Daniel Alban - Patient-centered Ethics: Pathography

Jul 16, 2022 at 04:28 pm by pj

J.P was a relatively healthy 68-year-old male that was being seen in the outpatient clinic to establish care. He said that he was new to the area after recently moving from Ohio and was encouraged by his wife to get connected with a primary care doctor. Simple enough. The encounter started off like any other – basic introductions, making note of and addressing any chief complaints or concerns, inquiring about routine health maintenance, etc. At first, he replied to my questions with short, annoyed, and unenthused retorts and, in response, I did my best to counter this with an open, friendly, and non-judgmental demeanor. This was done to disarm him and build rapport. I asked him about his hobbies, family, favorite sports teams, and even cracked a couple well-received jokes. As the encounter progressed and I started to gain his trust, he began opening up to me and disclosed that he was distrustful of medical professionals due to a series of poor experiences in the past with various previous providers. He went on to explain how he felt that he was undervalued and treated dismissively by previous physicians which ultimately led to him renouncing the medical community at large. This was more than 15 years ago with essentially no care since then. I recognized his anger/frustration and apologized for his past experiences, and remarked that we would do everything we could to provide him the quality patient-centered care he felt he was neglected many years ago. We could not change the past, but we could help create a better future experience for him.

About half-way through the physical exam, J.P stopped me and said, “Can I be real with you for a second?” to which I replied with a quick, “Of course!” I put my stethoscope down and gave him my undivided attention. His voice quivered and he started to tear up as he admitted to feeling depressed and sad for some time but never having had the opportunity to tell anyone. He was too embarrassed to talk to his wife, family, or friends about the state of his mental health and it had been weighing on him for a long time. After assessing for suicidality and self-harm, to which he denied, I reached over and placed my hand on his arm in a show of solidarity. We sat in somber silence for a few moments before I voiced my emotional support for him. He admitted that he needed help managing his mood and associated symptoms but that he was also reluctant to try medication and unwilling to attend therapy. He acknowledged the difficult situation he had presented by essentially eliminating the main treatment options we could have considered but he defended this by reiterating his distrust of the medical community. Overall, J.P was in a tough place. He knew that he had a problem and desired treatment, but he was also unwilling to accept that treatment due to deep-seated wariness of medical professionals. After completing the rest of the physical exam, I excused myself to report to my preceptor so we could discuss the situation and develop an appropriate plan of care.

We decided that, given the circumstances, we would recommend starting him on escitalopram (a relatively benign SSRI) and follow-up in a few weeks to monitor his response and assess for symptom improvement. However, when presented with the option of medication J.P expressed reservations because he did not want to be labeled a “crazy person needing psych meds” plus he had a remote history of non-life-threatening adverse medication reactions which made him hesitant to starting any new pharmaceutical therapies. What J.P did not know is that I was no stranger to this situation. At one point in time, I battled with depression (and anxiety) and had to take escitalopram to help get through that hard time in my life. I had an intimate understanding of what J.P was going through thanks to my own mental health journey.

After some back-and-forth between my preceptor and J.P, I interjected. I validated J.P.’s feelings and was forthright with my own personal mental health struggles and how the medication helped me for the better. The whole episode only lasted one to two minutes but it felt like I was speaking for an eternity. I had never been this vulnerable with anyone (besides my own doctor and my parents) but I was hoping that my personal anecdote could help J.P in becoming more receptive toward trying medication so he could get started on the appropriate treatment he needed. Once I finished speaking, J.P looked over at me with an empathetic look and said, “Thank you for that. I appreciate you more than you could ever know.” To which I replied, “No problem. I just want you to know that you’re not alone, we care about you, and we’re here to help you.” He agreed to give the escitalopram a try and follow-up in a few weeks. As the encounter was ending and my preceptor and I were leaving to prep for the next patient, J.P stopped me and shook my hand one more time as he smiled and mouthed the words “thank you”. I smiled back and nodded my head in acknowledgment.

Unfortunately, I did not get a chance to see J.P at his follow-up appointment but my preceptor informed me that he was doing-well on the medication and noticed an improvement in his mood. He was aware that he still had a long journey ahead of him, but he was grateful for the support and care we provided. Additionally, he informed my preceptor that we had challenged his preconceived notions of what to expect from health care providers and that he was pleasantly surprised by the degree of compassion we showed him and the quality of patient-centered care we had delivered. Hearing this reinforced my appreciation and passion for medicine. Despite only spending 15-20 minutes with J.P, he provided me with a lesson that will last me a lifetime: As providers, we have a chance to heal and treat various ailments (which is rewarding in and of itself) but we also have the privilege to foster and develop meaningful relationships with patients as well as explore the humanity in medicine with every encounter we have.