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Daniel Lee ~

1. Bipolar disorder
2. History of postpartum psychosis
3. No custody of her children
4. In treatment for cocaine abuse
5. Regular smoker

I digest each of these facts on the computer screen in rapid succession, progressively cementing the picture of Renee Pryce, a twenty-eight-year-old woman in her final months of pregnancy.

I'm a first-year resident in a large urban county hospital. In the course of my training, I've learned that some people (mostly older doctors) find the electronic medical record (EMR) burdensome and inefficient.

As a millennial, I've found the EMR very helpful. It's fast and comprehensive: I can absorb a full medical history in two minutes and develop a picture of a patient before ever setting eyes on him or her.

With this patient, I need only the five facts above to know that she'll be, to put it euphemistically, difficult. Her photo in the corner of her chart--an unkempt woman with a half-angry expression--tops it off.

In my six months here, I've seen hundreds of patients with similar problem lists. They blend together into a composite person in my mind's eye. I begin to imagine our interview.

I'll enter the room and pleasantly say, "Hello, Ms. Pryce, I'm Dr. Lee." She'll shoot me an annoyed look.

Ignoring that, I'll ask, "What's brought you to the hospital today?"

She'll pause, look at her phone, then offer a vague two- or three-word explanation.

Two girlfriends who've come with her will start talking: "I know what she has--something's wrong with her liver, probably stones or something. My sister's friend had that same thing when she was pregnant. They had to do surgery to get them out. She needs to have those stones out, I'm telling you--"

"You're crazy," girlfriend number two interrupts. "She doesn't have stones, she's got morning sickness. She needs some strong pain medicine. That fixed me up when I was pregnant."

"Well, first let me get more of the story from Ms. Pryce," I'll answer, my patience already wearing thin.

She'll give me a few more specifics, then get irritated--"You're the doctor, why don't you figure it out?"--before returning to pressing her long, manicured fingers into her smartphone.

I'll start to examine her, palpating her abdomen, feeling her legs for swelling and listening to her heart and lungs while asking more questions. The whole time, she'll be staring at her phone.

She'll smell like weed. "Yeah, I'm still smoking cigarettes," she'll say--but she's not drinking alcohol: "That's bad for the baby." She'll say that she got kicked out of treatment for relapsing on cocaine.

She won't want to see a psychiatrist or take any medications for her bipolar disorder: "What makes you think I need a shrink? And who told you I have bipolar, anyways?"

Still staring at her phone, she'll say, "It hurts a lot everywhere you're touching."

I'll make one more attempt to find out what's wrong: "What's your main concern today?"

"I'm in pain," she'll answer. "I need something strong for it." She'll refuse my suggestion of Tylenol: "I'm allergic." Same with trying an abdominal binder: "I tried it in my last pregnancy, and it doesn't do anything."

"Why don't we order a few simple tests and see where that takes us?" I'll suggest.

There will be no response. I'll leave quickly.

Returning to the present, I trudge reluctantly towards Ms. Pryce's room. I've already suffered through the encounter in my head; now I'm being punished twice. I take a deep breath, grab some cleaning foam, put a smile on my face, knock twice and step around the curtain into the room.

"Hi, Renee, I'm Dr. Lee, one of the resident doctors taking care of you. Nice to meet you."

She sits up in bed, looks me in the eye and reaches out to shake my hand.

"Thank you, it's very nice to meet you," she says.

I'm taken aback by her politeness, but even more so by her calm, controlled voice. She's wearing a college sweater. There's no one else in the room. There's no cell phone.

"What's bringing you in today?"

She swings her legs over the side of the bed and sits there, hands folded in her lap.

"I've been having a lot of vomiting and diarrhea, and I don't have an appetite."

"Can you tell me more about that?"

She offers a succinct summary of her pertinent symptoms. She's on medication for her bipolar disorder. She's seen the obstetric psychiatrist and knows the date of her follow-up appointment. All of her prenatal care is up to date. She hasn't smoked since becoming pregnant, and she's taking prenatal vitamins. She's in treatment for cocaine and has been sober for a year. She needs a letter to take back to her treatment center, stating that she was seen in the hospital.

Her speech is measured, thoughtful, pleasant. Eyes clear, intelligent, kind. Her posture straightens when I examine her. She's clean, well-groomed, plain.

As we talk, I am struck with respect for this woman. She has weathered the storms of life in a way that has, paradoxically, strengthened her. I don't feel a need to ask her how she did it, or to revisit the past. To do so, I feel, would somehow take away from her dignity. In seeing and recognizing her transformation, I feel uplifted.

I finish our conversation.

"This sounds like gastroenteritis, or the stomach flu," I say. "I think we should try some nausea medication and get a urine sample to rule out an infection."

"That sounds fine. Thank you very much. I just wanted to make sure it wasn't something else."

Her test results take a long time. When they finally come back, I go to see how Renee is doing.

"I'm sorry the test took so long," I say. "The results are normal, with no signs of infection or low nutrition."

"Oh, no problem," she says, smiling. "That medicine worked really well. I feel much better, and I ate some crackers. Do you think you could prescribe me some of that medication?"

I put in the script, then give her the discharge instructions and the letter to take to treatment.

I come away from our interview feeling bewildered by the disconnect between what I was expecting and what I encountered. Ruefully, I reflect that Renee's medical record told me as much about my cynicism and biases as it did about her medical history.

I'm surprised that, after only six months of residency, I've begun to assume things about my patients' character based on their diagnoses. These stereotypes presume that they are incapable of changing their lives for the better; ironically, that's one of the things that physicians are called to encourage patients to do. If I were a patient, I would want my doctor to see me in a nonjudgmental way. No matter how many mistakes I've made or how many times I failed in life, I would still want the chance at a clean slate.

Renee reminded me that illness, including mental illness, has no bearing on a person's character. People are dynamic--they suffer, they regress, they hope, they grow and transform.

And while bringing me face to face with my own shortcomings, she's also reminded me that no one is ever hopeless--and that everyone, myself included, could use a little bit of grace.


About the author:

Daniel Lee is a second-year emergency-medicine resident at Hennepin County Medical Center, in Minneapolis. He wrote his first Pulse story while in medical school. "Writing has always been a way to process my thoughts--a practice I've found crucial in understanding the complex, often messy situations that arise in medicine. This experience with my amazing patient was a wake-up moment amid a challenging first year in residency. Medical training leaves little time for reflection, thus I felt compelled to memorialize this event in writing."

Story editor:

Diane Guernsey

Comments   

# Sharon Dobie 2019-05-22 01:30
I love this piece. My book: Heart Murmurs; What Patients Teach their Doctors has a whole chapter on assumptions. One of my stories is right up there with yours. I have come to love it when I am shown how assumptions are wrong.
Thank you
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# Karen DeBonis 2019-05-23 07:03
Your book sounds interesting. I put it on my "to-read" list.
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# Dorothy Blake 2019-05-13 17:32
Thank you for writing the article. It reminds us all as health care givers and as humans to keep our preconceptions on a leash.
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# Karen DeBonis 2019-05-12 08:26
I really appreciate this discussion. I'm writing a memoir about my son's childhood brain tumor, which went undiagnosed for 3 years. As we went from specialist to specialist, I knew I had to sell each doctor on ME as a mom, so they would listen to my concerns. I didn't do a great job. Can anyone tell me how much communication/d ialogue/doctor- patient relationship is taught in medical school?
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# Susan S Turner 2019-05-11 16:20
Thank you for your honesty. Great story!
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# JOSEPH fennelly 2019-05-11 12:13
This is an excellent article. We in medicine take a course in art. The object is a 4-dimensional work of art: body mind psyche and spirit. We learn to love that art be close reading , close listening, close seeing. Only then can we discover the patient as person. Thus the physician enriched her physician as person.
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# Alice Fornari 2019-05-11 10:29
I am a medical educator always looking for amazing stories to use in our curriculum and this is one of them!! So many learning moments for the resident to share with our learners. I thank the author for this level of teaching and reflective capacity. A true gift to medical educator. Pay it forward and use in curriculum please. Honor PULSE and all it does for us weekly. Alice Fornari
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# Karen DeBonis 2019-05-14 07:49
Alice, what is the role of a medical educator? I have an amazing story you may be interested in.
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# Alice Fornari 2019-05-14 08:28
There is literature describing a role as a medical educator. There are four Common categories Of teaching excellence, educational focused leadership scholarship, curriculum development, assessment and evaluation knowledge and skills. Leadership includes mentorship.
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# Sara Ann Conkling 2019-05-11 09:42
This is a frightening story, which underscores the courage and honesty it took to write it. Thank you. As a patient with a pheochromocytom a that is is being evaluated at the present moment, I've connected with a support group of patients online, the majority of whom were diagnosed with serious mental illness - usually along with factitious disorder - before their large, catecholamine-s ecreting tumor was removed. The judgemental misdiagnoses affected not only the proper treatment of their pheochromocytom a, but all of their subsequent medical care. As a patient with genetic anomalies and more than one zebra in my personal medical zoo, I am sobered to the biases, and the incompetence of so many providers when it comes to treating someone with a rare disorder (or three or four, in my case). And when I find the relatively rare physician who cares enough to admit what they don't know (and then find out what they don't know so they can be of real help), I notice and I am very grateful.
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# Karen DeBonis 2019-05-11 08:10
I'm glad to see this doctor's honesty. I've always felt, as a patient, that first impressions are so important. I guess I'm right.
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# Pris Campbell 2019-05-11 05:53
What’s frightening is that too many doctors make assumptions based on lists of diagnoses in charts. I hope this doctor learned something lasting from this encounter. I appreciate his honesty about his initial bias.
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# Laurin Bellg, MD 2019-05-10 22:37
As a physician, I understand how easy it is to succumb to our own generalizations , often without even realizing it. We want to believe in the best of humanity, but our personal experiences often inform us erroniously and, sadly, affect our behavior. It's an unfortunate human habit, no matter our circumstances. I recently had my own experience of misplaced preconceptions with a well-coiffed patient who, based on years of treating similar patients, I fully expected to present me with a long list of important community connections, money-speak and lawyer threats if "an outcome didn't meet her expectations". I was prepared to navigate those circumstances, until she crumpled into tears in front of me, completely terrified by the limited mortality her diagnosis was wielding. Which, in the lovely words of Dr. Lee, succeeded in "bringing me face to face with my own shortcomings" and "reminded me that no one is ever hopeless--and that everyone, myself included, could use a little bit of grace."
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# Teresa 2019-05-10 19:18
As a minority woman, I am frightened by this article. This physician seems to think that admitting his biases absolves him of his stereotypes, and there are many. Even the way he describes his expectation that the patient has "long nails tapping on the phone". He has a long way to go to keep his blind-spots from influencing patient care. This is why minority patients are mistrustful of the medical system. I pity the patient who falls outside of his socio-economic class whom he can not identify with.
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# Rachel Weiner 2019-05-17 12:30
Thank you Theresa for naming this. I think this is an important story because it shows how implicit bias is real. But it is negligent in not addressing race directly while indirectly painting a stereotypical image of a black woman (I know this is an assumption and I do not know the race of the patient but by leaving it unnamed I suspect the image most readers came up with is an angry black woman). And the author is able to connect with the patient only when he finds she fits into his definition of acceptable dress and behavior. I feel disappointed in Pulse for publishing this, at least without a deeper analysis of what's at play.
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