| | | |

a meta-clinical dialogue

and subjectively annotated
by the moderator

I present this transcript, which is really only a small bit of raw data, because I believe many clinicians may recognize the value of scrutinizing clinical phenomena through the patient's experiences and motivations, and will recognize the importance of team dynamics in the struggle to deal successfully with the clinical reality of the suffering and confounded patient in a complex and confusing health care network.

Clinicians tend to defend themselves from the live and painful realities of clinical relationship by means of "objectifying" defenses, emphasizing pathology and implying the patient is blameworthy.  Administrators defend so to the second power because their responsibilities are in an additional dimension.  Patients generally seek personal contact, and often choose it over technical competence if both are not obviously available.  As clinicians we need very much to be sensitive to and to accept the patient's experience without imposing stringent conditions or demands at the outset, when the patient cannot yet be confident that the clinical relationship is real and durable.


(all from the Adult Medicine Clinic staff of a Neighborhood Health Center):

N.P., M.D. (moderator, staff physician)
H.R., M.D. (presenter, staff physician)
R.W., M.D. (medical supervisor)
B.E., R.N. (nursing supervisor)
L.Z., M.D. (associate physician)
M.W., M.D. (staff physician)
M.R., R.N. (nurse practitioner)
P.R., R.N. (staff nurse)
C.C., R.N. (nurse practitioner)
L.P., R.N. (nurse practitioner interne)
D.S., L.P.N. (nurse aid)
Other staff were present.


(brief descriptions as distributed before the conference):

29-year-old Caucasian female, college graduate.  Ten years earlier had been told of hypertension, treated with sedatives.  Had avoided further treatment because she felt she had not been treated with respect for her ability to comprehend and decide about  treatment.  Aware of her delay in resuming treatment.  She comes to our clinic because of an indirect acquaintance with a medical staff person.  Initial encounter lengthy because of presence of chest pain, need to evaluate possible ischemia.

65-year-old Black female concerned about high blood pressure and nervousness. Had consulted other physicians in past, but felt they cared more about money than they did about her.  Had no insurance, but qualified as zero-pay in our system.  Manifested anxiety by laughing and crying simultaneously.

Middle-aged Black female with prosthetic aortic valve.  On many medications including Coumadin, Lanoxin, diuretic.  Comes to our clinic because Medicaid coverage had been terminated.  Despite minimal education (third grade) attends night school.  When asked if she understands details of complex treatment, states, "Doctor, it's my life."

57-year old Caucasian male, not seen here in several years.  Had been followed at V.A.H. for hypertension, taking clonidine 0.2 mg., 4-6 per day.  Recent diarrhea without blood tested at V.A.H. one week earlier.  Anticipated delays in treatment at V.A.H.  His wife is regularly followed in several of our neighborhood and hospital clinics.  Anxious, vague.


N.P.:  There is nothing formal about this series of case conferences (and nothing regular about it).  It is a little different, because we try especially to pay attention to real cases we see in our clinic, to some of the things that happen not in terms of the particular disease a person may have but more in terms of the problem the patient presents to us in understanding and helping people.  For today, I asked Dr. R. about some cases that we might discuss briefly.  We found something in common with several cases, so we picked four people who had some sort of lack of success with their previous diagnosis and treatment, and then had come to our clinic.  That is not an uncommon situation and it presents some special problems, which I am sure will come out very clearly as we start our discussion.  The main purpose as far as I'm concerned is for us as a group to pay special attention for just one hour to the problems that are presented by the patient who has already had some kind of "tough luck" and then comes to our clinic for the first time.  Dr. R. saw two of these folks and I saw two.  We will discuss briefly what our experiences were on those first encounters, and what we understood at that time.  I am sure that will bring up important ideas from the whole staff.

H.R.:  The first patient is a 29-year-old woman I saw some months ago who came in because of her known diagnosis of hypertension, and new chest pains.  She had been an indirect friend of a staff member.  She had finally come to the conclusion that she was ready to get medical care for her problems.  She had moderately severe hypertension (blood pressure 180/140), and her chest pain was rather troublesome for a 29-year old, sounding too much like angina to let me be comfortable.  We got to talking, and she was very direct that first day about her previous medical care and why at 29 she was walking around with blood pressure in this range.  She had originally been told she was hypertensive in college (at the student health center) and had been treated primarily with sedatives.  She did not understand what hypertension was.  It had never been explained to her.  She had one or two other encounters with medical care along the way, the most recent at a clinic where she had been treated with a diuretic.  For several weeks there was no explanation of what was going on, why she had hypertension since she was in her late teens, and consequently she had not felt brave enough to submit  to extensive diagnostic tests or really follow her condition.

N.P.:  Let me ask you a couple of questions, which I will ask myself too.  What was your understanding at the time of what it took for her to come to the clinic and to express her problem in whatever way she did?  Would you share with us the process of decision-making that you experienced in yourself sorting out what to do and what to say in that first encounter?  What I assume is that when people have some difficulty in their treatment they have misgivings.  They come to our clinic with some misgivings, some trepidation.  If we don't see it quickly enough that person may just evaporate, and we'll never know the difference but she surely will.  That is why I want to pay special attention to what part of it you picked up on in the beginning, and what allowed you to do what you did, and what kinds of decision-making or action or communication you used at that first encounter.

H.R.:  This particular patient was pretty easy, because she told me that she was very reluctant to get involved in medical care.  I think the things that led to it were her feeling significantly unwell both generally and in the chest.  The pain had frightened her.  Many  other things in her life had just changed enough that she was now willing to accept the fact that she had something wrong with her, and that it needed to be evaluated.  She felt pressed to submit to medical care.  The things that I picked up also were easy because she was straightforward about it.  She wanted to know what was going on.  She wouldn't settle for "You have a little of this and a little of that and you wouldn't understand anyway so I won't bother to tell you what it is all about."  I think the thing that kept her there that day was that I gave her some explanation of what I thought might be going on.  We talked about the various kinds of hypertension and what I thought was appropriate to do to find out what was happening.

N.P.:  You told me you did a lot that day.

H.R.: Yes. Partly because of her presentation with the chest pain and the magnitude of her hypertension, she spent the better part of the day in the clinic getting the initial diagnostic evaluations, blood work, x-ray, cardiogram.  I continued checking her blood pressure.  Coming and going we talked.  We had several encounters between things being done, so I could get a better feeling that day for what the chest pain was all about.

N.P.: You decided to make it a lengthy encounter.  Were there alternatives?  Could it have been done more briefly, successfully?

H.R.: I think it probably could. She was willing to stay and get everything done that I thought was necessary that day, plus talking about what was going on and planning some diagnostic and therapeutic regimen for the near future.  She was willing.  I think that had a lot to do with the fact she stayed around.  I did not want her to leave, and she agreed.

R.W.:  Let me ask you a question. What I'm getting from your presentation is that this is a young woman with very bad hypertension, with diagnosis of having hypertension some years ago, but unfortunately she did not receive adequate therapy, and certainly did not receive adequate explanation about the disease and need for therapy.  Am I correct?  [Dr. R. assents.]  Her main reason for coming to this clinic at this point in time was mainly her chest pain?1

H.R.:  No.  She had been feeling generally bad as well; and she knew this diagnosis, which frightened her.  She had tried to deny it over the years, but something had happened so she finally was able to say, "Okay, maybe something is wrong with me, so I'm going to find out about it," rather than saying, "Something is wrong with me; I think I'll go bury my head."

N.P.:  Let me summarize the general conditions in a way that doesn't have to do merely with hypertension in a young person.  From Dr. R.'s perceptions and from what she found subsequently, this is a patient who had delayed diagnosis and treatment of her disease because she did not experience a satisfactory clinical contact.  Then the disease had pressed, had proceeded to the point she was now pained and frightened, and in spite of previous negative experience had to proceed with diagnosis and treatment.  I think that may happen for many patients, that they may be aware of a condition but it may be difficult to proceed with diagnosis and treatment; then the condition progresses and so things shift.

B.E.:2  I get a feel for some of the matters involved.  There were pyschosocial aspects mentioned.  What I'm not getting is a total picture of this woman, and I'm not getting why this case is being presented.  I'm not getting what we can give as input to help find those things that are missing, so I'd like for us to focus on those so that I can understand.  If I have something to offer I certainly want to give it.

N.P.:  I hope so! It's my job to facilitate the discussion and I'm going to do better in the next two minutes.

L.Z.:  Was it the patient's noncompliance that was responsible for delay, or was it a lack of motivation and education on part of the staff here?

N.P.:  I can answer the second question.  It was not lack of motivation or education on the part of the staff here because she hadn't been here until that day.  I propose an alternative explanation to that idea of "noncompliance" and I think we may be able to get a handle on it in this discussion.  I'll ask that we hold off.  Let us present the other three cases briefly, see if there is a common thing about different situations in which patients come to our clinic for the first time having had some lack of success in the past.

R.W.:  N., before we do that, I think we are getting a little bit confused by going on to the next case.  I think what people are asking for is what are the basic problems that  this patient had with regard to our system.  Was it a matter of noncompliance?  Was it a matter of inappropriate transfer of information from her previous care providers to her, so that she was  very  confused  about these things?

N.P.:  But we can't know. There are many factors...

R.W.:  N., excuse me. Please don't interrupt me.  Basically the most important factors with this case are what we would like to key in on at this point in time, for our own edification.  A part of this point I think is very important in the length of the problem. Here is a patient who comes into our system very confused, upset.  She has a lot of discomfort, bad hypertension.  Suddenly a care provider gets this patient for a 15-minute encounter, already overloaded  in  the schedule.  The confusion that can come about as a result of having just a very small time to spend with the patient who has large demands can even further magnify the problem. I don't know if that's the position you were  in,  but that’s another aspect in this case that could be important for us to look at.  I would like to know from H. if she thought that was a problem.

H.R.:  Yes, but I think of this particular person and her psychosocial setting, what has prevented her from seeking care.  (I don't think I can understand entirely as it was a ten-year thing).  I don't understand exactly what was going on in her life although I knew some things that were going on.  She was moving around a lot, and she was in and out of school.  She was having identity problems.  I don’t know how much those things played into her reluctance to seek medical care or follow it, but I know that I felt pretty strongly that somehow communicating an acknowledgement of her intelligence, her desire to participate in her care, my being non-judgmental about other things in her life [the patient was a lesbian, ed.], all made it easier for her to stay.  I don't know whether things were so negative in other settings or whether she was finally coming around to expressing her own problems.  I think I could have put her off.  I think the system could have put her off.  I could have said, "You have a little high blood pressure.  Here is the prescription.  Go fill it at the pharmacy and I'll see you next week for a half hour."  The chances that she would have come back would have gone down.

N.P.:  The questions you are asking I think are good questions.  I believe we can't answer those questions with any certainty of what had happened in the past.  But what might have happened if H. had treated this lady differently?  The answers to your questions, which I hope we will bring out of this conference, we don't know right now.  We use this case material to consider questions that may come out gradually.

B.E.:  I would like to thank Dr. R. because what she told me is that here is a woman with much anxiety.  (That may have something to do with her hypertension.)  Certainly her anxiety is shown by instability, in choosing not to face the problems, continuing to move her location with the hope that she will avoid those problems, that they will go away.  It all feeds into her denial.  Those are the statements you need--the little bit that you gave me which gives a whole picture of this person.  I don't think you're asking for too much, but if you don't get that you sure miss a lot.

M.W.:  I think in this situation, where someone keeps telling you, "No one has ever told me that"--when you tell them, make that a big note on the chart.  Record it.  I know in dealing with cancer patients you can tell them, "You've got cancer," but two days later do they know it?  It's always good to record it. 3

N.P.:  One reason I want to get to the general pattern of these patients' situations, rather than the particular problem of hypertension in a young person, is that I think these are much more common phenomena than we would like to acknowledge.  What you just described beautifully well, B., about this woman who was anxious, who had moved around in the past, might have something to do with the pattern of relationship  in  H.'s first, encounter; and yet I think to myself  you're  not  describing  an exceptional case.  You are describing a vast majority of the patients whom I encounter.  Everyone, especially first coming to a clinic, uses some processes of evasion and denial that are built in for some reason.  Those patterns are really quite prominent.  Maybe that is one of the areas we can get to today also, in terms of practical ways  of perceiving and dealing with these processes.

M.R.:4  Giving time to people gives them a feeling of respect and understanding.  This woman learned that before she came to our clinic.  If she doesn't get it she won't come back.

H.R.:  I'm not sure.  I know her better now.  We gave her the time.  I think that  was my desire.  I don't know what she would have done had I been brusque with her, but I could have given her less time and I don't think she would have demanded more or felt short-changed.  For my own peace of mind, evaluating her initially, I needed the time.  I don't think she was a demanding person, that I had to drop everything to take care of her all day.

M.W.:  You might feel guilty.

H.R.:  But I'm not; I didn't.

N.P.:  But you did make a decision that her situation required an additional amount of time and attention.  The quantity is not so important as the fact that the decision looks in retrospect to have allowed diagnosis and treatment to proceed. That's the kind of thing we are looking for--one that succeeded, or even one that didn't succeed, so we can see what to do.  Shall  we  go  on,  briefly  touch  these other cases, broaden the discussion?  I was struck. This patient came into the clinic when C. had to go to a meeting and she asked if I would see this lady briefly.  "She just needs a medicine refill."  I said, "Sure, go ahead," but I knew when someone says she just needs a medicine  refill  it  sometimes  is  a "trick" (not a conscious trick).  It doesn't always work out so easily.  I came into the room and smiled.  I wanted to be especially nice because she was C.'s patient, so I introduced myself and smiled and I looked at the patient (since there was no chart to be read over). I looked at her and I asked how I could help her.  She seemed very anxious, and told her story about the doctor she had consulted recently, and her great concern about her high blood pressure.  Especially striking was that she was convinced the doctor had been much more interested in money than he was in her, because she had to pay cash in advance.  It crossed my mind that the structure of paying for medical care might have more to do with that than the deficient personality of that particular physician.  She was telling me some medical facts and talking about medication in a way that made sense for her condition, so he may have done a pretty good job.  But he is in private practice; she has no insurance and he probably can't afford to treat people for nothing forever and so he probably did have to get money in advance in order to be paid for her treatment.  Perhaps that was what threw her off.  She didn't know she was a zero-pay patient in our system.  It made much more sense for her to come to our clinic not because of her previous doctor, herself, me or anyone else.  It made more sense for her to come to our clinic because she could get good treatment without having to pay cash out of her pocket.  To go to him she had to pay cash in advance.  She didn't perceive that to be the problem, but I got it pretty clearly.  Her blood pressure wasn't terribly high.  She was quite anxious and actually laughed and cried at the same time.  What I tried to do was put her at ease about the issue that I perceived in the first few moments.  I thanked her for giving me clear information about her previous diagnosis and treatment.  I reconfirmed that the medication she was taking did make sense and probably was helping with her blood pressure.  Even though I couldn't read the mind of the doctor she had consulted recently it sounded to me as if he might be taking very good care of her, and might even like her a lot.  Of course I couldn't say that, but it seemed nice to open the door to her considering it was possible.  I made a proposal that we follow up her condition in a reasonable manner.  I was sure there was no emergency diagnosis or treatment that needed to be made.  We had enough information to know nothing terrible would happen, that I would give her similar medications (and left the reserpine out) to maintain the status quo.

R.W.:  Let me ask you one question.  Do you think in this situation that patient's anxiety, as she was undoubtedly very anxious, coming into the new system she was confused, concerned about paying for her hospital care or her health care that she was unable to pay for it in the private sector, and unable to do so she had to terminate what may be a very important relationship with her physician and that her physician was equally anxious about that?

N.P.:  The reason I chose this case is that it is so clear.  I am sure she had long-standing hypertension, a basically “nervous” constitution (for many years she had had frequent episodes of insomnia, crying, restlessness and so forth).  But her recent encounter with an otherwise satisfactory physician was obviously disrupted very badly by the financial structure of medical care. That was easy to see and to try to rectify.

R.W.:  Let me ask you another question.  Do you think that her anxiety over that issue was even further magnified when she came to this institution by the fact that a time when she came for some medication, and by the time she had gone through our screening process, was also confused about if she now approached a new health care system to get "free care," but maybe was confused with her financial arrangements with our institution would she have to pay or would she not have to pay?

N.P.:  That1s why I clarified it.  I looked at the screening documents.  She was rated zero-pay.

R.W.:  Did she understand it?

N.P.:  That's why I explained it to her.  I think she understood clearly.  I said because of her income...

R.W.:  Didn't she know that?

N.P.:  No.  She may have been told. I assume she was told, but it was a separate piece of information which may have meant something to her and she may even have known it, but as I integrated that information into my conversation with her I presented it as if she did not already know it, because I saw how important it was.

R.W.:  One important aspect is this.  I don't know how often the nurses are asked by patients, "Hey, how much will I have to pay for my health care here?" and often they show you concern, and some confusion (more importantly) with regard  to  the  financial arrangement.  Does that happen not infrequently?

P.R.:  Yes, yes.

R.W.:  That is an important aspect because it may be the patient is just anxious and at the first encounter she will just forget.  We do need to look at that with regard to the clerical staff giving the information, how we can support them, and the nursing staff, the physician staff, et cetera., particularly with a patient like this who we know is making a real major transition.  We've seen that more and more in our new building, patients who say, "Well, I'm going over there because I can't pay for my health care."5

N.P.:  There are some other concerns which come up.  She didn't voice these directly but I sensed their being present and responded to them directly.  First I explained that I am a very good physician, at least as good as the physician whom she had seen.  Even though I didn't know him well I assumed from what she told me he was very good and had actually done a better job than she had thought.  He was not preoccupied with her paying cash in advance perhaps and, even if he was, he had done the right kinds of things for her health.  I explained that it  happened that  the financial structure allowed her to pay no cash in our clinic, but that some people might actually do better in his clinic because they might be charged more here.  Ironic, but true--I knew so from my experience.  So I was pointing out two things to her:  We have good treatment here, and financial structure is not necessarily related to quality of care.

L.Z.:  N., with reference to the good treatment, I think the nervousness is a primary manifestation, and not related to the financial burden, so we have to look at another aspect of the hypertension associated with nervousness.  Could it be a pheochromocytoma?6

N.P.:  It could be.  I think it's not.  I think it's essential hypertension in a lady with a chronic tendency toward depressive symptoms.  But as moderator of this  discussion I say, "I don't care about that."  (This woman is still my patient so I do care about that.)  For this discussion I don't care, because if someone came in with gangrene of the left great toe and said, "I think the doctor I saw only cared about cash in advance," it would be the same problem.  In this particular case the difficulty was the financial one.  I don't care what her pathology was.  What I do care about is being able to perceive her misgivings and being able to speak to them, and then...  In all four of these cases we had a certain measure of success; the failures we don't even know about.

M.W.:  Back to pathology.  The reserpine might not have helped much if she really had depression.  Another thing: isn't that part of the protocol, to tell them at the end what their financial rating is?

N.P.:  Yes.  She probably was told.  I'm just saying the information may not have been integrated a few minutes earlier when she talked to the clerical staff.

R.W.:  You never know how much they get out of that...

N.P.:  I had an opportunity to bring together quality of care and pay scale in our conversation, and that is perhaps the best thing that I did that day.

R.W.:  One more question.  One statement that you didn't make:  What is your responsibility to the other physician?  Have you contacted him?

N.P.:  You bet.  We got a release of information that day, and soon after a written note from him.  He was glad to give us the information.

R.W.:  Did you personally call for the information, and did you discuss why she was transferring her care?

N.P.:  I could have.  I didn't.  Well, maybe I did.  I called his office, but never talked to him.  But I think I assumed because he responded quickly and cordially with the appropriate information that he realized the same thing I did--that the financial structure of medical care sometimes excludes a patient from one person's practice, and (hopefully) includes that patient in another's.

C.C.:  Many patients need to have a reason or an excuse to come here.  Once you make them feel comfortable and let them know that you're interested  in them,  that sort of thing is all resolved, and is not a problem again.  I don't know for what reason, but a lot of people will come, almost apologize, "Well, I have to come here now," (which is really too bad).

N.P.:  Thank you very much. That leads us to the next case, which H. will briefly describe.

H.R.:  The next case is very similar.  A middle-aged woman.  I re-read the first encounter and P.'s introductory note to what this lady's problem was:  "Needs medication for heart."  She had been doctoring with a cardiologist in town for about six years and had been on Medicaid.  One of her sons had just gotten old enough that she had been taken off it.  She had been with this doctor through the aortic valve replacement last spring, and then the Medicaid was stopped, so she couldn't see him any more because she didn't have the money to pay him.  She was very concerned about her treatment, but I wasn't sure how much she understood about what was going on.  She told me she was on "Coumadin," but she didn't say it quite right, so I was not quite sure she understood what her illness was or what her medications were.  I had the gall to challenge her on it, and asked her if she was sure that she took Coumadin the way she was describing--two pills and then one pill.  She got very upset with me, said, "It's my life!"  She knew exactly what was going on with that aortic valve and her Coumadin.  I don't think that was the major thing of our first encounter, but that some of the things we have already discussed were really identical.  She had a long-term relationship with a physician who could no longer see her because of her financial status.  She has continued to apologize to me about money.

N.P.:  He could no longer see her?

H.R.:  He would no longer see her.  I did speak to his nurse on the phone that day about her because I wanted some details about her cardiac catheterization and medications.  He was pretty brusque about the whole thing.  His nurse said something like, "Oh yes, Hattie, we've known her for so long."  The physician himself didn't have much to say.  The patient subsequently had difficulty getting a disability statement from him.  I don't know if he was angry, didn't care or what, but I saw this as a traumatic relationship for her.

N.P.:  Can we guess?  Should we unfairly project ourselves into that physician's position?

H.R.:  No.

N.P.:  How can we help it?  I certainly do it.  What assumptions can we make about what this doctor was feeling about this patient at that time?

P.R.:  I think he didn't care, once he knew she didn't have the money.

L.P.:  But you must start where you are in the relationship to that lady on that day.  Keeping that in mind, I don't think you have to waste a lot of time.

N.P.:  I want to take that little side trip because, P., for all practical purposes I think you're exactly right.  As far  as  she is  concerned, it must be that.  What impact it must have on her to put her life in his hands for so many years, and then to have a sudden superficial financial change terminate the relationship, terminate his concern for her!  As a matter of fact, I think "he protesteth too much" from what you say--that he was so brusque.  I'll bet you he was a guy who was convinced either by his accountant or by things he had been told that he could not continue care gracefully for someone who couldn't pay.  (How could he pay the rent or whatever?)  So he felt that he must terminate her care, and yet he must have had some unconscious misgivings about it to have been so defensive in talking about her care.  Often physicians can speak very warmly about patients who do not give them a penny.

R.W.:   Let me ask you a question, H.  In talking with him and his staff, did you get the impression that they had a negative impression of her, for some other reason?  (We don't know why the nurse would be perturbed, unless the doctor had projected those misgivings on her.)  On the other hand, was this a problematic patient, a manipulator, a complainer, someone who would have made him and his staff nervous about her?

H.R.:  I think what I got from the nurse was not a negative response.  She was positive:  "Oh, yes, we've known her for years..."  But this woman was on Elavil (a small dose) which the physician had put her on.  I thought about that, too--whether she was a pain in the neck to him and finally he said, "Here, take a pill at night and maybe you'll be better.."  Maybe she wasn't his favorite patient.  She had gone through the major expense of her illness already, and to carry her along with prothrombin times, seeing her once in a while might not pay, but I wondered why at that time he couldn't afford to, or didn't want to.  She hasn't been a pain in my neck, but I don't know how he felt.

B.E.:  Can I interject something?  I worked with H. at Georgetown for a while when heart pumps and putting people on machines were still new yet.  For a while I thought about doing a paper about psychotic depressions in those people, the heart patients.  I think that has a lot to do with her being on Elavil.  Quite a few people who go through these kinds of operations become tremendously psychotic and depressed.

N.P.:  Those are details of particular pathologies that can be important.  I am sorry if I got us on the wrong track.  I think we do make assumptions and projections about the previous care.  We know pretty well what the situation is, and we do make assumptions about what the other physician may have felt or done.  It is not fair to do it, but we must have a working assumption of some kind, which we qualify by saying we can't be certain our assumptions are accurate.

C.C.:  Wouldn't it be great when a physician gets in that position and recommends that a patient go someplace else, that he calls us, says, "My patient is coming?"  Wouldn't that be wonderful?  (Group laughs.7)

N.P.:  Why doesn't he initiate the contact?

C.C.:  That's what is done in private practice.

D.S.:  It would be nice if we knew why a person comes to our clinic.

P.R.:  When they refuse a patient because of money that's when they should do it.

C.C.:  And they recommend that patient get care here because it's free.

M.R.:  If they were made more aware of our clinics (which we haven't done) perhaps they might do just that.  Rather than feel so guilty they wouldn't have a place to send the patient.  I don't think the doctor necessarily didn't want her.  He may have felt a lot of guilt, but sometimes you have to do what you have to do.

H.R.:  I don't think he sent her. I don't know what the relationship was.  I don't know that he said, "Well, I see your Medicaid has run out," and then the patient said, "Oh, I guess I can't afford to come."  I don't know.

P.R.:  But the doctor doesn't do this, his bookkeeper does.  Those bills are very impersonal.

M.R.:  How much are the private doctors aware of our facilities?  They are only vaguely aware.

L.Z.:  I am just starting my private practice.  Most doctors practice with the private hospitals.  Most doctors, when the patient can't afford to pay or even wants to terminate their service, normally arrange with the clinics of the hospital, which are free because they teach residents and interns.  But, in this case, it surprises me that this happens with a doctor who has been taking care of a patient.  Perhaps there is something which is the fault of the patient, or some unadmitted complication.  I cannot accept all these statements as true.

N.P.:  I think the important point is this:  We get a picture of our patient's experience, which may not be an accurate reflection of the real attitude of the other physician.  It is the same as when a patient may say, "I took a green pill for blood pressure,"  when actually it was a red pill for urine infection.  But the patient's experience was  such and the patient has reported it to us as such.  There may be distortions built in for various reasons, but we take the story at face value to begin with, because that is what we understand of the patient‘s experience.

R.W.:  Before we get into the next case let me add some more comments.  Let us look at the situation a little differently.  Number one, I think if a patient has to terminate care for any reason, like the very overt, obvious, objective and concrete case in which the patient has to say, "I can't afford this care any more," the doctor is more inclined to give some advice about where to go, or try for another source of care that can be satisfactory, where financial arrangements can be made.  On the other hand, in this case there may be other things going on.  I previously alluded to "Was this patient a pain in the neck?"  What I suspect did happen was that this physician, a cardiologist providing secondary or tertiary care, a specialist, is not interested in providing what we call primary care.  In that situation we deal with a patient who may feel like a pain in the neck because that's all part of primary care, and he being unable to function as a primary physician and deal with all the psychosocial problems, she started to appear as a pain in the neck and she was not satisfied with the care she was getting and he wasn't satisfied with the kind of care he was giving her, and as a result it was a slow transition, a slow or gradual awareness that neither was getting needs met.  Maybe that's the situation.  She said, "I can't afford the care here any more; maybe I should go someplace else."8

L.P.:  Most of the patients that haven't been in this system may not realize what is good here, but I have been really impressed with this system--how patients are treated, the quality of care they get.  The pharmacist and I were talking last night.  His wife works in collections at  another  hospital.  When she talks to patients who can't pay their bills, she says, "We have health centers.  Why don't you go to one of the health centers?"  "I wouldn't go over there."  It's because they haven't had any exposure to the system and they assume because it's free, it's not as good.  Since I've been here, every time I see a new patient I incorporate into the history, "What has been your experience with other care-givers or other health care systems?"  I try to explain to them that I am a newcomer to this system too, and tell them my experience of it.  When I'm finished I always ask them, "What did you think of the health center?"  Sometimes I have taken people for a little tour (especially older ones).  If I weren't a student I might not be able to afford the time [Laughter from all].  But I figure I do that because I learn something too.  Patients are always pleasantly surprised.  I haven't had anybody say, "Well, I don't know..."  When we get new patients I think we have to do a little public relations work.  It might improve compliance.

N.P.:  It is terribly important to interject that we are not perfect (but we're pretty darn good).  Part of it has to do with the structure of our service.  R. pointed out we are mainly interested in primary care.  Generally, people who are ill want primary care, but it's not always available.  One advantage is the kind of product we are offering, and the other is that we're not as bad as some of our public reputation.

L.P.:  Part of our reputation comes from our general hospital.  I was horrified the first day I was over there, the way people were treated.

N.P.:  Thank you, L., for leading to our last case.
L.P.:  You want me to shut up.9

N.P.:  No.

L.P.:  One more thing--when my patients are going to the general hospital who have never been there I tell them what to expect, that they will get good care (but very impersonal), to be prepared to wait hours (that these things happen).  Some patients have to go over there traumatically, and we haven't been able to prepare them.  We have to go through a "session" to help them withdraw from it.

N.P.:  ...just like at the University Medical Center.  A man who had been a patient in the Medical Center and had come into the clinic because he was in the building to bring his wife for one of her many appointments.  (His wife had been a patient of R.'s and of every sub-specialty clinic at the general hospital for several years.)  He was familiar with us, but he hadn't been in any of our clinics for many years.  He did come in for an acute problem, that he had had diarrhea for more than two weeks without blood, vomiting or really bad signs.  His diarrhea had been a bit prolonged and he was anxious about it, but tried to "underplay" it.  Ordinarily I would have given him the advice, "Drink plenty of fluids, take some Lomotil (very temporarily)."  But instead of just telling him that, giving him a prescription and thinking, "Now, beat it," I asked him what he had done already.  He had been to the V.A. a week earlier where those simple recommendations were made.  Things had even improved a bit, but he was still concerned.  I did nothing in particular that day but assess the situation with him, to take it seriously.  I explained to him it might still be within the expected range of a minor transient illness, and made arrangements for him to come back.  I told him what tests we would do if it proceeded much further.  He liked me for having said those kinds of things.  What I find interesting in reviewing the notes is that the encounter at the V.A. was much more satisfactory technically than mine was, but I had responded to something in his dissatisfaction without putting down the V.A.  (I know the V.A.; I've worked at the V.A.  It's good but slow, and sometimes people expect not to get much attention.) He was very anxious and wanted attention, so I gave him personal attention,  and he completed his diagnosis and treatment at the V.A.  I don't know what else to say.  The thing that is intriguing is that he was convinced he had cancer.  There was no technical sign that it was so. Pathology reports recently showed a very malignant and unusual cell-type of rectal cancer.  Before there was any technical way to know that was so, before there was any sign of bleeding, he feared that it was so.  What I had done that day was to make room for him to sit in my examining room and be afraid, and not tell him to stop being afraid.  I did say things to him in the course of our encounter and the following weeks, that I had not yet seen any reason for him to be afraid in such an extreme way.  But I didn't tell him to stop being afraid.  I sat and shared his fear with him, but tried to stick with the facts.  It turned out the facts were very unfortunate.

B.E.:   Oh, N., now let's have your "pill."  What do you feel is the common element of these four cases?

N.P.:  I think R. has already given us the key to that.

B.E.:  No, let's have it, succinctly.

N.P.:  I put down in writing atop my notes, "Four patients who had experienced some lack of success in previous care."  In the one case I see it as having been an unsuccessful communication (no matter what the reasons were), a young lady who at nineteen was not well-equipped to accept illness.  Most teenagers aren't.  They are not supposed to have to.  They are not programmed for it.  Maybe someone did poorly in the choice of idiom in speaking to her about her illness.  Whatever it may have been, it had gone on for ten years and was progressing, and she was pained and frightened by it.  And because she had a clinician who was able to appreciate that and respond to it, the subsequent shape of her diagnosis and treatment changed.  I think we can identify the factors which allowed change.  In the second case, a lady had a financial condition which distorted her medical care.  I think I understand what was going on there.  I think she made it easy for me by telling me straightforwardly.  By being willing to listen, not just to write a prescription for "HCTZ" in a mere...okay, half an hour, but that's not a very long time...It paid off because it made things nice and clean.  Instead of having to go from this clinic to the next, from that one to the next one, now her fairly simple problem can be managed here efficiently.  In the third case, a lady believed she had been cared for well enough, but termination of her Medicaid did violence to her care.  Repair of that breach had to be accomplished somehow for her complicated cardiac condition and multiple medications to be monitored properly.  Dr. R. skillfully "stayed in there," offended the patient with one of her approaches, but understood immediately what the meaning was of the patient's response, adjusted herself readily to the realities of the patient.  She was ready to treat her as a dependent person who was ignorant of the importance of her condition and medications.  The patient corrected her immediately, and she took the correction!  Maybe that's not the only thing that happened between you and that woman, but I see that as the pivotal point in that initial encounter.  And the fourth case is of a man familiar with our clinic and comfortable to come here, who was not completely satisfied with his consultations at the V.A.  He wanted to be a V.A. patient, and returned to the V.A. for his surgical treatment.  I gave him an interim consultation on the primary care level:  that the V.A. emergency service had not let him feel he had had his diarrhea cared for, and encouraged him to pursue caring for it.  It's just awareness and allowing him to be afraid of cancer even when it seemed that he didn't likely have it that allowed the consultation to seem positive.

B.E.:  Let me bounce off my impression of what I have gotten from this conference.  I feel strongly that we are important in communications, and the type of communications that we do is vital  for good patient care.  We can feel good when we do accomplish them (which we certainly need).  We do quite a bit here and need to continue.

N.P.:  I say R. gave us the key.  He did it in very formal language, but that's okay.  He said we offer primary care some people don't, and that's important.  ["Right," R.W.]  When we offer primary care, and we know that responsiveness is one of the important keys to that, then we can be proud of it, we can be willing to offer it.  These cases are to point out you can't predict just by the external circumstances of the encounter which responses are really going to be important or which time a patient merely wants a piece of paper so that the supervisor at work won't give him a hard time, or which time the patient merely needs a supply of medications (that understanding and feelings about his illness, his diagnosis, are not really critical).  It is hard to predict who is going to come through the door needing our special components as well as just our technical components.  The whole team provides those "special components."  Any one of us could cut off that flow of responsiveness.  Every one of the physician staff has done it many times (hopefully not too often).  If you are preoccupied with something else and brusque with a patient, sometimes you turn around and say to yourself, "I blew it. That wasn't really what she wanted."  The nice thing is because we have continuing care you can give 83% (or something respectable) and it may not be 100% all the time but you can bridge the gap.  That patient will come back even if you stub your toe.  If you made a mistake the patient's basic faith goes on.  Patients will come for  years, sometimes have fist-fights with us for very good reasons, and then come back in.  That's an ongoing process.

R.W.:  It shows me that we may have patients transferring in here because of difficulties with payments.  This may increase in the future because of the financial problems many of our patients are going to have, with decrease in social programs.  The most important thing is that we should certainly be aware of the fact that patients are going to be seeking care and usually when they come into our institutions, often with a variety of complaints, the most important thing we can do is to find out if this is a new patient and why he or she is coming here rather than going to someplace else.  Ask patients if they have other sources of care, and ask them if they are going to use those sources or transfer their care to our clinic.  Why will they transfer their care?  What are the problems?  Once we recognize those problems, I think we can deal with them.  It may have been they have lost their Medicare or whatever, or have been denied health care.  It is important that we facilitate that transition, doing that by communicating with the other health care provider (call on the phone; try to get medical records); and what L. said--maybe better public relations.  Nursing and medical associations certainly should be aware of these facilities.  Private physicians should understand that we do exist, do give good care.  If they run into a bind, they should make informal as well as formal referral to one of our facilities.  That kind of information should be given to some of the outside facilities.

N.P.:  I think it's important to realize that anything a patient does is legitimate.  A patient comes in the best way he can.  Patients feel obligated to present an "entry ticket," what looks like a medical complaint.  One's needs may be much broader than that complaint, but a patient is going to cooperate with the expectations he thinks we have by trying to put it in our language.  Also patients,  especially those who have had some lack of success in the past, come here with negative expectations, so that meeting a patient for the first time is really terribly important.  What is important may be much more the attitude we respond with as well as the patient's medical condition--to be able to take the time and to give the attention, so that a patient can rectify the negative expectations he has, know that we're a primary care facility that offers broad care and continuing care.  We don't have to put it in those formal terms.  We simply sit long enough listening and offering what the patient needs so that he can feel that it is so!  Then we have a successful beginning.  It can be easy from then on.

[This conference took place at the Neighborhood Health Center in December, 1980.  The problems and their consideration in dialogue among health care professionals was no different then than from today, nor indeed from the time of Hippocrates.]


1The medical  supervisor  intervenes early, perhaps responding to the unconventionally subjective and clinician-oriented trend of the conversation.  He exemplifies the defense of "objectification" commonly used by clinicians, which recurs in several of the subsequent contributions.  He identifies the patient by the diagnosis "hypertension" and focuses on the reported concrete symptom "chest pain”, steering away from the references to "other changes in her life" and the several statements referring to the physician's own feelings and judgments.

2  The nursing supervisor soon responds in a manner similar to that of the medical supervisor.  Just as he tends to emphasize diagnosable organic disease, she early brings up "psychosocial aspects," but in a later remark about depression in heart patients reflects the "objective" attitude which wishes to research and prescribe to patients as objects.  Neither of these persons is by character cold and uncaring, but trained and coerced by job description, and likely also by the life-long pressure of minority status (which I also have suffered) to take a more formal or "scientific" stance toward other persons' bodies and feelings.

3  Another physician recognizes a real clinical phenomenon (denial manifest by the patient's not hearing), but responds in this self-protective manner.  The purpose of ethical behavior is not merely to avoid litigation.  We always express emotion even when we act "objective."  (This is the doctor who soon  says, "You  might  feel guilty...")  [When I presented this transcript to the participants she responded with a special delivery letter written by her lawyer-husband demanding that I destroy it or suffer legal action, and that happened even before I had added these subjective footnotes, ed.

4 The doctors have spoken (and the nursing supervisor); now a nurse can speak. From this point several nurses will enter the conversation with their own personalities and  sympathies for patients to guide them.

5  The medical supervisor pays attention to knitting the team together, a task each clinician needs the administrator to do.  This man is also a clinician.  The mixture of roles is not easy, but if it is successful there will be a real team; if not, not.

6 Some "pathologic" thinking never stops!

7  This is the time of greatest group comfort, spontaneous laughter and chatter reconfirming comradeship, especially among the nurses.

8  He continues to become more comfortable in the conference, and can attend to the phenomena and processes of the real case:  the patient's experience, the clinician's experience and the nature of the relationship.

9   Such candor is possible only because of reliable mutual respect between colleagues.

| | | |