The tempo hadbeen building since our clinic session began. It was a typical Thursday afternoon, and the din was rising as our internal medicine residents traded patient stories and plans for dinner, waiting for their turn to present their patients to the attending physicians.
Stationed at my computer, I stared at the schedule: Thirty patients on the list, and we were only halfway done. I shook my head. No one on the schedule appeared to have a routine concern, such as a sore throat or a cold. They were patients with poorly controlled diabetes, requiring medication adjustments; patients with complicated pain syndromes, warranting narcotic medications; or patients with high blood pressure who hadn’t taken their medication in months.
The conference room where I sat was the inner sanctum of our clinic, a federally qualified health center where residents in training learn the fundamentals of ambulatory care. My colleagues and I are responsible for the primary-care needs of a medically underserved population. Rows of shelves lining the walls contained textbooks and patient brochures on managing diabetes, hypertension and high cholesterol, in English and Spanish. Pinned to corkboards were telephone lists of community centers, information about accessing phone interpretation and pamphlets on resources for victims of domestic violence. The doors on either side of the room were closed to protect patient confidentiality and to shield us from the glares of angry patients, frustrated by the long waits.
I felt a prickling irritation as I thought of the clinic’s decision to schedule 40-minute appointment slots for new patients and 20-
minute slots for follow-up patients. One could spend hours with these patients, many with limited English and low health literacy, before getting to the bottom of their symptoms.
Yet, that afternoon the most essential thing we managed to provide to one particular patient was a bit of extra time. If we had not taken that time, we would have missed the opportunity to intervene at a critical moment — and save a life.
It began with a simple request from a resident: “Can I tell you about a patient?” she asked. She was an exceptionally smart, conscientious and thorough physician in training, but this time she seemed uncertain. “I think what’s going on with this patient is that she’s anxious, but something doesn’t feel right,” she began. “I don’t want to blow this off as just depression and anxiety.”
A puzzling history
The patient was a Spanish-speaking, 62-year-old woman following up after an emergency department visit where she had received a diagnosis of anxiety and been treated with the drug Ativan. The medicine wasn’t helping. For two weeks, the woman complained of right-arm weakness. “But I don’t find anything unusual on exam,” the resident told me, seeming anxious herself. “The patient is worried and is hoping that her symptoms are due to increased stress.” The resident had performed the appropriate neurologic exam, which tests muscle strength and reflexes, and everything seemed normal.