During our first week of the internal medicine rotation, my classmates and I skimmed the “Chief Complaint” column to find interesting patients and to confirm that we completed all cases. We came across one patient we had met in the Emergency Department the previous night. She was a morbidly obese African-American woman in advanced renal failure. One of my colleagues, AE, quickly expressed an interest in the assumption of her care. My peer had consistently demonstrated excellence in patient-centered psychosocial care and the three of us were in agreement that she may be the best suited among us to serve as her medical advocate. Shortly after assigning patients we went our separate ways and reconvened with our attending after a couple of hours to present.
AE began, “Ms. W is a 42-year-old morbidly obese African-American female presenting with end-stage renal disease and sacroiliac decubitus pressure ulcers. She has a history of DM2, hypertension and anxiety. She is currently using a tunneled line for dialysis and is scheduled for fistula creation in three days. She is currently on IV fluid replacement and Vanc/Zosyn for her ulcers. She is really scared. I saw her in the dialysis unit today and she began crying with me, understanding that she has not managed her weight or DM well. I think that she feels responsible for her current condition. I think she would also benefit from a psychiatry consult.”
I was impressed at the thoroughness of this presentation. Only two weeks into our very first rotation AE had integrated health determinants like social concerns, insurance status and financial challenges into her oral summaries. Our attending was in agreement and, after consulting with Ms. W, we ordered a psychiatry consult and explained her current condition.
As we all gathered our bags and prepared to leave the hospital for the day, AE let us know that she was going to take a few more minutes to visit with Ms. W. She was already taking it upon herself to become the primary health care advocate for this woman, an undoubtedly tremendous task. Ms. W had a complicated history, both medically and socially. She had poorly managed diabetes and hypertension, complicated by her weight. By this time she had gained so much weight that she was unable to ambulate and was dependent on her youngest daughter for her activities of daily living. She had three children, none of whose fathers were particularly involved or financially supportive. She continued to watch the scale numbers climb despite her multiple attempts to lose weight. She was underinsured and received only Medicaid. She had difficulty affording medications, let alone accessing them given her current health status. She saw the doctor only irregularly and usually when she had complaints. She sought admission to the hospital because of nausea and vomiting for the past three days, generalized weakness and fatigue. Her initial labs were remarkable for elevated BUN and creatinine with an eGFR indicative of stage 4 renal failure. Hemodialysis was her only option and treatment began immediately. She was alone both in the ED and in her hospital room; her journey would be particularly difficult without the support of family or friends.
The next morning I found myself alone in the onsite office awaiting my classmates’ arrival. After I reviewed the previous day’s notes for a few minutes I noticed that AE’s bag had been in the chair across from mine since before my arrival. A few minutes later she came through the door and informed me that she came in early to talk with Ms. W. We again prepared the patient census and made rounds and once more AE demonstrated mastery of her patient. At the end of this day, too, she stayed a few minutes later to spend time with Ms. W. This became something of a routine for AE; she arrived early and stayed late to spend time with her patient. Ms. W had declined our psychiatry referral but AE persisted, discussing the importance of mental health and her physical wellness until she finally agreed for evaluation later in the week. When it came time for her fistula, AE was the first to visit before and after the operation to check in with her and to reassure that all was well.
When it came time for Ms. W to go home, AE was beaming. She had spent countless hours with the patient in excess of what was required during an already demanding rotation for the sole purpose of doing what was right. She epitomized Hippocratic values with her provision of care and expected nothing in return, taking on the patient’s case as if it was her own family member’s. AE navigated all the complexities of her story and left her in a better medical, psychological and social state every day.
Since matriculation, AE has demonstrated values critical to the practice of patient-centered medicine. She is completely selfless and never hesitant to lend a hand to those in need. Passionate and eloquent, she articulates the concerns of those without voices in critical conversations with poise and ease. As an advocate for the underserved, her ability to navigate psychosocial issues with all populations is unmatched. She asks the proper questions sensitively and offers feasible advice for all of her patients. Her care for Ms. W was the perfect opportunity to utilize all of her strengths to provide sophisticated care for a woman in need.
As a physician in training, I continue to look not only to my attending, but also to my classmates to typify the ideal practice of patient-centered medicine. As we prepare our notes and oral presentations we have the greatest amount of time to dive into the lives of patients to understand all of the factors affecting their health. In this way, we can make the greatest difference, as listeners, counselors, advocates and educators. Though we are learning to save lives with medications and procedures, we also change them with our words and our time. In every exam room is a story. In every classmate, there is a lesson. The observation of my colleagues and the development of their practices has transformed my own and improved my approach to patients and their families.
This experience with my colleague challenged me and changed my understanding of our role as physicians in training. To this day, I reflect on her care for Ms. W and emulate her example with every patient I visit. Each has a story. A case like Ms. W’s, when many are likely to attribute her disease to her lifestyle rather than to the social determinants driving her choices, AE provided non-judgmentally with acceptance, respect and empathy. These values are those at the core of medicine. Sometimes the best intervention is not a medication but rather a listening ear, not a vaccination but rather a shoulder to cry on, not a screening test but instead an advocate. The physician’s roles in the practice of modern medicine are innumerable but AE reminds me that perhaps the most important of these positions is that of an ally and health partner in our patients’ most trying times. I am forever indebted to her for allowing me to both share this experience and to admire her practice every day as my colleague and friend.