Sunday, July 19, 2009

Patience with Patients

From the beginning of medical school, we have been taught to extend the same attention, compassion, and skill to each patient we see. A noble expectation, no doubt. So what do you do when you have a patient that is so dreadful, so condescending, and so entitled, that every interaction feels like verbal assault? Let me tell you about S.M., a 61 year old female with newly diagnosed Endometrial Cancer. Her cancer was caught so early, that we were able to cure her with the most benign of GYN Oncology surgeries – a transvaginal hysterectomy. Now this is a surgery that is so minimally invasive, women usually head home the very next day. Wonderful news, right?

Not for this particular patient. S.M., a heavyset Caucasian woman with a wild coif of graying hair, was convinced she was on the verge of death from the moment she arrived onto our hospital floor. How dare we ask her to roll on her side so we could listen to her lungs! She was suffering! And it didn’t matter that she had doctors to guide her medical decision-making – she was going to tell you what kind of medications she wanted. “I only want Demerol”, she ordered, “And Tylenol too! But not the generic, it has to be brand name!” And when she needed her IV replaced, we were ordered to bring up the Anesthesiologist from the OR to do it. No mere nurse could come near her. It had to be a licensed physician who placed her IV. Within her first 24 hours in the Oncology unit, after having to wait about 5 minutes for a nurse to fulfill one of her many demands, she picked up the phone and called the hospital C.E.O. to complain. Everything was wrong with her care. The food was bad. It made her nauseous. She didn’t get the right pain medication. The care was sub-par. How could we treat a little old lady so egregiously?

S.M. complained about anything and everything under the sun. So much so that after a while, I found it hard not to tune her out. Especially when I had a floor full of truly sick or dying cancer patients. Whereas normally I will pop into my patients’ rooms to chit chat throughout the day, I found myself avoiding hers like the plague.

By the afternoon of her second hospital day, she complained of worsening belly pain. And just like each exam before, she moaned and groaned when I touched her belly. The nurses and I rolled our eyes. Dutifully, I reviewed her vitals. Wait a minute. Her heart rate was up. I looked back at her labs over the last two days. Her hemoglobin had dropped 5 points since before her operation. A tell tale sign that she was losing blood somewhere. A CT scan later that night confirmed this. There was a large hematoma (blood collection) in her pelvic cavity where her uterus used to be. And it was making her sick.

The evening was spent stabilizing the patient. We transfused her. We did serial checks of her blood counts. We gave her pain medication. We did all the things we would have done for any other patient in the same condition. And in the end, S.M. was fine.

That night, I couldn’t stop thinking about this patient. She had been 36 hours out from her surgery before I noticed her drop in hemoglobin. Why? Was it just carelessness? Would I have missed that in one of my more beloved patients? Had I let her attitude affect the medical care I was providing? I knew the answer to these questions. I had let myself miss something in my patient, simply because I didn’t like her. And I was ashamed.

S.M. was discharged home on Friday. And thankfully I can say I strived to be a different kind of doctor after this incident. I know that I am limited by being human and I would be lying if I said I ever grew fond of this patient. But I learned a valuable lesson about keeping the practice of medicine separate from the emotions of human nature.

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