Ms. M greeted us cheerfully as we walked into the room. She was a middle-aged Caucasian woman, but the lines on her face and the long white hair made her appear perhaps a decade older. She had suffered from major depression on and off for many years and was now in the midst of a relapse. Unfortunately, as the interview progressed, the story unfolded of her recent eviction from her home as well having to give away her pets. A former desk worker, she had been laid off as part of her company’s large downsizing process over eight months ago. She had collected unemployment for six months but now was without income. While this triggered a major depressive episode, it also made her angry as she lost her independence and moved in with her son and daughter-in-law. Her depressive phenomenology included not just guilt, shame, and sadness, but episodes of rage where she locked herself in her room for fear of verbally assaulting those she loved. The victim of a slow economy and systemic injustice, her ability to thrive as a person was in jeopardy.
While this is a moving story, I believe it is a story which could have been missed without this unique provider bringing to this unique patient encounter her own empathetic frame of reference. This frame of reference I believe is what allowed this provider to gather the appropriate details of the story, and for the story’s retelling I have arranged those details in a patient-centered, nonjudgmental way which aligns with the spirit of the provider. To illustrate how this frame of reference motivated the provider, I will finish the story.
Before Ms. M came to clinic, the provider Dr. R was already aware of her history of depression, her predisposition for relapse, her recent eviction, her medical comorbidities, and the importance that her mental health would be in managing those comorbidities. She actually entered the room with mental health as the most important subject to address, and thus she was able to respond appropriately as the patient divulged the issues most important to her. And as a rheumatologist would ask questions to assess for involvement of Lupus in new organ systems and use knowledge of Lupus to alert the patient to possible complications, Dr. R asked questions to assess for complications of Ms. M’s social situation. “How are you getting along with your son?” “How are you paying for prescriptions?” The latter provoked frustration on all parties as we realized the pharmacy had rejected her newly acquired Medicaid prescription account because she had not yet received the prescription card which Dr. R had helped her apply for at her last visit. In the context of a recent acute visit for shortness of breath ruled out for cardiac ischemia equivalent and instead attributed to COPD, Dr. R knew that she should not go long without her inhaler, and that she should not delay starting the antidepressant which was being prescribed today. Therefore, in the middle of the visit, Dr. R called the pharmacy, sent her prescriptions over electronically, and double checked that they would be covered by the prescription plan number in the absence of the card. Joining in the patient’s anger at injustice, Dr. R shouldered the patient’s burdens as her own, and not just for twenty minutes in the clinic.
By retelling this story now, I hope to show how clinical expertise must involve at least three components. First, diagnostic acumen cannot be underestimated. Her prior visit was for acute shortness of breath, and in the context of a cardiac history and risk factors, Dr. R appropriately acted quickly in an outpatient setting to rule out cardiac ischemia. This is a great service to the patient which as students we spend the majority of our time learning. But just as importantly, this acumen absolutely must be applied in the context of a therapeutic relationship. An incredibly large amount of progress was made in this patient’s care in twenty minutes because the agenda was motivated by knowing the intricate details of the patient’s medical history, personality, predispositions, and social situation. Every move Dr. R made was motivated by her memory of who the patient was and why certain actions should be prioritized and others should not. And finally, expert care moves beyond empathetic listening and towards the shouldering of burdens carried by our patients. A process happened in the mind and spirit of the provider whereby she internalized the patient’s concerns, fears, and hopes, processed the most important action items, and actually did them. I feel very fortunate not just to have witnessed true and genuine service today, but to consider how that internalization process and move to action will happen in my own mind and spirit for the duration of my career in primary care.
John Marshall, MSIV