My patient Maria sits before me, looking vaguely distressed.
She’s returned for a follow-up visit, six weeks after our first. The morning is half over, and I’m clipping along, staying on time, using the new electronic medical record system (EMR) without a glitch and with a sense of satisfaction. Three months back, when I joined this small-town practice as part of my new position as a health-system medical director, I found the EMR challenging, so I’m pleased that I’ve finally mastered it.
Maria’s face looks familiar–pretty, but with a worried look that matches her hastily applied makeup.
Checking her last progress note, I recall her history: a sixty-year-old teacher, she moved alone to this town several months ago. She has an irregular heartbeat, for which she’s received multiple cardiac procedures. Although the condition is now controlled, she’s reluctant to give up her official status as disabled. She’s not sure she can withstand the physical demands of teaching, and she’s also uncertain whether, at sixty, she could get a new teaching job.
I remember feeling apprehensive during our first meeting; for some reason, we both seemed to feel uneasy about making eye contact. I’d even wondered fleetingly whether she might be seeking narcotics.
During that visit, Maria had complained of left leg and knee pain that I couldn’t fit into a convenient musculoskeletal category. I’d taken the time to recommend and demonstrate some stretching exercises and to prescribe an anti-inflammatory.
Reviewing Maria’s record, I see that she missed her follow-up appointment. She rescheduled a visit for last week, but missed that one too.
I remember reading that no-shows often reflect a patient’s feeling of having been treated disrespectfully by the office or the provider.
Did I miss something at our first visit? I wonder uneasily. I view creating a respectful and trusting relationship as fundamental to good care; it’s disturbing to think that I may not have succeeded with Maria. Did she find me uncaring or disrespectful?
Still, she’s sitting here in front of me now. Perhaps I’m being given a second chance.
“How have you been doing since our last visit?” I ask. “Did the stretching exercises help?”
“No, they didn’t,” Maria replies. “The pain is still there.”
Now it’s concentrated about the knee. I perform a knee exam and order an x-ray.
For a moment she looks satisfied. Then she quickly points to three salmon-colored spots on her arm.
“I worried about these, too,” she says.
How severe could her knee pain really be, if she moves so quickly to these trivial skin lesions? I wonder. Is she afraid of cancer?
“Oh, those are nothing to worry about,” I reassure her. “Those spots are keratoses; they’re benign. I can freeze those off if they bother you.”
Again, Maria’s expression clears for a moment; then she speaks again.
“Doctor, I’m afraid my urine is infected, because it has a dark color and a strong odor.”
No, she doesn’t have painful or frequent urination. I ask her for a urine specimen, and she heads down the hallway to produce it.
Returning, she says, “Doctor, I lost the prescription for the DEXA scan that you gave me at our last visit. Could you reprint it for me?”
This visit is taking longer than I’d expected…so many complaints!
I smile weakly and reply, “Sure.” I’m still not behind…
Maria’s urine results are normal, except that her urine is concentrated, with a specific gravity of 1.030 (the average is 1.015). I explain that there’s no sign of infection, but that the concentrated urine, due to inadequate fluid intake, could cause the odor and color.
She looks skeptical, but admits, “Yes, I don’t drink enough water much of the time.”
I order a urine culture to reassure her, even though it’s not medically indicated. At this point, I feel like I’m bargaining. As I focus on typing Maria’s diagnoses and visit codes into the EMR, she speaks again, quietly.
“Doctor, would you renew my Xanax prescription? And…how do I see somebody for counseling?”
“There’s an 800 number on the back of your insurance card for mental-health services,” I reply. “You don’t need a referral.”
I pause…Do I have time?
“Why do you need to see somebody?”
“I’m having crazy thoughts,” she says. “Sometimes I think I’ll take all of my pills at once.”
Our eyes meet. The discomfort between us wasn’t about me, I realize; it was about this.
With a sweep of her hand, Maria shows me a scar across her neck–a scar that I’d assumed was from thyroid surgery. Looking more closely, I realize that the scar is much wider than any surgeon would need.
“In 1996, my husband tried to kill me by slitting my throat,” Maria says almost inaudibly. Tears fill her eyes.
I catch my breath. Embarrassed and caught off guard, I struggle to keep meeting Maria’s eyes.
Then I take what seems like my trivial focus on time and efficiency and set it aside, along with my laptop.
Doing my best to be collected and completely present, I ask, “Is he still around? Do you feel safe?”
Maria’s gaze drops to the floor.
“Yes, he is…” she murmurs. “I never pressed charges.”
I sense her shame, and I feel angry that she feels responsible for this crime and guilty for not pressing charges. Paradoxically, those who have been abused often feel responsible for it–I know this. I feel angry on behalf of the little boy I used to be, who felt responsible for my father’s rages and abusive behavior. My heart goes out to Maria in her pain and sadness.
“My daughter doesn’t understand how much it still affects me,” she continues, drying her eyes and sounding relieved. “I moved here to get away from him…but now I sit all alone, just watching TV. I’m only sixty, and I still want to work, but I have this cardiac disability.”
Together, we make a plan. Maria agrees to see a therapist within two weeks; she will let me know when she’s scheduled the appointment.
I tell her that I don’t want to prescribe a month’s worth of Xanax if she’s going to take it in a suicide attempt.
“I won’t do that,” she assures me. I believe her.
We talk about my perhaps ordering an antidepressant after she starts counseling, if her therapist agrees.
The visit draws to a close.
“I meant to tell you about this last time,” Maria says.
“I’m glad you trusted me enough to tell me,” I answer.
She leaves, clearly feeling relieved. I feel relieved too–and grateful that I’ve been given a second chance.
About the author:
Mitch Kaminski is a family physician who has practiced, taught and led in primary care for thirty years. He is the medical director for AtlantiCare Physician Group in southern New Jersey. “Like all of us in medicine, I know that we are privileged to enter the personal lives of countless patients. There are many memorable encounters; writing about them helps me to learn from, and teach about, caring for patients. For me, this kind of encounter represents the most challenging and most rewarding opportunity in primary care. It is a sacred moment that can only happen when I’m able to be fully present. Being mindful during a visit, observing the interaction between the patient and myself and taking note of the dialogue helps me to miss fewer of these moments on busy or stressful days.”