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Routine Office Visit

“I have good news for you,” my resident exclaimed as she walked into the exam room. She was holding the patient’s most recent vitals handed to her by a nurse practitioner.

I scurried behind the resident, feeling a bit nervous. This was the first week of my family medicine rotation in the rural town of Hillsboro, and I was still getting used to the overall flow of the clinic. In my arms was the patient’s medical information I reviewed the day before.

On the left side of the room sat the patient — a well-groomed, 45-year-old man wearing a blue T-shirt and black jeans. He presented for his three month follow-up appointment for hypertension and type II diabetes.

“Your blood pressure today was 120/70!” My resident exclaimed as she sat across from the patient. He looked up to meet the resident’s eyes, and I could sense a smile light up behind his mask.

“That is amazing…” The patient said in a quiet, cheerful voice.

My resident also shared that his HbA1c today was 6.4%, much improved from 7.6% three months ago. More good news elicited a sigh of relief from the patient.

Then, the patient turned his head towards the door where I was standing. I responded with a smile and took a moment to introduce myself. “Hi, my name is Bo, and I am a new medical student. Thank you for letting me observe today.”

Over the next half hour together, the patient shared his dietary changes with us, including controlling portion sizes and increasing vegetable intake. He had also been monitoring his blood pressure at home weekly and taking all of his medications as instructed. For many years, the patient had been taking lisinopril and amlodipine for hypertension along with metformin for diabetes. Given that his blood pressure was well-controlled, my resident let him know that he could taper off amlodipine. She added that he can always resume the medication if his blood pressure rises again. 

At the end of his visit, my resident asked the patient about his goals for the next visit in three months. After a brief silence, the patient shared that he wanted to maintain his healthier diet. He also hoped to find ways to stay physically active, which had been challenging due to the pandemic restrictions.

When we picture the phrase “good news” used in a hospital setting, many of us naturally perceive emergency situations that often involve life and death — the successful delivery of a preterm infant, acute resuscitation of a trauma patient or the completion of a complex operation. Therefore, it took me some time to get used to my resident’s frequent use of this same phrase, “good news,” during routine office visits. In addition to this particular patient who was managing hypertension with diet and medication adherence, this phrase was also used to describe, among others, a patient with a 20-pack-year smoking history setting up a quitting date or a patient with opioid dependence attending their first methadone maintenance therapy session. 

Over time, I came to appreciate my resident’s use of the phrase “good news” when interacting with patients. The medical field often dichotomizes human activities as either good or bad and criticizes the latter — poor diet, smoking and substance use, to name a few. For many patients, this leads to shame and fear of judgment when they fail at quitting the “bad” activity completely.

As a result, patients are often reluctant to have open and honest communication with their physicians. On the other hand, my resident grounded her relationships with patients in acceptance and affirmation. Rather than criticizing the patients and their behaviors, she made sure to acknowledge even the smallest improvement patients had made since their last visit. By doing so, she wore down the arbitrary dichotomy between good and bad and validated the wide spectrum in between the two extremes where patients often struggle. 

This brings us to a clinical framework known as harm reduction. Instead of perceiving anything less than quitting as a failure, providers are encouraged to understand and appreciate the patient’s current stage of change within larger psychosocial contexts. Providers can then work with the patient to find the most individualized and pragmatic goal for the next visit, which can help mitigate negative health consequences. This shared decision making, focused on progress over perfection, describes the core of harm reduction and, from my perspective, captures the art of family medicine.

During my subsequent patient encounters, I learned how important it is to take a step back and acknowledge the steps that patients are taking towards achieving their health goals. I am reminded every time that my toolbox as a future healthcare provider is not limited to medical knowledge or skills. Importantly, it also encompasses every word and gesture I use to interact with my patients.

Simple acknowledgement of a patient’s efforts and progress that may go otherwise unnoticed can ground each patient on their “small wins” rather than eventual outcomes. As I continually reflect on my family medicine rotation, I have a renewed appreciation for my role as an advocate for patients in their life-long journey towards better health.

Author’s note: Some of the clinical and personal details of this story have been changed to preserve the patient’s privacy.

Boyoung Ahn (5 Posts)

Contributing Writer

Geisel School of Medicine at Dartmouth

Bo is a fourth year medical student at the Geisel School of Medicine at Dartmouth in Hanover, NH class of 2024. In 2018, Bo graduated from Dartmouth with a Bachelor's degree in psychology, then pursued a Master's in global health at UCSF. Bo enjoys running, hiking, and volunteering in her free time. Bo would like to pursue a career in internal medicine and geriatrics.