The Personal Touch: Patients Are More Than Their Charts

Anthony Accurso, MD

As I looked at the glossy white dry-erase board and read the name of my new consult patient, written in crisp royal blue letters, I straightened my tie. I was ready to meet a new patient with a life-threatening cancer. I was ready to instill hope in someone who feared the end. Could I help cure this patient? I was confdent that, at the very least, I could offer this person more time managing the disease and a better quality of life.

I placed my palm over the computer mouse located to my right. The small white arrowhead outlined in black moved across the monitor until it found the medical record number of my new patient. My right index fnger pressed the left button, and I opened the patient’s electronic chart.

“Please evaluate this patient’s anemia” was noted on the chart. I exhaled slowly and rolled my eyes. I reviewed the laboratory workup, which had previously been obtained by the referring physician.

• Hemoglobin is 1 point below the reference range
• Normal mean corpuscular volume
• Normal renal function
• Normal peripheral blood smear
• Normal white blood cell count
• Folate is borderline

I proceeded to review the patient’s medication list.

• Primidone
• Quetiapine
• Sertraline

I paused and shook my head. “So, it takes a hematologist to know that psychiatric medications and folate defciency can cause anemia? I chose this feld to take care of people with life-threatening illness—what a waste of time!” I thought.

I locked the computer and left the workroom. I turned to my right and walked 2 steps toward the door to Exam Room 2. I looked at the stainless steel door handle. Before turning it, I tried to relax my face and the muscles in my shoulders to conceal any tension. I knocked on the door 3 times, and then pulled down on the shiny lever.

“Hello!” I introduced myself. “I’m one of the hematology/ oncology fellows.”

As I greeted a man sitting in the chair directly across from the door, about 3 feet away, I forced a smile.

The man was wearing an old T-shirt and faded blue jeans. He extended his right arm to shake my hand. His body leaned forward and to the left, as his free arm rested on a cane. Scattered scabs covered his forearms. Each wound was between 1 and 2 centimeters, and all seemed to be of diferent shapes and at diferent stages of healing. His eyes met mine through a pair of thick lenses.

“Hello, Doctor,” the man replied. His face, hidden behind an uneven white beard, moved very little. His bottom lip quivered slightly.

I asked the patient, “What do you know about why you are here in the hematology clinic?” I looked to my left. A middle-aged woman smiled at me. We gently shook hands.

The man quickly responded, “My primary doctor says my blood counts are low.” His eyes remained still. “That’s right,” I said, “but I don’t think there is anything serious going on.” I spoke more softly and slowly as I tried to reassure him. “Some of the important medications your psychiatrist is prescribing can lower the blood counts slightly.”

I proceeded to obtain a full medical history and asked for his permission to examine him. He agreed and slowly walked toward the exam table. He leaned heavily on his cane and grimaced with each step. I ofered my hand and helped boost him up onto the table.

“You look like you’re in a lot of pain,” I said. The patient looked back at me with still eyes. His bottom lip continued to quiver slightly. “I’m always in a lot of pain,” he said. “It’s the arthritis.”

As I examined the patient carefully, I remembered the words of my internal medicine professor during hospital rounds 5 years prior. One of my fellow medical students had grumbled about the unnecessary transfer of a surgical patient to our medicine service for comanagement.

My professor had suggested that the transfer was ridiculous and surgeons could have managed the patient. Putting his arm around the student, the professor said, “Always remember this: We are internists. This is what we do. We take care of patients. Someday you will be asked to take care of a patient, and the task may not seem to be very rewarding.”

The students around me nodded their heads slowly and opened their eyes a little wider.

The professor continued, “Another doctor may ask for your help in consultation. The question may seem too simple—a waste of your time. Maybe a surgeon, busy in the operating room, will ask for your help managing a patient’s short list of medications. Each of you may even be asked to care for a patient without any actual medical issues.”

A few students stepped forward, shrinking the semicircle surrounding our professor. “When those situations arise, instead of complaining about the simplicity or lack of necessity of your task, ask yourself this question: ‘What can I do to help the person in front of me?’ If you keep that question in mind, I promise your career will be very rewarding,” the professor said.

I helped my new patient down of the exam table and laid my right hand across his back during the trek back to his seat.

“How are things going with your mental illness?” I asked. “OK, I guess,” he responded. I continued. “Are you seeing your psychiatrist regularly?”

“Yes.”

“Any thoughts of hurting yourself or others?” I waited for the same answer to the question I had asked dozens of times of other patients.

“Myself,” the man said as he looked down toward the foor. I stood up slightly, lifted my chair a few inches, and repositioned just to the patient’s left. I put my right arm around his back.

“Why would you want to hurt yourself?” I asked.

“The voices in my head are always telling me I’m worthless and that I’d be better of dead.” A tear streamed down the woman’s cheek. She moved in closer. Her right hand covered her mouth, and she took his right hand with her left.

“Honey, I had no idea,” the man’s wife said. She embraced him, and they both cried.

“You’re not worthless,” she continued.

I felt a dull ache in the center of my chest as I watched the couple endure their anguish. I rubbed the man’s back softly as he told me of his plan to wait on the train tracks near his home, until he would fnally be free from the antagonistic voices. Then I stated with confdence in my voice, “We can help you. We can make this better.”

The couple gave me their permission to contact our emergency psychiatric team and arrange for admission to the hospital. As he gingerly walked out of the clinic, I attempted to reassure him one last time: “You’re a good person with a lot to offer. We can get through this.” He nodded his head slightly as his eyes looked toward the floor.

Sixty-three days passed. I sat in front of the same workroom computer, prepping to see the sixth of my 8 scheduled patients on another Tuesday afternoon schedule. I did not recognize the name of my follow-up patient. I opened the electronic medical record and the still face and white beard from 7 weeks prior appeared on the top left portion of my computer screen.

I smiled and quickly walked toward his exam room. I knocked 3 times, but this time, I was too eager to enter to wait for permission. I pulled down on the shiny steel lever.

“You’re back!” I said with excitement. I walked toward the bearded man, and he briskly propped himself to his feet with his cane. “How are you?”

The man smiled. There was no quiver in his lip.

“We celebrated our 25th wedding anniversary last night,” the man said. He pointed at his wife, who was standing to my left. “We got Mongolian food at Genghis Khan. It was a wonderful night. We can’t aford to eat out often, but we celebrated. All because of you.” He paused. “I was going to kill myself. Probably that same day we met. But you helped me. Now when I hear those voices calling me names and telling me to kill myself, I take control! I say, ‘If I kill myself, that means you die, too!’ ” He threw his arms around me again. “Doctor, thank you. You saved my life.”