Medicine from the heart . . . Kristen Kelly

On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.

Kristen Kelly, MD, a second-year obstetrics & gynecology resident at UMass Memorial Medical Center, reflects on the need to treat all patients with respect.—Hugh Silk, MD

As an elementary school teacher, I thought a lot about how much of an impact educators have on their students, specifically their willingness and ability to learn. In making the transition to a career in medicine, I see strong parallels between relationships with patients and relationships with students. In the classroom, a facial expression or side comment had the power to make a student feel wonderful or terrible. Likewise, the subtle behaviors I demonstrate after hearing a patient’s story can make them feel validated or humiliated. Expectations and reactions matter tremendously. When presented with a problem that a patient deems embarrassing, physicians have the potential to encourage well-being and establish a partnership for healing if they choose to act in an appropriate manner.

As an elementary school teacher, I thought a lot about how much of an impact educators have on their students, specifically their willingness and ability to learn. In making the transition to a career in medicine, I see strong parallels between relationships with patients and relationships with students. In the classroom, a facial expression or side comment had the power to make a student feel wonderful or terrible. Likewise, the subtle behaviors I demonstrate after hearing a patient’s story can make them feel validated or humiliated. Expectations and reactions matter tremendously. When presented with a problem that a patient deems embarrassing, physicians have the potential to encourage well-being and establish a partnership for healing if they choose to act in an appropriate manner.

 Mr. P came to the Emergency Department because he was tired of the unhealed ulcers on his lower legs. Our team was on call and when we arrived to admit Mr. P, we could smell his wounds from the nurses’ station. Upon entering his room, the smell was overwhelming, as were our exam findings. Mr. P was in his late thirties, extremely overweight, had poor hygiene, and was in need of surgical debridement for the worst venous insufficiency ulcers I had ever seen. He explained that the ulcers just wouldn’t go away despite multiple courses of both topical and oral antibiotics. During our time with him, my resident was brief and hurried in order to get out of the room quickly. We explained that the wounds might need surgical debridement and they weren’t the type of thing that responds to antibiotics. While we were finishing up his admission paperwork at a workstation, the resident told me that I didn’t need to pick up Mr. P because there wasn’t really anything to be learned from his case and he wanted to spare me from having to smell his wounds. Despite this suggestion, I added him to my list the next morning and saw him without writing a formal note. After seeing his frustration and embarrassment during his admission, I thought he would benefit from talking with someone who didn’t treat him as “the patient with the smelly legs.”

During the course of Mr. P’s stay, I noticed that caregivers frequently reacted in two ways: pity or avoidance. Despite bandaging, his wounds could still be smelled down the hall and he was quite self conscious of them. When my resident went to see him, his visits were always extremely brief. In contrast, pastoral care spent a long time talking with him and one of the nurses brought him some books to read. Admittedly, being in Mr. P’s room for longer than a minute or two was difficult because of the smell. On the other hand, patient care should not suffer because a caregiver cannot tolerate a patient’s affliction. Neither pity nor avoidance empowers patients to take action for their illness and neither will help elicit the changes necessary for improvement.

 While my encounter with Mr. P was not the type of ethical dilemma that works its way into medical television shows or the nightly news, the situation is one that physicians encounter regularly. In addition to their physical complaints, patients bring emotional issues with them when they come for an office visit. Physicians work long hours, are saddled with inordinate amounts of debt, and have an always expanding list of responsibilities such that the glamorous job of being a physician can lose its luster. Research has shown that empathy declines through the course of medical school as students make the transition from the classroom to the wards. While the average physician is unlikely to cause obvious harm to their patient, it becomes easy to belittle someone or brush their complaints aside in order to just get the job done. I am conscious of this pitfall and strive to be cognizant of it all the time, especially when I am overtired and stressed.

 Mr. P’s case made me think about the idea that as physicians, we take an oath outlining philosophical guidelines for practicing medicine that include remembering to “not treat a fever chart or a cancerous growth, but a sick human being.” For me, this is one of the most important tenets of my career in medicine. No matter how tired I may be or how difficult a patient may be, I strive to remember that every patient is first and foremost a human being with needs and problems. Ethically, our duty to act starts with an obligation to treat our patients in a respectful manner.