR. I just sat with her in this place of chaos. Of her gathering more and more details in an effort to make sense out of her life, forever changed by a long-past history of trauma. I allowed myself to not just see but also feel the complexity of her internal situation. Trying so hard to corral all of her problems and all of the data - and gathering more data- in an effort to control her life. In an effort to regain the control, autonomy, and understanding that had been taken from her when she was a little girl and was abused.
Many people can order medications, and compare lists, and check databases. Few will take the time, and take the risk, to sit in an uncomfortable - even a terrifying - place with a desperately ill patient, to share the space with the patient, and then look forward through the same lens, from the same place, and imagine a different future. To join the patient to think about a path that the patient (not the clinician) might imagine to get from here to there. This is the heart of hearts of family medicine, of primary care, of being a physician.
Learn more about primary care challenges and innovation solutions to overcome them at the 2019 Primary Care Conference on October 5th in Boston, MA:
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