The practice of medicine in a hospital environment can, at times, feel strained, rushed, and disjointed. I have enjoyed the first few months of my internal medicine residency, but for reasons that are common in many high-volume, academic medical centers, the totality of the care we deliver does not always leave patients as satisfied as they might be. Between the flurry of diagnostic tests, imaging studies, and therapeutic interventions, I cannot escape the notion that sometimes patients feel left behind in the wake of our urgency. Despite the thoroughness of our attention to medical care, my sense is that other nonmedical issues relevant to patients, including their understanding of their condition and ability to cope with their associated challenges, are often incompletely addressed.
Ms. F was a 42-year-old diabetic woman I met while on call on the cardiology service. On the morning of the day she was admitted, she awoke feeling “unwell,” with a vague sense of nausea and abdominal pain. While at work later that morning, her symptoms worsened, and she also developed a sensation of pressure over her neck and chest. Her coworkers wisely directed her to the emergency department, where she was diagnosed with an acute heart attack. She was emergently transported to the cardiac catheterization laboratory, where a complete occlusion of one of her major coronary arteries was stented—an intervention that likely saved her life.
Her hospital course was only modestly eventful when compared with those of some of our sicker patients, but it was nonetheless tumultuous: in the few days that she was an inpatient, she underwent a work-up for systemic infection, a CT scan of her chest to check for pulmonary emboli, and a CT scan of her head to rule out intracranial bleeding after her blood counts fell and she developed a severe headache. At each turning point, I tried to keep her abreast of our thoughts and treatment plan, but I had the impression that my efforts to communicate this information were only marginally effective.
“You have a fever and I am worried that you might have pneumonia, so I am going to start you on an antibiotic,” I told her one morning, after a chest X-ray showed an area of infiltration in her lungs.
“OK, thank you,” she said, and nodded her head.
Despite her confirmatory response, it was plain to see that questions and concerns lingered in her glance. But I felt strained. I wanted to talk to her more, ask her how she was dealing with the enormity of being so young and experiencing such a life-altering event, how it might feel to be told you have pneumonia when previously you had been relatively healthy, how the fear and anxiety she clearly felt were normal, but that we would take good care of her. I wanted to talk to her about all of these things, but the strain of internship was visible in my face. I felt the pressure of mounting responsibilities, since I had other sick patients to see, treatments to initiate, and studies to follow up on. With some chagrin, I accepted her nod and walked out of the room.
A few days later, on the afternoon of her discharge, Ms. F and I found some moments to talk, and I asked her how she was doing. She appeared emotionally exhausted and described feeling overwhelmed about how life would be after having a heart attack. She expressed appreciation for the care we had given her, but she also made a remark about her hospital stay that brought the issues that had gnawed at me to center stage.
“I’m from the Midwest, and service is different out there,” she said with a half smile.
I immediately knew what she was implying. “What do you mean?” I asked anyway. “Did you feel like things were rushed while you were here? Did you feel like we didn’t talk enough about your concerns?”
“Yeah,” she responded, almost reluctantly, “but I know that everyone is busy and that you all have a lot of patients to take care of.”
I apologized to Ms. F for contributing to the hurried atmosphere of the hospital, and I made a mental note to do my best to prevent other patients from sharing the same sentiment. “As an intern, I feel spread very thin, and I know the staff is busy too,” I confessed, “but we should never let patients feel that way. It was a pleasure to take care of you while you were here.” We ended our conversation with a smile and a laugh and she thanked me as I walked out of the room.
In an age of prospective payment, rising healthcare costs, capitation, and fierce competition, it is difficult to imagine financial incentives lining up in a way that addresses patient needs as seen through a nonmedical lens. However, the current system casts this aside as a tertiary concern, and a critical piece of patient care is lost in the process. Because it is difficult to imagine physicians being less busy than they already are, one solution might be for hospitals to adopt a staffing level for nurses that enables them to ensure patients’ questions are answered with a rhythm and pace that suit the patient—and not the needs of the medical staff.
Joseph Ladapo, HMS ’08, is an intern in internal medicine at Beth Israel Deaconess Medical Center.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
