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.”
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.
I knew there were still some additional neurologic tests to be performed, but anxiety seemed the leading cause of her symptoms.
Many of our immigrant patients experience depression and anxiety that couldn’t be underestimated, I told my resident. The intractable sadness that many feel from being separated from family members often translates into pain and other symptoms.
Nevertheless, I could tell that the resident wanted me to confirm her findings. In the exam room, our patient seemed younger than her 62 years, petite and neatly dressed in a pair of trousers and bright floral blouse. She wasn’t overtly nervous. She smiled warmly, but her worry was faintly apparent in the lines of her forehead.
“Can you tell me more about what’s going on with you?” I asked, an interpreter echoing my words in Spanish. “You’ve had this right-arm weakness and difficulty walking, and you think stress is causing the problem? Tell me more about that stress.”
The patient’s eyes filled with tears. “Well, my daughter is separated from her husband, and I’m worried about her,” she answered in Spanish. “I’m not working, and so I can’t help her financially.”
I waited for the translator.
“How long ago did your daughter get separated?” I asked.
“One year ago,” she said.
The timeline didn’t make much sense, I thought. A stressful circumstance that began a year ago, and symptoms that started in the past two weeks? Then the patient added: “Oh, and one other thing that I forgot to tell the other doctor. I’m not sure this means anything. The other day I was typing and I couldn’t remember where the keys were.”
The resident and I exchanged uneasy glances. The history was becoming more ominous, and I made a conscious effort to keep my facial expression neutral. I was aware that we were spending more time in the room than I had intended. Out of the corner of my eye, I noticed that my resident kept surreptitiously checking her watch.
I repeated parts of the neurological exam. When I asked the patient to resist as I pulled her right arm, testing its strength, she did fine. But when I asked her to walk down the hallway, something my resident had not done, we noticed that she hugged her right arm close to her body, while the left arm swung naturally at her side. The resident and I glanced at each other again, warning bells ringing in our minds. We escorted the patient back into the exam room and stepped out to discuss the plan.
The next step was to get an imaging study of the patient’s brain, either a CT scan or an MRI. A stroke was a possibility, as was a brain tumor. The patient had no medical insurance, so we weighed the costs heavily. A CT scan would be less expensive; but if it was unrevealing, the patient would need the MRI. We decided to refer her for the MRI.
Our patient’s 20-minute appointment had lasted more than an hour.
Four days later, the patient’s MRI found two brain tumors, with evidence of brain swelling. In the end, our cautious and deliberate investigation had uncovered a medical emergency.
A colleague called the patient at home, advising her to go to the emergency department immediately, where steroids could be given to alleviate the brain swelling. The patient’s brain tumors were caused by metastatic spread of a primary tumor in her lung, we later learned. She underwent brain surgery to have her tumors resected at once, while the tumor in her lung would later be treated with chemotherapy. I didn’t see the patient again until six months later, when she presented again to our clinic for follow-up. She was feeling “just fine,” she said. I couldn’t help thinking how it could have gone another way.
My colleagues and I often discuss the difficulties of providing patient-centered care to the complex patient population typical of federally qualified health centers such as ours in Stamford, Conn. The Institute of Medicine says that quality care is defined in part by a patient-centered focus that includes smooth coordination and timely access. The Accreditation Council for Graduate Medical Education expects residency programs to teach their residents to identify and incorporate patient preferences into shared decision-making and to seek to understand each patient’s unique needs, based on culture, ethnicity, sex and religion.
In safety-net settings, there is often little time to appropriately address the twin challenges of limited English proficiency and low health literacy while also pursuing our educational mission. Our medically underserved patients are more likely to have persistent psychiatric problems, drug and alcohol addiction, and unstable economic circumstances that make it difficult to achieve optimal treatment. After years of delaying care for financial reasons or because of their immigration status, many of our patients present with complex chronic illness and in advanced stages of disease. Uninsured and underinsured patients often lack access to specialty care; it is fairly typical for our clinic’s physicians to handle chronic illnesses that are usually managed by specialists. Further, physicians who care for safety-net populations frequently burn out. They may become less empathetic to patients, compromising the quality of care.
Physicians in training often make up the majority of the workforce in community-hospital-based clinics and health centers. With so little time to devise appropriate solutions to their patients’ complex scenarios, is it any wonder that they later choose careers in specialty disciplines instead of primary care? That is what most of my own residents have done.
A portion of the Affordable Care Act attempts to address the looming shortage of primary-care physicians willing to work with underserved communities through a program that funnels federal funds for graduate medical education to community health centers instead of to hospitals where residency programs are historically seated. The teaching health centers are held accountable for the number of residents who, after their training, go on to deliver primary care to underserved areas.
But establishing a teaching health center is a lengthy process, and to date few have been established, and funding for them is guaranteed only through 2015.
In the meantime, I think about the messages we are sending to residents about who is entitled to patient-centered care and who is not. To recruit a new generation of physicians willing to tackle the challenges of the safety net, medical students and residents must be shown that even the most complex patient population must be cared for with compassion, skill, understanding — and, of course, time.
At a time when budgets are stretched thin, most people on the front lines caring for patients find themselves examining how their resources are being used and looking for ways to use them more productively and efficiently. Any discussion of health-care resource allocation must begin with the goals we value most as a society. Do we fundamentally believe that everyone has a right to high-value, patient-centered care? If so, we must accept that a unique set of barriers separates each patient from the care he or she needs, then build meaningful tools to overcome those barriers.
We need resources to do this, and one of the most valuable resources of all is time.
Maldonado is a clinical associate professor of medicine in the College of Physicians and Surgeons at Columbia University and the program director of the Internal Medicine Residency Program at Stamford Hospital. This article was excerpted from the Narrative Matters section of the journal Health Affairs.