I sighed. I was angry that I was stuck in this untenable, unfixable situation. And now, I was ashamed at my own behavior. I took a long look at my patient and then a long look at myself. Why was I so angry with her? Where did her responsibility lie? How did it come to this and how could I fix it?
I sat on my stool with my eyes closed for several long minutes while I considered each of these questions. Then I took a deep breath and opened my eyes. “Let’s start from scratch. Let’s look at everything again, like you were a new patient.” I cleared my throat. “Hello, I’m Dr. Zook. How may I help you today?”
I interviewed Rebekah in the same probing manner I use with each of my new patients. I listened with new ears and examined her with fresh eyes. I did a review of her medication list to be sure that each one made sense and was at the proper dosage. I looked to see where there were holes in diagnostic testing or where testing needed to be updated. I found more than a dozen simple—but important—issues in Rebekah’s chart that potentially affected her health. Together, we set a new plan in motion. I wrote everything down for Rebekah and reviewed it with her. I had my tasks and she had hers. We agreed to meet again in a month.
Four weeks later, Rebekah was ebullient. She was walking out to the mailbox daily and had cut back on her soda pop intake. Her weight was down three pounds. We continued with the changes we’d made and together implemented a few more. As Rebekah saw improvements in her health and weight, she was motivated to do even more. Little by little, and with few setbacks, we transformed Rebekah’s health. Today, Rebekah is 40 pounds lighter and walking a half mile most days of the week. She is on one quarter of the medications she used to take.
Rebekah taught me three lessons I carry with me every day, to every patient. First, complacency is dangerous. It’s easy in a busy office to just carry forward what’s been done. It takes time and effort to do a detailed review of a complex patient’s chart, tidy up loose ends, and thoroughly reassess a medication list. But taking the time to do so reassures me that there are no missing documents, no abnormal tests that need follow-up, and no alarming trends.
Second, when I see a patient I dread on the schedule, I ask myself why I’m looking for the emergency exit. If I can identify why I want to avoid the visit, then I can work toward a solution. There may be nothing that I can do differently. In that case, it may be that the patient would be better served by a different provider in the practice, or even by a different practice. But the burden is on me to have the introspection and courage to identify and put thoughts into action or remain silent and work through my feelings. In either case, awareness is the first step toward acceptance or change.
Third, when I am angry or annoyed at a patient during a visit, I need to check myself in that moment, and think about what’s triggering me. This gives me pause to take a deep breath and temper my response. Boundaries may have to be made clearer and put in writing, or I may need to encourage agenda-setting or more frequent visits. I can’t always identify the source of my emotions at that moment, but the consciousness prompts me to put the chart aside for review and reflection at a later time.
I am grateful for the lessons Rebekah has taught me.
Editor’s note: Names of the patient and her husband have been changed to preserve patient privacy.
Melissa Zook, MD, has practiced family medicine in London, Ky., for 14 years, focusing on addiction medicine and caring for patients with HIV. She derives great satisfaction from seeing patients in her care regain their mental and physical health. “Often the interventions with the biggest impact are the smallest and least expensive, like active listening and appropriate describing,” she says.
Zook’s choices of specialty and practice location have been driven by wanting to make the best use of the nearly $1 million worth of education she has acquired. “There is no better way to use that gift than in medical service to one of the poorest and sickest communities in the U.S,” she says.
Like most primary care doctors, Zook struggles with the reporting requirements imposed by payers and government agencies, as well as the ever-rising costs of medications and procedures her patients require. “Simple tests cost more than they should. Patients are forced to switch off meds that work well for them because their formulary changed, etc.”
When away from her practice, Zook enjoys writing, cooking, knitting, and reading with her two children, ages 12 and four. She hopes one day to sail the Indian Ocean and explore Asia.
Zook offers this advice to doctors starting out: “Give your family your undivided attention on a regular basis. Don’t work harder for your patients than they are willing to work for themselves. Whatever you’re going to be, be a good one.”