October 25, 2012

The Patient Who Showed Me the Light Behind the Shadows on the Wall

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“¿Doctor, perdone que te moleste, pero me puede explicar por qué estoy en el hospital para que pueda decir a mi familia que está pasando?” [“Doctor, forgive me for bothering you, but can you please explain to me why I’m in the hospital so that I can tell my family what’s happening?”] My patient groaned from amidst his dark, corner hospital room. With the blinds closed and lights off, I struggled to see his face — made more obscure by the dusk hour at which we rounded. Between his emergency laparoscopic appendectomy, a protracted bout of gram-negative sepsis and multiple evacuations of peritoneal abscesses, the surgery patient was unclear about his illness and treatment.

For whatever reason, the patient had not been able to fully grasp what was happening to him. Our team needed to rectify his lack of understanding. As I tried to come to grips with this gap in our communication, I grimaced as the patient rapidly clenched his right-lower abdomen in response to the resident’s palpation of the area. I introduced myself as the medical student (which did not deter him from calling me “doctor”), and — as the only Spanish speaker on the team — translated the patient’s request for the chief resident. “We have to get on with rounds. You explain to him what’s going on and meet us ahead when you’re done.” The team left, while I stayed behind. I took a deep breath and began to explain to the patient about his appendicitis, the subsequent complications he suffered and his need for continued antibiotics. He indicated to me his understanding and thanked me. I then made haste to catch up with the team — who had already seen three more patients on our list.

I left the hospital that day disillusioned. What I had witnessed seemed to fly in the face of the extensive Power-Point presentations and lectures on patient-centered care and culturally sensitive medicine that we were given as first and second year medical students in our “Medicine, Patients and Society” class. Wasn’t the first step in patient communication ensuring patient understanding? I scratched my head as I strolled through the lobby to the street. What went wrong? The surgeons at the hospital are excellent. All of the nurses speak Spanish. They must have told the patient what was happening to him when they rounded on him every morning — even if tersely. Still, some critical step was bypassed in communicating to the patient about his condition in a way that he could understand it.

Walking to the Metro stop, the contrast between the sunny May afternoon in New York and the darkness of the patient’s room reminded me of the allegory of Plato’s cave. I was witnessing the semblance of medicine — Plato’s shadows on the cave’s wall — where the “care plan” was taken to be the textbook steps to treating a complicated appendectomy. Yet, by no fault of any single person, something went wrong. I reached in my pocket for my patient list to review his plan. IV antibiotics. Check. Jackson-Pratt drains emptied. Check. Wound care. Check. Where was the communication about his condition? The sunlight — what Plato compares to truth — somehow did not make it to our patient’s room.

What was bothersome to me was not just the communication gap, but also the fact that he reminded me of how tempting it can be in medicine to rest in the cave. As Jerome Groopman notes in his best-selling work, How Doctors Think, studies show that it takes an average of 23 seconds after the patient starts talking for a doctor to interrupt and, at best, an average encounter with a patient lasts 15 minutes. With such terse interactions and so much information needed to gather a good history and physical exam and to formulate a treatment plan that is best for the patient, the environment is rife for miscommunications.

Why such brevity of interaction? One answer is that a heavy workload limits the amount of time that can be allocated for each patient. We all feel the time crunch and need to cut corners somewhere to get through our workload by the end of the day. More importantly, though, cutting short patients’ free responses adds structure to the chaotic world of dealing with people’s problems. As with any service profession, dealing with people’s problems — illness or whatever — can be messy business. Too much narrative or “touchy-feely” talk does not fit nicely and neatly into textbook-style medical histories for which we can make clean differentials and treatment plans. Plato was right. The sunlight reveals the randomness of nature that all of us would just as rather shelter ourselves from and look at shadows on the wall. Outside in the elements can be a scary place.

Of course, when it comes to what goes on the checklist, very little may change in the care plan by taking a few more extra moments to ensure effective communication. For my surgical patient, my few extra minutes talking to him did reveal insomnia symptoms that were remedied with medication, but management of his peritoneal infection would likely not have changed. The infection cleared, his fever broke, pain subsided, drains were removed and he was discharged home.

Nonetheless, something critical was lost by his being dragged along a complicated recovery path without knowing what exactly he was suffering from or how he was being treated. Good medicine is more than just good old bedside manners — which our team showed no lack of.  It’s an art of tuning into the patient’s communication needs that is all too easy to jump when we’re constructing scholarly differential diagnoses and comprehensive multi-point treatment plans. I don’t see any easy solutions in today’s environment of scarce time and growing patient loads, but suffice it to say that the art of communication merits a considerable share of doctors’ attention alongside the formulation of treatment plans.

During my last encounter with my surgical patient in his dark room, with lights out and blinds drawn, he appeared comfortable and content. “Doctor, te quiero decir algo,” [Doctor, I want to tell you something.] “Sì,” I said, taking a step back — desperately hoping that I was not in for another surprise like the last one. “Te agradezco mucho por haber tomado el tiempo para explicarme que me pasa. Me has tratado bien.” [I want to thank you for having taken the time to tell me what’s happening. You’ve treated me well.]

Original Author: Landon Roussel