January 31, 2013

This reflection from family physician Julia DeJoseph, MD, associate medical director at Joseph M. Smith Community Health Center in Waltham, is a powerful reminder of the importance of following up with patients, and having our roles reversed. Julia follows up carefully with patients to see that their needs are met. She also learns from, and is strengthened by, a role reversal with her patient. Being a patient with our own patients, can be very instructive.—Hugh Silk, MD

A Brief Role Reversal

A new patient presented to our community health center for an initial visit after losing her job. She suffered from many years of obesity, hypertension, chronic pain, diabetes and hypothyroidism, complicated by marked anxiety and depression. Over the last six months she'd developed recurrent kidney stones, requiring multiple hospitalizations. Throughout this time, she cared for her developmentally delayed son as well as a progressively ailing father who had been frequently transitioning between hospitals and skilled nursing and short-term rehabilitation facilities. She'd lost her job as a result of frequent health care-related absences, and thus the insurance that covered her care with her long-term primary care provider and multiple specialists.

Her entrance to our health center was sheer chaos. She walked through our clinic doors in hysterical tears, yelled and swore at our front desk staff in front of a waiting room full of patients, refused to have her vital signs recorded, demanded refills of all of her medications, many for which she could not provide correct doses or clearly explain their indications to her new primary care provider, again yelled and swore at our pharmacist due to the cost and/or lack of availability of the medications she'd requested, and ultimately received a stat 30-minute behavioral health consult secondary to clearly being in crisis. Her 30-minute new patient visit turned into a more than two-hour-long clinic-wide event.

I was not present in the health center on this day. However, as the site director of our clinic, I was concerned by the time and manpower required for the care of this single patient, as well as the emotional drain and abuse experienced by our staff. I shared our staff's concern that this patient had not received the quality of care we strive to provide secondary to the multiple barriers presented at the patient's visit. It felt like no one "benefited" from the patient's visit (including the patient).

I decided to call the patient prior to her next visit to gain insight into how we might avoid a repeat visit of this magnitude, to discuss some expectations of the patient and to clarify what she needed and could expect from us.

As a brief aside, I (rarely, thankfully) experience pretty severe migraines complete with aura, partial vision loss, and marked difficulty speaking clearly. My speech is almost comical in that I can get across what I want to say but I often mix up words and mis-order my sentences. I am fortunate that abortive therapies work well for me once I recognize the aura and I generally can get through the rest of my day with just a little post-migraine fatigue. The morning I decided to call the patient I had developed a migraine. I took abortive medications, felt better, and continued to do administrative work from home.

I called the patient, but while introducing myself and my role at our health center, suddenly found myself stumbling for words. To my great dismay, I realized that my migraine had not completely resolved and I was clearly not ready to speak with anyone, much less have a difficult conversation with a patient. I haltingly explained that I had called to follow up on her recent visit but that due to my migraine, I would need to call her back. I tried to smoothly apologize in an effort to excuse myself from this increasingly awkward situation, but due to my migraine was having increasing difficulty doing so. I felt mortified.

At this point the patient took over, stating that she understood completely and had suffered from migraines in the past. As I continued to awkwardly respond I said, "Thank you. I appreciate that you understand. I don't want you to think I'm crazy." She responded, "I completely understand. I don't think you're crazy. In fact, I was a crazy person at your clinic last week. Your nurse practitioner [the patient's new provider] was amazing and took such great care of me. I feel like anyone else would have had me committed. I was so beside myself and completely overwhelmed by all of the changes in my life that I just lost it." She concluded our conversation by advising me to call her back later when I felt better, and wishing me well with my migraine.

I was completely moved by this change of roles. I was reminded of how human we all are with our own down times and flaws. I was floored by the empathy and patience given to me by a woman who just days prior had turned our clinic upside down. Ultimately, I called her back a few days later. Our conversation was not perfect, nor easy. The patient exhibited several of the emotive behaviors previously witnessed at her initial visit. We spoke at length requiring frequent redirection in order to make gains and establish expectations and goals for her future visit. The conversation was difficult but I found that I had ample energy to provide the necessary empathy and patience she needed. I felt that I'd been renewed and cared for and I was hoping to give back. Ultimately, I felt that we had made progress by our conversation's conclusion, and the patient's follow-up visit proved to be a markedly better experience for both the patient and her provider.

There is much in current medical literature about modifying the role of provider and patient as we evolve from the previous paternalistic physician role to providers as patient-centered advocates and medical advisers working on a patient-included team. This unexpected perspective of the patient as the “care provider” and myself as the “care recipient” is not one I’ve often experienced. I felt humbled as I was reminded that I as a physician am not unique in my role as someone who is able to provide care. It is, in fact, our role as human beings (some of us just also happen to be trained clinically) to provide care in those times when care is needed.

Each Thursday, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.