Late last year, I decided I needed to get my health checked up on. I went through the motions, trying to make an appointment with the doctor that was assigned to me. Nothing was available for months. I called every other day, asking about cancellations that would fit into my schedule for days I already had off. It was a pain and difficult as well to switch a single workday when I was scheduled for a week. After a couple of months, payday! I finally got an appointment. Sort of. It wasn’t with my doctor, though. A trainee doctor had an opening in their schedule, and if I would see them, I could take that slot. I did. I was tired of waiting.
On the day of the appointment, I went through the usual motions. I got there early, checked in, and filled out some paperwork. Then someone brought me back to check some vital signs and asked me questions. I sat in the exam room, waiting until they were ready for me. Over time, I learned to make sure I had my ereader to keep me company and distract me. This time, I didn’t need to wait long, and they saw me within 15 minutes.
The doctor came in, and we started reviewing my medical history and the reason for my visit. I said I needed an annual physical, any updates to shots, and a general check-up after not being seen for several years. I needed basic lab work to check my health. We got through the physical and started talking about what else they could test me for that went beyond basic labs but was still important, like HIV testing. I agreed to everything but didn’t feel I needed any of the extras.
The conversation turned to me refusing to get the extra lab work. That was triggering. “Refusing” is a strong word. It felt more than just not wanting the labs but going against the recommendation, even if it was not meant as such.
In medicine, refusing something can be seen as going AMA, or Against Medical Advice. That phrase carries a lot of weight depending on the situation. While I was being taken care of by a resident physician, I also helped teach them. This experience became an example I could bring up when appropriate.
Now, months later, it is a Friday night, getting late, almost 11 pm, and I am on call when a resident calls because they need help.
“I have a new admission from this evening. They haven’t been seen by an attending, and now they want to go home. I’ve tried to convince them to stay, but they are adamant. They are willing to sign the AMA papers, but I wanted to make sure they are OK to go.”
We start with the resident going over the admission, presenting why they came to the emergency department, the workup, including any results, and a working differential diagnosis, the most likely reasons for the illness.
Once they are done, it is my opportunity to ask questions. How sick do they look? Any concerns in the workup?
They look well right now, and the workup so far is not showing any concerns, but cultures were drawn and are pending. The ED has given a dose of antibiotics just in case. They should be monitored overnight until the cultures come up, not growing anything for at least 24 hours.
Depending on the time of year, the resident might be newer in their role at the start of the academic year or more experienced closer to the end. Time to push their comfort level.
I ask what the risk is of letting them go. Will they not return? They already came in once. Do we expect they will get sicker based on the workup? Less likely with most things essentially normal. They also received one dose of ceftriaxone, which will cover a lot of standard things when there is not a source or sometimes seemingly, just because.
The resident agrees they look good and they do not seem to have anything serious, but they could.
Autonomy vs. comfort and the use of AMA as a weapon are far more prevalent the earlier someone is in their learning and career. There is an implied threat when bringing up to a family that they need to sign papers saying they will not be discharged, but they can leave if they accept the responsibility. Families will stay against their desire to avoid this kind of tactic. There is also an idea of some kind of medicolegal protection. It is difficult to choose patient autonomy over something that goes against your uncomfortableness. We do not want to make mistakes, or worse, have harm befall someone because of our actions or inaction.
At the end of the conversation with the resident, it ended up being a teaching moment going through the science, the differential diagnosis, and finally their concerns and fears. We played a game of pros and cons, culminating in asking the resident what they wanted to do. This is a teaching program, after all. The hesitation and hitch in the voice could be heard and felt through the phone.
“They are stable, and it seems like a viral process more than bacterial. The family is willing to return if they get worse or something happens. Cultures are running, and they’ve had a dose of ceftriaxone. Yeah. It’s OK to discharge them home.”
“Do we need the AMA form?”
“No. Just a regular discharge.”
Nirav Chaudhari is a pediatric hospitalist.