Joshua Boyd - Patient-centered Ethics: Pathography

Jul 16, 2022 at 04:25 pm by pj

Over the course of all my clerkships, I have observed countless interactions between my preceptors and their patients. Most of these encounters ranged from neutral to heartwarmingly positive, but a small minority were uncomfortably hostile. Patients would occasionally become angry with my physician, blaming them for unfortunate outcomes or yelling at them about the expense of a visit. When this happened, I would awkwardly stand out of the patient’s line of sight and hope that none of that rage would be directed at me. Until my internal medicine rotation, none of it ever was. This changed when I met JT.

JT was “my” patient. He was part of my four-person list who I rounded on alone and presented to my preceptor every day. JT was a survivor of a stroke that left him extremely dysarthric and paralyzed on his left side but with seemingly intact cognition. He had no visitors or family members who could advocate for him or facilitate communication; conversing challenged both of us at times, but we managed.  Initially, our interactions were pleasant. I would arrive, ask some standard questions, perform a brief physical exam, and go report to my preceptor and state my assessment of whether his presentation had changed at all. Despite some improvement with his dysarthria and weakness, he still had great difficulty swallowing and would aspirate anything given by mouth. He was determined to be at such a high risk that he received a GJ tube and was placed on NPO orders.

 It was at this point that JT started becoming progressively more frustrated with his care. It also became apparent to me that JT may not have fully appreciated what having a GJ tube and being NPO would entail.  Although difficult to understand at times, JT clearly regretted receiving the GJ tube and would ask me daily for Gatorade or food. I had witnessed the nurses acquire consent for the procedure, and at the time JT appeared to completely understand the ramifications of being NPO.

However, comprehending the steps of a procedure and truly appreciating what the aftermath will feel like are two radically different things. How could he have known how bad it would be? He had never experienced anything like this in his life prior to this point. His case illustrates that the superficially simple task of obtaining consent is actually very difficult, and even when the process is done correctly it doesn’t guarantee anything. No amount of education or counseling can adequately prepare a patient for the loss of something as essential as eating or drinking.

These circumstances wore on JT. On one particular day, his frustrations rose to a boiling point. He began yelling at me as soon as I entered his room, calling me a “damn liar” and refused to let me even approach his bed to conduct an examination. From what I could gather, JT believed that I had promised him ice chips the previous day; when no ice chips appeared, I was the one at fault. I was upset at being accused of lying, but in retrospect JT saw so many different people on any given day in the hospital that he most likely misattributed a conversation with someone else to one he had with me.

Walking out of that room left me with a mixed bag of emotions and questions that did not have easy answers. I felt bitter and insecure. Did I accidentally communicate so poorly with this patient that he thought I had control over his NPO orders? Am I a terrible medical student, or worse, a damn liar? How the heck am I going to tell my preceptor that I made his patient so angry that I can’t even round on him?

These were the thoughts flooding my mind as I made my way back to the doctor’s lounge to present, feeling dread with every step. This little pity part continued until I reached the elevator, when the reality of the situation hit me like a ton of bricks: I was making this situation about me and completely misunderstanding what was happening. Here is a man who has lost many of the things that most would consider fundamental to living an enjoyable life. He can no longer walk or talk like he used to. He cannot eat. He can’t even get up to use the bathroom alone. The GJ tube and NPO orders, interventions intended to help him, were only hurting him more. His frustration and general sense of discontent were completely normal and rational responses to the suffering he was enduring. 

To JT, I was simply another person involved in the worst days of his life. Anyone would lash out in those circumstances, regardless of what some medical student said or did. I needed to take a step back and stop taking his anger personally.  While he may never like me, I will forever be thankful to JT for reminding me to look at the bigger picture when faced with a patient’s resentment.