Caring for Ms. Mcaring_for_ms_m

If you care deeply about the practice of medicine – if you value doctors who are not only astute clinicians, but decent people who show compassion and empathy for their patients, and good teachers and mentors who encourage young doctors and doctors-to-be how to care deeply, too – you’re not alone.

This is what the Center for Innovative Medicine’s Miller-Coulson Academy of Clinical Excellence is all about, and the idea has spread from Johns Hopkins Bayview to Johns Hopkins Hospital and beyond, as other institutions adopt the Academy’s ideas and establish similar programs. The Academy has a blog, and from time to time, we here at Breakthrough like to share that blog on these pages. The following story comes from a post by John Marshall, a fourth-year medical student at Johns Hopkins, who wrote about a patient encounter he witnessed during his rotation with an Academy member – “Dr. R” in this story. You can read this and more blog posts at:

“Ms. M greeted us cheerfully as we walked into the room,” Marshall begins. “She was a middle-aged Caucasian woman, but the lines on her face and the long white hair made her appear perhaps a decade older.” Ms. M had suffered from major depression on and off for many years and was now in the midst of a relapse. She had lost her job – been laid off when the company she worked for downsized. “She had collected unemployment for six months, but now was without income. While this triggered a major depressive episode, it also made her angry as she lost her independence and moved in with her son and daughter-in-law.”

She had lost her job – been laid off when the company she worked for downsized. This triggered a major depressive episode. It also made her angry.

Ms. M was going through hell, and her depression was accompanied by overwhelming feelings of guilt, shame, sadness, and “episodes of rage where she locked herself in her room for fear of verbally assaulting those she loved,” Marshall writes.

But there’s more – the doctor side of this doctor-patient encounter. Dr. R brought “her own empathetic frame of reference,” and this, “I believe, is what allowed this provider to gather the appropriate details of the story,” says Marshall. Before the visit, Dr. R already knew of Ms. M’s history of depression, her predisposition for relapse, her recent eviction, her medical comorbidities,” and how important her mental health would be in managing these other health problems. Dr. R “actually entered the room with mental health as the most important subject to address, and thus she was able to respond appropriately as the patient divulged the issues most important to her. And as a rheumatologist would ask questions to assess for involvement of lupus in new organ systems and use knowledge of lupus to alert the patient to possible complications, Dr. R asked questions to assess for complications of Ms. M’s social situation.”

Dr. R’s questions included,“How are you getting along with your son?” and “How are you paying for prescriptions?” As it turned out, the answer to this question “provoked frustration on all parties as we realized the pharmacy had rejected her newly acquired Medicaid prescription account, because she had not yet received the prescription card which Dr. R had helped her apply for at her last visit.” Ms. M really needed her prescription; in addition to the depression, she had shortness of breath from chronic obstructive pulmonary disease. She desperately needed an inhaler as well as the antidepressant Dr. R was prescribing today.

“Therefore, in the middle of the visit, Dr. R called the pharmacy, sent her prescriptions over electronically, and double-checked that they would be covered by the prescription plan number in the absence of the card. Dr. R shouldered the patient’s burdens as her own, and not just for twenty minutes in the clinic.”

What did Marshall learn here about clinical excellence? “First, diagnostic acumen cannot be underestimated… But just as importantly, this acumen absolutely must be applied in the context of a therapeutic relationship. An incredibly large amount of progress was made in this patient’s care in twenty minutes because the agenda was motivated by knowing the intricate details of the patient’s medical history, personality, predispositions, and social situation. Every move Dr. R made was motivated by her memory of who the patient was and why certain actions should be prioritized and others should not. And finally, expert care moves beyond empathetic listening and towards the shouldering of burdens carried by our patients. A process happened in the mind and spirit of the provider, whereby she internalized the patient’s concerns, fears, and hopes, processed the most important action items, and actually did them. I feel very fortunate not just to have witnessed true and genuine service today, but to consider how that internalization and move to action will happen in my own mind and spirit for the duration of my career in primary care.”

John Marshall, MSIV
May 2015