Focusing on the patient while under pressure

Dr. Afshar is a third-year resident in the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, CA.

“Medicine is inherently a literary field as it can be taught and discussed exclusively through the telling of stories.” Mark Reid, MD

A 36-year-old presented to my continuity clinic as a new patient. She had been followed for abnormal Paps and was scheduled for a repeat colposcopy. It had only been 6 months since her previous colpo. I opened up my American Society for Colposcopy and Cervical Pathology iPhone application and iterated her information to make sure she was not due; she was not. I would just take a look - working quickly without hurrying.

I placed a speculum in her introitus and there it was: a 6-cm fungating mass. Each spherical tumor reflected its own callous heart lined along the void of her cervix. I was staring deep into the proliferating soul of cancer- “badness” was in my face. I had to tell this struggling single mom that I did not know exactly what this all meant but we needed to follow up.

Medicine today is an open book. I can easily deduce diagnoses by searching descriptive keywords in my browser. Access to endless information, showers of texts, plug-in guidelines, atlases, and histology from centuries ago are all at my fingertips. I am thankful for the privilege of practicing medicine today.

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As I started the patient’s SOAP note, the EMR fields began to auto-populate before I could transcribe via keyboard. This auto-filled template was not my patient. I wanted to grab the computer and tell it to stop, but my job was to translate to the screen that I had a sick patient who needed help. My cell phone went off, my meter was running out in front of clinic.

The patient was seen at the free clinic, which meant she was uninsured. How would I get her to a gyn oncologist? Does providing healthcare in the 21st century mean I need to be an expert navigator of the health system? No. But it means that I need to know when to reach out for help. I spent that afternoon on hold with the MediCal eligibility officer because that is what I could do for this patient. I waited for 45 minutes-calm progress.

The next morning at 5:30, my Twitter feed and PubMed keywords started flooding my phone. While reading a news-breaking abstract, I was receiving live tweets from a conference back east. I noticed a retweet from a Facebook posting I made and I forgot that I started reading an abstract and got distracted midway by an email about logging duty hours.

Medicine today, more than ever, must be sustainable and acutely humanitarian-wholesome medicine, I’ll call it. As residents, we must make acute decisions while appreciating the effect on a chronic life-course model. As an example, and in the words of ACOG, “preventing the first Caesarean.”¹

When I visited my patient with the newly diagnosed cervical cancer the day after her radical hysterectomy, she gave me another reminder and lesson in the art of medicine. In spite of flawless sign-outs and detailed hand-offs, medicine remains largely about the direct interaction between the physician and patient. She had waited up anxiously all night for a physician to enter her room. Now, every day, before I go into a patient’s room for rounds, I remember that this encounter is one of the most important parts of her day; I’ll stop thinking about how early I have to get there to round. 

It’s difficult to remain grounded in the non-stop all-action bustle of the day. We must aspire to be advocates of patients in a healthcare system that is difficult to navigate. In training, we are humbled by the expanses of information at our reach. We should not assume anything and continue to question all data points. We must analyze objectively while taking initiative. We must give credit where it is due and practice humility. This dynamism cannot wait for clinic to be over or for residency to end. As a young physician today, I call myself an ob/gyn, just another “member of society, with special obligations to all my fellow human beings …” This was true in the 5th century BC when the Hippocratic Oath was written and still is true today.

Reference

1. American College of Obstetricians and Gynecologists. Obstetric care consensus no. 1: Safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014;123:693.