Tough Love

The art of medicine is really about getting people to do what you want them to do, which (if you are a decent doc) is what will make them better and maybe even save their life. Ideally this is accomplished without too much of a fight, but unfortunately it's not always that easy.

The other night a 70ish year old woman who had spent her career working for our local cardiologist's office came in with a really good story for chest pain of cardiac orgigin. She knew all of the cardiologists that cover our ER, and I assumed (stupidly) that she knew the ins and outs of a chest pain work-up. The history (what a patient tells you) is key in deciding how to proceed with a chest pain complaint, and this woman told me all the classic symptoms of cardiac chest pain, probably unstable angina. So I told her I was going to proceed with a high level of urgency, talk to the cardiologist on call, and probably plan on admitting her. She seemed sophisticated enough to comprehend all of this.

So I left her and ordered all the necessary medications, lab work and x-rays, and then, because it was already 12:30am, I decided to call the cardiologist and have her admitted to the hospital based on history and risk-factors alone, since I knew the cardiologist wouldn't want to hear from me at 1:30 or 2am when all of the test results come back. It was a slam-dunk admission, especially when I mentioned that the patient is the woman who worked in their office for years and years. So I filled out the admission paperwork and went back to give the patient a prompt update, assuming she'd be pleased at how expeditiously everything was handled.

"Mrs. H, I talked to Dr. B and he is going to admit you to the hospital because of how concerning your chest pain is tonight."

Well, damned if Mrs. H didn't go postal on me. She couldn't stay.... She had to go home and take care of her husband.... She didn't understand what about her chest pain was so concerning... Why couldn't it be done as an out-patient?.... blah-blah-blah. It was the same initial response most people have when they think they're just coming to the ER to get told there's nothing wrong with them and get discharged, but then their doctor tells them they have to stay.

Problem was, Mrs. H apparently thought her career as a cardiologist's secretary made her more qualified than me to decide what she needed. "I'm not staying." Then she proceeded to drill me about why her chest pain was so urgent. I tried to play along and re-hash all the eliments in her history that were concerning, and she fought me tooth-and-nail on every miniscule point... even denying some of her initial history. "I never said I was nauseated!" she snapped at me. Why the hell do people come to the ER when they're not going to listen to what the ER doc has to say?

Finally, she wore out my patience. When someone is threatening to leave AMA (against medical advice) and they have an emergent and potentially lethal medical condition, you do what you have to do and say what you have to say to try to get them to stay. I could have said "Whatever you want," and given up and walked out of the room. But, no, I fought for her well-being and I fought to get her to stay. And, yes, I was stern and, yes, I was threatening, i.e., you could DIE if you leave here tonight! I can count on one hand the times I've played the Yale card with patients, but she was so incredulous of my decision-making that I finally said, "Look, based on my education and experience, you need to stay. I know I look young, but I have a degree from Yale Medical School and I'm residency-trained in emergency medicine. I know what I'm talking about."

And damned if the stubborn old bag STILL would not consent to stay. So I just told her I wasn't going to argue with her and left the room, leaving her family members in there with her to hopefully convince her not to leave AMA.

It was a busy night and I had plenty of other patients to keep me busy. I optimistically kept the orders for Mrs. H's care active and went about my work. About an hour or so later I looked up and saw Mrs. H's daughter at the desk and I dashed over to get the scoop. "Is she going to stay?"

Well, according to the daughter, Mrs. H was, in fact, going to stay, but she thought I was very rude. Rude? RUDE? Excuse me for trying to save her life! I told the daughter, "Whether or not she thinks I'm rude, the important thing is that she's going to stay, and as long as she IS staying, I was effective."

But it really bothered me that this woman who, as my luck would have it, knows every cardiologist in town, thought I was rude, because normally patients love me. I'm not used to getting that kind of feedback.

I went about my work again but it kept eating at me and eating at me.

Finally I went back to Mrs. H's room and said "I've come to make nice. I'm sorry if you thought I was rude, but I was concerned about you and I didn't want you to leave here and die."

The stupid old bitch STILL wouldn't come around. She gave me this pouty nasty face and said in a condescending way "I accept your apology," in a way that was all too clear that she was going to hold a grudge to her grave.

Great, she hates me. This is what I get for trying to get her to do what was in her best interest. Sometimes you really can't win. Tough love is hard.