The Way Things Are Supposed to Work
An attending talks about caring for a difficult patient
Mrs. M is 56 year old “problem patient.” She is on chronic anxiolytics for anxiety and panic attacks, and she always calls early needing more than prescribed, either saying she has had more stress, or they were stolen, or fell in the toilet, etc. Despite always needing more clonazepam, she rarely keeps her regular appointments with the resident who is her PCP. About a month ago she paged him, saying she was having difficulty swallowing, especially solid food. He tried to get her to come in for an appointment, but she resisted. He agreed to order a barium swallow and then to see her, but the initial appointment for the test was scheduled in almost a month. When she called back in a week saying she was having more difficulty swallowing, the resident called radiology and was able to move the test up.
On the day of the test, the resident was called by the radiologist who said the patient had a 7 cm mass constricting her esophagus suggestive of esophageal cancer. They recommended a CT scan. The resident called the patient to say she needed another test, and several days later the CT confirmed a mass in the esophagus, but no obvious local invasion or adenopathy. An EGD was then quickly obtained, and biopsy of the mass did show she had an squamous cell carcinoma. Through all of this, the patient still hadn’t been seen at UMA, but she was calling the resident and his firm nurse at least daily. After the procedure, he had no clinic time to go over the diagnosis with the patient, so she was scheduled to see me instead. On the morning of her appointment, she called once again to cancel, saying she had no transportation, but she wanted to know the results of the biopsy.
The resident, the firm nurse and I discussed this, and decided it would be best for the resident to call her and give her the results over the phone. She had already had breast cancer successfully treated with surgery so she knew something about what to expect. When he called her, he said she took the news well, and indicated she had support at home and wasn’t feeling depressed. She said she would keep an appointment with me in two days to discuss her diagnosis in more detail. In the interim, her firm nurse called the surgeon’s office to find out what other tests he would want, and arranged an appointment in 6 days. Before that, she scheduled both the PET scan and endoscopic ultrasound he wanted.
When I saw her two days later, she was quite calm. She said her family was taking it very hard, and she needed to be strong for them. She was very thankful that she could get the other tests she needed and see the surgeon within a few days. She was still having trouble eating solids, but was eating pudding and five or six cans of Ensure a day. She didn’t need more anxiety medicine or anything for pain.
She had her tests and saw the surgeon, who recommended chemotherapy and radiation followed by surgery as her cancer appeared localized. Before the diagnosis, she called one of her providers at least daily. After the diagnosis, no one heard from her. When we realized she wasn’t calling, the firm nurse called her. She e-mailed us the outcome. The patient said she was ok. Her family had bought her a new dress and her sister had taken her to get her fingernails and toenails done. The nurse told her not to milk this for too much. They both had a good laugh.
This episode struck me because of the way that the resident, the firm nurse and I were able to work together in a tough situation, with a patient with a potentially fatal condition who wasn’t making it easy for us. The resident took the lead when he could, I was able to help out, and the firm nurse made sure everything got done and held it all together. The patient wound up getting a barium swallow, CT scan, EGD, EUS a PET scan and saw a surgeon in two weeks, all as an outpatient. That’s quite remarkable in our system, and is the way things are supposed to work, but it wouldn’t have happened without us working as a team, and especially without the firm nurse knowing how to get things done. The resident did a good job of directing things and being willing to give the diagnosis under less than ideal circumstances, and he was also willing to appropriately let others help him. My role was mostly as a facilitator, supporting the resident and the firm nurse and filling in when I needed to.
The biggest surprise for all of us was the patient, who has demonstrated amazing resilience and courage. She still has a very difficult and uncertain future ahead, but I feel much better about our ability to provide her excellent care, and her ability to participate positively in her own care, than I did a month ago.