The Discussions We Don't Have

[![elderly_hands](http://www.medicineforchange.com/wp-content/uploads/2013/03/elderly_hands-300x199.jpg)](http://www.medicineforchange.com/wp-content/uploads/2013/03/elderly_hands.jpg)She’s obese. She smokes. She has chronic disease. She’s pregnant. You ask her to get out of bed the day after surgery, telling her that yes, you know that it hurts and she is uncomfortable and overwhelmed, but if she doesn’t she it at risk for worse outcomes, blood clots and other terrible things. You ask her to quit smoking because it is not only good for her, but good for her baby. She says no, she can’t. She won’t.
Any health care provider reading this will tell you that they talk to these patients all the time. We have words we use to describe them. “Noncompliant” chief among them, along with many others that all come down to our sense that she is not really understanding of her condition. We talk on rounds about how the connections that seem so logical to us are not connecting for her. We apologize to each other for handing off this “difficult” patient to one another. We shrug and let her stay in the hospital a few more days, for “education” and “physical therapy,” hoping that maybe tomorrow she will understand that she can get out of bed, walk down the hall with her babies and out of our hospital.

We — the greater we, the people concerned about healthcare as a field and an industry and a neverending sink on our national economy — talk about this patient as well sometimes. We wonder what a role she might have in increasing our healthcare costs. We are concerned that in many ways, the many regulations we have pushed through in health care reform are never going to touch people like her. For all our talk of wanting to fund patient education, health literacy and primary care, we still know that these “soft” public health measures will and are on the chopping block when funds are tight. So we ignore her, and move to enforcing her treatment with the health care team, reminding them that insurance will not reimburse if the patient is not out the door by a certain hour, and that there will be penalties if too many of these patients are readmitted within 30 days.

As the medical student on the team, I have an obligation to see this patient every morning that she is in the hospital, to wake her up before dawn and ask her how she is feeling (besides tired of being woken up), whether we are controlling her pain, whether she is moving her bowels, and how often she is walking up and down the hallways. I remind her to keep her leg boots on while she is in bed, that not-so-gently provide intermittent pressure in an effort to prevent clotting (even as I know that they aren’t fully protective). I write a note on her progress, even though I know it will likely never be read and counts for nothing, and I present her briefly, succinctly, in the technical terms that I have been trained in and my attending is expecting.

I do not talk about how I wanted to stop and sit with her this morning. How wrong I felt being brusque about her pain. I do not mention how I feel that is perfectly reasonable for an obese, in pain woman to feel uncomfortable moving around so soon after an operation. I do not question the plan of getting her up and out of bed so soon because I know the evidence, the risk of thromboembolism so soon after an operation. I know we have to push her through this, but I also know that there is no way that we can force her.

This is the frustrating “art” of medicine that I am learning – the art of persuasion, of communication, and also of forgetting the individual struggles by conflating all our patients into the medical categories in which they fit. And the more I learn, the less surprised I am that trainees are seen to “lose” empathy the further along they get in their training.

Based on an amalgamation of real patients. Some details have been changed to protect the patients’ identities.

Image Credit: Rosie O’Beirne