Thursday, September 3, 2009

It's not about me: Reflections from a Monday at Grady

"Nobody understands my pain," my patient said solemnly, "I wish I could get somebody to know how I feel. People think they know me, but they just don't." He gazed back at me with ocean blue eyes, and then, in a split second, they were hidden behind a clenched grimace. I rubbed the side of my neck and prepared myself to be patient. My residents stood in respectful silence in a semi-circle at the foot of the bed.

The thing is. . . . I knew this patient. In fact, I knew this forty-something year old gentleman quite well from the last two or three times I had admitted him to the hospital. He'd remotely had a few blood clots -- what we refer to as a DVT or deep venous thrombosis, that in his case traveled through the veins to his lungs, where it then became what we call a pulmonary embolism. To protect him from further clots, he was supposed to be on lifelong anticoagulation (blood thinners) which he often neglected to take. When we'd see him, he usually complained of pain in his legs that rarely matched clinical findings, and the complaint was almost always accompanied by a request for narcotic pain medications.

The first time I cared for him, he left the hospital with a cross-my-heart promise that he would indeed take his medication as prescribed. Unfortunately, he didn't take the medicine as prescribed, and like clockwork, he'd subsequently show up in the Grady ER. After a complaint of pain or shortness of breath, he'd get admitted to the hospital to thin out his blood again and exclude a new clot again.

(Background for non-doctors: There are a few types of blood thinners. Heparin can be given IV, and thins the blood immediately. This is often started right away when someone is hospitalized for a clot or suspected clot. Warfarin comes in a pill form, and has to build up in the system. This process can take as much as five to seven days, depending on the patient. We often "bridge" our patients in the hospital by giving them heparin while the warfarin levels reach therapeutic level. Unfortunately, this means a hospitalization. While there is a type of heparin that can be given outside of the hospital for bridging, it is quite expensive making it sometimes difficult for uninsured patients to obtain. It is also a self administered shot, so takes a very compliant and motivated patient--which this patient was not.)

"Have you tried Motrin?" I asked even though I knew the answer.
"I'm allergic to Motrin. I'm also allergic to Tylenol and Ultram, too," he reported. Again the clench-eyed wince, again my neck rub. I could feel myself getting annoyed, which isn't really a good way for a doctor to feel about her patient. I shifted my feet from side to side in an effort to redistribute my emotions.

"Do you know when my nurse is going to be back to give me some more pain medicine? I'm in agony, doctor." He pulled the covers up to his chin and peered over them like a child who had just been tucked in. The residents cast fleeting glances to one another. They are watching what you do. Treat this guy badly, and you give them license to do the same. I cleared my throat and proceeded to look over his medication administration record.

"You actually received quite a bit of pain medicine about an hour ago, so you aren't quite due yet." I swallowed hard and willed myself to be patient with him.

"Doctor," his muffled voice spoke through the blankets, "that Morphine don't do nothing at that dose. One time when I was here they gave me some Dilaudid, and that helped a lot." Of course it worked, man. Okay, Manning . . . .Stay calm. Be professional. Stay calm. Be professional.

"I'm sorry you feel that way. I'm looking closely at what you've been given, and this is a pretty good dose of morphine, sir." More throat clearing, more foot shifting. Stay calm. Be professional. Stay calm. Be professional. "I'm not sure if you were told or not, but your tests confirm that you did not have a new clot."

He lifted his chin to get a better view beyond his blankets. Next came another grimace; this one exceptionally melodramatic. I reached for my neck, but decided against it. This is not about you. This is about him. Stay calm. Be professional. Stay calm. Be professional.

"I'm so glad I don't have a new clot, doctor," he continued in his best earnest voice. "I am very worried about what could happen with my blood so thick. How long do you think it will take to get my levels up? Last time it took 6 days, but I will just be patient with whatever y'all think."

I pressed my lips together, trying to think of an empathic response. The problem is, I wasn't feeling so empathic even though I knew I should. The pregnant pause continued as he periodically writhed in his alleged pain. I found myself looking for gestures other than the signature neck rub to blow off steam. Even though you are annoyed, don't look annoyed. Stay calm. Be professional. Stay calm. Be professional. Your residents are watching you. They will follow your lead.

And so we went on with our doctor-patient interaction. The residents stood quietly and listened carefully. I could feel my patience waning and hanging on by a thread. If something didn't change quickly, I'd be sure to erupt into neck-rolling and finger wagging--gestures I am certain he'd pushed doctors to before. He was also probably used to doctors becoming so frustrated that they'd a.) give in and become indifferent or b.) make passive-aggressive medication changes that would force the patient to leave AMA (against medical advice.) I am pretty sure the last time I'd cared for him, I'd done some hybrid of the last two.

Feeling like I was reaching boiling point, I made a decision to talk this over with myself before uttering another word.

Real me: What is this guy's deal? Why do we keep having to admit him when we know he just wants pain medicines? This is so ridiculous!

Empathic me: Do you think he wants to be forty-three and getting admitted to Grady five times per year?

Real me: No, but the dude is like, not even taking responsibility for any of his own actions. He is not taking his medicines. He knows that if he shows up in the ER he will get admitted.

Empathic me: Yeah, but why do you think that is? Do you think when he was in kindergarten, he said, "Hey, when I grow up I want to be addicted to Percocet and manipulating doctors at Grady!"

Real me: Probably not.

Empathic me: What IS his deal?

Real me: His deal is that he is annoying.

Empathic me: No, his deal is that he has a problem. He probably does have some pain, but the pain medicine is a problem. He does not have stable housing, he doesn't have family support, and every doctor he sees treats him like he is annoying.

Real me: But he IS annoying.

Empathic me: But that should not affect you being his doctor. Get off your high horse.

Real me: High horse? Give me a break.

Empathic me: You can start with some honesty.

Real me: I am being honest. I am trying to help but he is insulting my intelligence and it really is annoying. We have way too many patients to see to be dealing with this again.

Empathic me: But this is not about you. This is about your patient--and you signed up for this. Focus on that, and not yourself.

My direction became a little more clear right then. I would be honest. Even if he did not like it, I would be honest. And I would focus on him, not me.

"Sir, here's the thing," I chose my words carefully; ever-cognizant of my residents' eyes and ears. "I am really concerned about a few things. My first concern is that you absolutely have pain, but in talking to you, it is a long-standing or chronic type of pain. The pain you describe today is identical to what you told me before. And while I know that it is uncomfortable for you, I am not sure giving you habit-forming narcotic medicines for this is the right thing to do." I waited for him to speak, and when he didn't, I continued. "This time you didn't have a new clot, and from all of our work-up, you seem to be clinically stable. I am concerned that having you come in and out of the hospital is also not good. You seem to have trouble taking the warfarin. Why do you think that is?"

"Doctor, I stay in a rooming house and I am on foot everywhere I go. It is hard for me to make it to the clinic and when you go to the pharmacy, the wait is really long. My legs hurt, and all that walking makes it worse. I tried other stuff, but it doesn't help." His blue eyes were like pools, and for the first time, he looked truly sincere.

"That does sound rough,"I replied softly. "I didn't think about that." That sucks, yes. But still, this isn't working either. "What do you think about us looking into you taking the Heparin injections while your warfarin levels increase? We could see if we could get it covered and possibly try again."

"I hate them shots, and I just can't do it. Plus they said I am not a good candidate since I had so many clots in the past." Empathic me gave me a shoulder rub, reminding me to keep the proper focus. Be honest.

"Sir. . . again, my concern is that this has become a cycle. The easy thing to do is to give you pain medicine and keep you here while your warfarin reaches therapeutic levels. But I can't say that this won't happen again, and this is really not good what we're doing now," I spoke calmly. This time I did feel empathic.

"So what does that mean? You just kick me out?" he asked.

"No, sir. I am going to first contact our social worker to see if she can assist you with your medicines and where you live. Then, I am going to consult our Ethics Team. They help us with tricky and confusing situations or what we call 'ethical dilemmas', and, sir, I really think this is an ethical dilemma. You have clots and you need your blood thinned. You have pain, too. But it is your responsibility to take your medicine and keep appointments, and you haven't been doing that. Having you admitted over and over is bad for you, it really is. And we can't help you make more responsible decisions unless we hold you accountable to some degree. You understand what I'm saying?"

He didn't exactly care for what I was saying, but he did seem to respect my honesty. "Do you think it would hurt if I took those shots? I mean the Heparin shots."

"It's probably a bit uncomfortable, but I'm told it's bearable," I answered with my first smile of the encounter. "Would you like me to have the pharmacist come look over your chart and talk to you about it?"

"That would be good," he said with a half-smile.

When I left his room, I didn't feel annoyed any more. In fact, I thought about him a lot for the rest of the day. I wondered what he did when he wasn't in the hospital-- was he lonely or bored or scared? How did he even end up like this? And did he wish that he could be somewhere else. . . .without a history of clots, or unstable housing, or inevitable hospital admissions? It was true--this wasn't about me.

His care was later transferred to one of my colleagues a few days ago, and I am still not sure what ultimately happened. I do know that, on that day, his doctor was honest and tried to get over herself long enough to treat him with some dignity. Hopefully, the doctors-in-training who stood in the wings watching will take pause the next time, welcoming a little internal dialogue before reducing themselves to an unprofessional or passive-aggressive default . . .

Afterall. . . it's not about us, and we signed up for this.


  1. Dr. M, I just discovered your blog and I can't stop reading - it's wonderful. I'm laughing and crying with you. Thank you. - Marae S.




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