Anyway, this post is not from me. It is from a sweet medical student that I have known for nearly 3 years. She is a 3rd year Med student here at UT Southwestern Medical Center and she is in the stage of her learning where they do rounds in the University hospitals, clinics, VA, Parkland, etc… She recently wrote a "Reflection Essay", which is a requirement for the students upon finishing rounds for a particular specialty. For this essay she was on Neurology rounds at St. Paul Hospital. I am sure you all see where I am going with this. So without further comment from me I am going to let Laurie speak (I have left off her last name for her privacy).
Laurie
November 11, 2013
Neurology Reflection Essay
The day before I finished my two week rotation at St. Paul, I was assigned a patient with one of the scariest HPI’s I had heard in a long time: she was a woman who had had an aortic dissection and subsequent rupture, had coded, underwent emergency endovascular repair, and later had developed altered mental status, which is why we had been consulted. Her primary team thought she might have had a stroke, and my resident explained that based on the history alone, he thought this was likely. He gave me her last name and room number and I went off to see her, noting incidentally that her last name was the same as someone else’s that I knew.
I walked up to her room in the ICU, saw her lying in bed through the sliding glass doors and reeled backwards. She wasn’t a generic patient who shared a last name with my friend; the patient was my friend, and she looked every bit as terrible as my resident had promised she would. I was frozen standing outside her room, my brain jammed, unable to process this situation. I turned to my teammates who had come down to see her with me and kept repeating, “I know her, I know her!” over and over. It was several seconds before I was able to pull myself together and walk into her room.
She looked awful. She was drowsy and would only occasionally follow commands, fighting feebly against her restraints. I fumbled through my neurologic exam and hurried out. To my immense relief, her family convinced the primary team to give her a sedation holiday later that day and it was discovered that she had not, in fact, had a stroke, and once off the sedatives her mental status returned to her normal baseline.
It wasn’t until I went back to visit her days later simply as a friend and not as a member of her healthcare team that I realized how foolish it had been for me to accept her as a patient at all. Apart from the fact that I nearly had a meltdown in the middle of the ICU, I hadn’t even come close to doing a complete neurologic history and physical on her: despite the patently obvious finding that she had lost most of her sensation and motor function in her legs, I didn’t ask about bowel or bladder control, I didn’t check rectal tone or perianal sensation—I didn’t even get a pinprick sensory level on her because I didn’t want to have to lift her gown.
In reflecting on this experience, I discovered something that surprised me: I had always thought that the primary reason treating family and friends is discouraged in medicine was because, in their zeal to go above and beyond and do everything for their loved one, physicians might end up doing something not truly in the patient’s best interests. That wasn’t at all my experience, which in fact had been quite the opposite—I had delivered unquestionably subpar care in my efforts to not embarrass my friend.
As it turns out, this is apparently more often than not the case. Dr. Scott Kirby, medical director of the North Carolina Medical Board, is quoted in an article on treating family and friends, remarking, “Physicians provide care to family members [and friends]…that is generally below standards. They cut corners. They don't do things they would normally do in treating a patient” (1). In the American College of Physician’s Ethics Manual, the authors elaborate: “The patient may be at risk of receiving inferior care from the physician. Problems may include effects on clinical objectivity, inadequate history-taking or physical examination, overtesting, inappropriate prescribing, incomplete counseling on sensitive issues, or failure to keep appropriate medical records” (2).
That doesn’t mean it doesn’t happen, of course. In a landmark 1991 study published in The New England Journal of Medicine, authors found that 99% of 465 survey respondents had been asked for medical advice by a family member, and the vast majority of them had provided it. In fact, their level of involvement in their family member’s care ranged from performing a physical exam (72%) and prescribing medication (83%) to acting as their attending physician in a hospital (15%) and even performing elective (9%) or emergency surgery (4%) (3).
Though my experience was perhaps rather dramatic, it did highlight for me the perils of participating in the care of a patient whom I knew personally. Already I have been asked countless times for medical advice both from family and friends, and I will continue my current party line: “That is an excellent question that I encourage you to discuss with your doctor.” More to the point, though, if in the future I should come across people I know personally as patients, I plan to respectfully decline to care for them in an effort to preserve the highest standards of care for the patient.
(I have left off the references to this essay because they are not pertinent to the story!!)
Laurie is a sweet soul and a brave young woman. I have spoken with her and seen her several times since the incident. She is going to be a great doctor and I am proud of her. She told me she was afraid that she couldn't handle surprises like the shock she got from seeing me in the bed in the Cardio Vascular ICU unit. I told her that she was wrong, that this incident has made her a better doctor because she learned that each patient behind the glass is not just a patient but a person. That is a lesson all doctors in training need to learn.
With Much Love,
Sonnie
