Don’t assume your patients’ character based on their diagnoses

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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 28-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, anyway?”

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.

Daniel Lee is an emergency medicine resident. This piece was originally published in Pulse — voices from the heart of medicine

Image credit: Shutterstock.com

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