As a medical student nearing the end of my pre-residency training, I have come to realize a few principles that I would like to use to build the foundation of my practice. I want to be a physician who can truly listen to my patients and learn more about the context of their presentations. I want to truly understand my patients’ goals so that I can best help them achieve these goals, during and especially after their hospitalization or clinic visit. I want to work together with my patients in a balanced partnership, where we can come to an agreement on a plan that is best for their needs. However, these principles were challenged when I admitted a certain patient during my time on the internal medicine service.
I was tasked with the final admission for my team one evening. I had scanned through this patient’s ED note and was already anticipating a problematic visit: he was a young heroin user. Previous attempts with suboxone had been unsuccessful. He had come to our hospital and was being admitted to our team with a fever and chest pain. He had just been diagnosed with cholecystitis at another hospital two days ago, but had suddenly left against medical advice and without adequate treatment for his condition because of, according to the notes from that visit, “inadequate pain control.”
Upon further workup, we discovered he had developed a right-sided pneumonia, a large parapneumonic effusion, and Staphylococcus aureus bacteremia. He was started on IV antibiotics to treat his infection. However, given his daily IV heroin use and the risks for serious complications from his Staphylococcus bacteremia, the best option for him was to complete a full four- to six-week course of antibiotics as an inpatient. With his pattern of abruptly leaving during his prior hospitalizations against medical advice, we attempted to plan a backup oral course for him just in case this stay would meet a similar outcome given the serious nature of his infection.
While getting our patient to agree to this antibiotic plan, especially the prolonged inpatient stay, was challenging, the most difficult task my team and I faced was controlling his pain. He had a very real reason to have pain and to require a more aggressive pain management plan compared to the average patient on our service but, with his history of years of daily heroin use, we were hesitant to provide a more aggressive regimen that included more than low-dose opioid medications and clonidine to help with his pain and withdrawal. Yet, for any other patient without a history of substance abuse, we would not hesitate to increase opioid dosing or frequency until their pain was adequately addressed. I found this dichotomy particularly unsettling, as it seemed to be based heavily on whether or not one decided to trust their patient, rather than an objective analysis of a patient’s needs.
Despite how much I detested it, I found myself struggling to avoid embracing this dichotomy. Each day when I reassessed my patient, he would tell me his pain was not controlled and would ask if he could have more pain medication. And each day, I couldn’t help but question if what he was telling me was the truth. He generally appeared comfortable, and he did not seem to be in the excruciating pain he described to me. I couldn’t help but wonder: was he asking for more pain medication because he was craving opioids since he didn’t have his heroin? I was discouraged by how quickly I came to doubt my patient. I knew that, in almost any other situation, my team and I would have been more aggressive in changing his pain regimen. However, because of his history, we struggled to find a medication regimen to better manage his pain, the war between practicing good opioid stewardship and meeting our patient’s alleged needs making it nearly impossible to feel confident about any of our decisions.
Unfortunately, our patient tired of our hesitation to increase his opioid medications and ultimately left against medical advice, only days into his antibiotic course. Even though we had spent so much time discussing the complications of inadequately treating his infection, he left so quickly that we couldn’t even provide him with oral antibiotics, our carefully crafted backup plan now also a failure. This triggered a storm of emotions for me, mostly anger and frustration. I was frustrated that my team and I had spent so many hours revising his care plan only to produce no improvement in his outcome. I was frustrated by the limitations of the healthcare system that prevented us from providing other safe alternative options for his care. I was angry that our patient’s addiction to heroin suppressed his ability to adequately assess the risks of insufficient treatment of his infection.
What angered me the most was how this patient had forced me to confront so many challenges to my personal beliefs about how I want to practice medicine. I want to be able to trust the patients under my care, but I could never allow myself to really believe what he had told me about the severity of his pain and his need for more pain medication. I tried to consider his case within the context of his presentation, accepting his difficult history of heroin addiction and homelessness, however I could not authentically understand or empathize with the challenges he faced and how they affected his decisions during his hospital stay. I tried but eventually could not effectively partner with him in directing his care, as I was unwilling to compromise in giving him more opioid medications due to a strong belief that the risks outweighed the benefits for him. And I was even more upset that his departure, due to “inadequate pain control” as in so many of his previous encounters with the healthcare system, seemed to validate the doubts I had about my patient’s reports of pain and the hesitancy I felt to collaborate with him on his pain plan.
However, after reflecting on this encounter and reminding myself to assume that he may have only been able to tolerate so much, I was able to appreciate much more about this experience. Spending about one week in the hospital, completing only one-sixth of the recommended IV antibiotic therapy, may have been the best he could manage given his opioid addiction, his cravings, and his previously questionable history with the healthcare system. After all, in most of his recent hospitalizations, he had left after only one to two days at most. My team and I had been able to convince him to stay for almost a week of IV antibiotics, and while not an ideal course, this likely helped to prevent some severe outcomes. We had also educated his partner and family about the importance of completing antibiotic treatment, and we were confident that they would be vigilant and prioritize his safety. We had also discussed the options of substance use treatment, and he had actually agreed to consider addiction treatment in the future. Though these points had initially seemed insignificant, I realized that my team and I had made major strides in his care, especially considering his complicated history with the healthcare system. I was then able to recall this experience without experiencing anger or frustration. Instead, assuming that he had been doing the best that he could manage, I only regretted that we weren’t able to do more for him. Though we had been able to treat his infection with IV antibiotics for nearly a week, we had only managed to provide him basic addiction medicine counseling, offering treatment some time in the future. I couldn’t help thinking that, if we had been able to find him inpatient addiction treatment options immediately, and had he been agreeable, that we may have been able to make an even more significant difference in his life. However, I also recognized that we, too, as a team had simply done the best that we could, offering him the best care that we had available.
When reflecting on this experience through this therapeutic lens, I am more energized to make a difference in my patients’ lives. Assuming my patients are doing the best that they can will help me maintain a more positive and encouraging outlook on my practice, even in the most difficult situations. An angry patient is not someone who is antagonizing me or the healthcare system, but simply a person who is struggling to deal with everything that has been thrown their way; one challenging interaction does not define them. A patient who leaves against medical advice is not someone who doesn’t care about their medical condition or treatment plan, but one who has endured all the changes to their routine that they can handle at that moment; they may be able to do even better with their next encounter with the healthcare system if I can make their experience with me as supportive and positive an experience as possible. Even if it is difficult to maintain this outlook in the moment during a patient encounter, using the assumption that everyone is doing their best to reflect upon a negative experience or on an outcome that was unsatisfactory, such as a patient leaving against medical advice or one refusing life-altering interventions, can help alleviate lingering regrets or remorse and instead transform the experience into a more positive one. This assumption will allow me to encounter difficult patient care situations while reaffirming, instead of challenging, the principles I have chosen for the foundation of my future practice, while also allowing me to remain engaged in providing the best care possible for my patients.