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'You Can’t Just Give News Like This'

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It was nearly the end of my 9-hour shift in a busy, urban community health center. In walked C — the 16th patient I had seen that day. Two more patients arrived after her. Both had been kept waiting for more than an hour.

"NEW PATIENT" was written next to her name. I quickly skimmed her vitals: normal. I looked at the section on Epic titled “Health Maintenance,” which are the statistics I’ve gotten reprimanded for not remembering to check off during previous visits.

“But you need objective data. You need to improve your numbers,” was the feedback I was given by supervisors reminding me to check off immunizations, screenings like colonoscopies, mammograms, etc.

Patient C’s vaccines were up-to-date. She was too young for colonoscopy and mammograms. PAP, however, shone in bright green font to indicate she was due.

Pain shot through my legs as I had barely had a chance to sit, let alone eat lunch. As I stood and parsed through her chart closely, I had several questions: Did she get a PAP done elsewhere? I opened our Care Everywhere database that shows charts in other hospitals under a patient’s name. Sure enough, there was a PAP done two years ago, which was abnormal. I don’t see a colposcopy as the next step. In fact, I did not see any correspondence regarding any follow-up results.

Then, my medical assistant ran up to me.

“Your last patient is threatening to leave. The one before him, L, is endorsing shortness of breath.”

I take a break from reading C’s chart to quickly check on L's vitals: pulse is normal, no chest pain, negative cardiac history, asthma controlled.

“It’s very hot here. I need to go home,” L said.

“I’ll be with you soon, L. I just want to make sure you were okay, but I have to see someone ahead of you,” I had said to her.

When I walk into C’s room, she looks up from her phone with her face beaming.

“Hello, doctor! So good to meet you,” she said. It was startled by her chipper demeanor despite being kept waiting for so long. I was accustomed to meeting angry or disappointed patients to the point that C’s joy took me by surprise. I was too tired for small talk.

“Good to meet you as well. I see you are interested in establishing care here.”

“Yes.” She flashes another radiant smile.

I turn to the screen. “Your vitals are good. Let’s get some of the routine health screening things out of the way first.”

She throws a quizzical glance at me.

“When was your last PAP?” I ask

“I think a year or two ago.”

“Did your gynecologist follow up with your results?”

“I think so.”

“Because I see here that your PAP was abnormal. Are you sure you weren’t told about it?”

“What do you mean?” The blood drained from her face. Her hands started to shake from tightly holding onto her phone.

“Looks like your PAP was positive for HPV.”

“No! I wasn’t told about it.”

“Did you ever get a colposcopy done?”

“Never,” said C, her voice growing softer.

“Can you look up any records you have to see what the plan was? Maybe they repeated your PAP a second time and it came back normal?”

“I can try.”

My medical assistant pops into the room. “Doctor, I think patient L is wheezing. Can you please check on her?”

“I need to step out to take care of something potentially urgent,” I said to C, “I’ll be back shortly.”

L’s heart and lungs sounded normal. While she was here for renewal of her medications, her albuterol was the most pressing. “I am running out of that and can’t sleep if I don’t have it.”

I renewed her albuterol, urged her to wait, and made a follow-up appointment with me just in case.

Then, I quickly scurried to C’s room. I find this woman crumpled on the floor — her knees bent and head in her lap. She looked up at me, startled, as the door closed.

“They never told me. And now you’re telling me I could have cancer?”’ Her voice trailed off at the last word.

“How could you drop a bomb like this and leave me alone for so long?”

She cried again, unable to stop her tears this time, so I hand her tissues. She doesn’t take any from me.

“I am sorry, C. I thought there might be an emergency in the other room. I am sorry it took me so long to return to you,” I said to her. I started to explain that having HPV doesn’t necessarily lead to cancer and that many women manage to clear the infection on their own.

“You can’t just give news like this and not think about how it will affect someone” she said while clearly lost in thought.

My eyes finally met hers. I had nothing to say except that I was sorry. When her tears finally stopped, I told her I would be there for her. I told her that I would be there to help her through the next steps.

“We can do a PAP here today and see if everything normal. I can also try to get more information from your gynecologist," I offered as another option for care. "You can choose what feels right to you.”

She chose to do the PAP, so I prepped her for the procedure.

“If you feel uncomfortable at any time, you can tell me to stop.”

The procedure was quick. Her cervix appeared grossly normal and I gave her some reassurance about this. I told her I would call as soon as the results came back. She hurriedly put on her jacket. I wondered if I will ever see her again.

“You can reach me via our emailing system. I am here twice a week and feel free to come in if you want to discuss anything in the meantime.”

“My best friend said that I should come here and see you," C said to me. "She thought you were great, so I came.”

I apologized again as I handed passed her pocketbook to her hands. It was this moment that taught me how to put the patient first.

Did you have a similar experience that taught you to put the patient first? Leave your answer in the comments below.

Jafeen Ilmudeen, MD is a third-year family medicine resident in New York. Originally from Sri Lanka, her interests include women’s health and narrative medicine. In her spare time, she enjoys reading, mentoring, independent film and theater, and travel.

All names and identifying information have been modified to protect patient privacy.

Image: fizkes / shutterstock

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