Julie Davila - Patient Centered Ethics: Pathography

Jan 21, 2022 at 01:57 pm by pj


The Privilege of Trust

      “Doc, that dang pain on the side of my face is back again!” My preceptor received this call one morning, and he looked at me and told me that she needs to be seen by a surgeon urgently. I learned that she had a prior episode of this unilateral facial pain 3 months ago. My preceptor told me his suspicion was high for Giant Cell Arteritis (GCA), as she has a history of autoimmune disease. When she initially presented with this facial pain, she was placed on steroids. She was told that she needed to have her ESR and CRP levels checked, as well as a surgery consult for a temporal artery biopsy. We emphasized that this was urgent as she can risk losing her eyesight if she does not receive the appropriate treatment. She did not report any visual changes at this time. She was put on steroids after the first episode, and a surgery referral was placed. The steroids completely resolved her symptoms, and she did not want to seek further treatment at that time. Her labs revealed significantly elevated inflammatory markers, further pointing to the diagnosis of GCA, yet she was still hesitant to seek additional treatment. That brings us to the morning when she called the office to tell us her she has facial pain again. She agreed to go see the surgeon because the pain returned. As part of my family medicine rotation, one of our assignments was to accompany a patient to a referral appointment. I am thankful for this opportunity as it allowed me to spend a significant amount of time with this patient, and she taught me many valuable lessons that I wish to implement when I am a practicing physician.


     I experienced what it is like to balance the multiple roles a physician plays through my encounters with this patient. I took on the role of a supporter, a friend, and a healthcare provider. She let me attend her surgical consultation with her without hesitation. We sat in the quiet waiting room, and we delved into all of the details that made her the person she is. She told me how she raised her son and is now helping her son raise his son. She is a very spiritual person, and she expressed multiple times that she is not afraid of death. This is how she lives an enjoyable life despite facing numerous hardships with her chronic illnesses. One day, a medical assistant went to take her temperature. He pointed the infrared thermometer at her head and this caused her significant distress. She screamed, “What are you doing?!? You don’t stick things in the third eye, son!”. I was slightly confused at first, but I kept that to myself. I don’t think I will forget the look the medical assistant turned and gave me. Though I do not personally know much about this belief, I know I will encounter numerous different beliefs and people from different backgrounds than my own. It is important that we accept and invite different beliefs of our patients, as they make a profound impact on our patients’ lives.


     I learned that she was a teacher for many years, and she spent time teaching every grade from elementary school to high school. We discussed her passion for teaching which is why she was so enthusiastic about my participation in her care and sharing her story with me. This also impacted how she interacted with her healthcare providers. Her passion for education made her a curious learner, and she does her own research on her diagnoses. During my first encounter with her, she explained her history of autoimmune disease, and she mentioned the possibility of Giant Cell Arteritis before I did. She also explained an accurate description of the pathophysiology behind it. I believe that she has an excellent understanding of her illness. She knew that if she wasn’t treated with steroids there was a high risk of losing her vision. She knew that her primary care doctor wanted to have a temporal artery biopsy to confirm the diagnosis before treating her with high dose steroids for a prolonged period of time. Before her surgery consultation, she looked at me and said, “I don’t even care what this surgeon says. If Dr. X (her primary care doctor) wants me to get this done, I’m going to get it done. I know he has my best interest at heart”. The surgeon did an excellent job at explaining the reason for the procedure, the procedure itself, and the possible risks and complications. He answered all of her questions. Despite all of this, she canceled her appointment on the morning of the procedure. I was shocked when I heard this, why did she not want to have this procedure done?


     To understand this, I reflected on some of my previous conversations with this patient. She once told me that the only healthcare provider she trusts is her primary care doctor. She does not believe that hospitals or other healthcare providers would do what is in her best interest. This saddened me when she told me this. However, it also gave me insight on the type of relationship I wish to have with my patients and how I wish to treat them in the future. This brings up a tough subject. At the end of the day, it is the patients who make the decisions regarding their medical care, regardless of if it is the decision you want them to make. My interactions with her fortified the importance of the physician-patient relationship. It was important for her to receive care from someone she trusted. This put my preceptor and I in a tough situation. We ideally wanted her to have the biopsy to confirm the diagnosis and justify putting her on high dose steroids for a prolonged period of time; however, my preceptor has known this patient for a very long time. He knew that she is very set in her beliefs, and we would have to work with her to determine the next steps of care. There were multiple factors that led to her not wanting to get the biopsy. She would have to find care for her grandson the day of the procedure, she does not trust other healthcare providers, and she believes that the prognosis of her diagnosis is not in her or our hands, but ultimately in the hands of God. This patient fortified the fact that everyone makes their decisions based off of their own beliefs and experiences. As physicians, we should try our best to get to know our patients, their beliefs, and experiences, and more importantly respect them even if they are different than our own.








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