There’s nothing better than sitting down with a patient, going though an entire visit, and collaborating on a well thought out plan that meets everyone’s expectations. Shared decision making is a wonderful and necessary concept in modern patient care. Paternalistic attitudes are fading away in the medical community as the next generations of doctors continue to get educated on how to manage patients who are very knowledgeable and yearn to be active participants in their care.
I often debate whether I should be calling patients by their first name or last name. The gregarious part of me that wants to create a personal family atmosphere thinks first names are better. The professional, respectful part of me sticks to using Mr. or Mrs. The age of the patient also affects my decision. I’m 34, and will not hesitate to use first names with patients younger than me. With a rapidly aging population, most of my patients are much older, and formal salutations are the norm. For middle aged patients, I’m usually torn. Sometimes they’ll just tell me to use their first name. If the issue never comes up, I arbitrarily will switch between formal and informal, depending on my mood, my recollection of their personality, the lunar phase or potentially any other random irrelevant thought process.
Mrs. Silva (name changed) , who despite efforts to hide her age wearing bright ill fitting outfits and loud hats, was definitely 68 years old. No matter how hard she tried to look younger, I always used formal salutations.
“Mrs. Silva, what’s going on with the diabetes?”
“Well Dr. Hossain, I gotta be honest with you, I’ve been cheating more this past month.”
“Mrs. Silva, How’s Mr. Silva doing?”
“Oh he’s good. I keep telling him to make an appointment here. He won’t listen to me.”
“Mrs Silva, did you get your mammogram done?”
“Oh yeah! it’s not due until next month. I’ve already got it scheduled.”
“How’s the breathing Mrs. Silva?”
“It still stinks. I’m still always short of breath and no I haven’t stopped smoking yet Dr. Hossain. But I’m really gonna try these next few months.”
“Mrs. Silva, are you still coughing up a lot of junk?”
“Yeah Dr. Hossain. I can’t seem to shake this cough, even after the antibiotics. And I could’ve sworn I thought I saw a spot of blood in it.”
Soon after mentioning the last complaint, Mrs. Silva was diagnosed with Non small cell Lung cancer. Shortly after, it was discovered she had metastasis to the brain. Because of the myriad of oncology, surgery, neurology, neurosurgery, radiation oncology appointments, and 2 hospitalizations, she wasn’t able to make it for an appointment to my office. A few times she tried to schedule an appointment but cancelled. Throughout the process, we spoke on the phone a few times, and she remained delightfully optimistic and didn’t express any specific needs from me.
Finally, after 6 months, Mrs. Silva made it our office at the urging of her oncologist.. She had lost a great deal of weight and gave up the makeup and bright outfits for more demure, darker and simpler clothing. She lost all her hair but had a closet full of hats for this occasion. Since she was a resident clinic patient, the case was presented to me and I was well aware of all these details even before I walked in the room. I knew I would not be seeing the same Mrs. Silva.
I knocked on the exam room door and with a lump in my throat, ready to discuss some difficult issues.
“Hi. Dr. Hossain.”
I don’t recall what exactly went through my mind when I saw Mrs. Silva in front me, a shell of her former self. But I remember beginning the visit by trying to smile and saying,
“Hi Lily, how are you doing?”
I routinely hear from relatives, how the medical system in my native country of Bangladesh is terrible. As a third world country, access to care, diagnostics and medications is a difficult everyday reality, especially for the millions in poverty. But even for those with money and access to the best care, my relatives often insist they don’t know what they’re doing. They complain to me and encourage their sick family members to find a way to get to a country with more advanced care. They tell me these things as I think about how physicians in 3rd world countries are excellent diagnosticians because they don’t rely as much on imaging or even blood tests. I think about how, despite our advanced technology and monetary investment in healthcare, our mortality data lags behind many other industrialized nations. I respect my elders and their belief in our healthcare system, and graciously accept their praise of my “expertise,” while secretly harboring skepticism towards their beliefs.
Last year, I saw a 44 year old gentleman immigrant from Bangladesh who presented as a new patient. He had a fairly long list of medical problems for a young man. He had diabetes mellitus requiring insulin, he had a history of a coronary artery disease, high cholesterol, anxiety and depression. He was a pleasant gentlemen, who had been doing well without any particular chief complaint. His primary concern was getting refills on his medications. For the past 6 months, his physician in Bangladesh had been mailing them, but realized this was a dangerous proposition after 1 shipment was delayed and he missed a few doses. I looked at his medication list and didn’t recognize a single name except aspirin. After doing some research online, his deciphered medication list included an Angiotensin receptor blocker (ARB), a beta blocker, a statin, an ssri for depression, and a long acting insulin. It seemed like a very sensible evidence based regimen, and by all accounts had kept him symptom free, without any recent hospitalizations.
Despite my preconceived notions about his health care in Bangladesh, I was thrilled at how well he was doing. As we were concluding the visit and I began renewing his medications, the dreaded “I” word reared its ugly head. He was a working man but unable to afford insurance yet. Quickly, I realized he would not be able to afford the ARB. I suggested an ACE inhibitor, which he recalled getting a cough from. But he would take it. We found the same beta blocker, except it wasn’t an extended release version, so he’d have to take it twice a day. He was on a brand name statin but now would have to settle for something less efficacious. The SSRI needed to be changed to something cheaper, despite its success. The insulin, despite being generically available here would be far more expensive than back home.
In the spirit of full disclosure, I was embarrassed to tell my countryman, some of his new medications maybe inferior to what he was already on. He had a perplexed look on his face, waiting for an explanation. I have a hard enough time trying to cogently describe to a medical student or a resident, how our healthcare system operates, let alone an immigrant lay person. I couldn’t give him a straight answer, except to reassure him, we would make this current regimen work. His last question for me was whether he should finish the last 10 days of these 3rd world medicines. My 1st world expert training and sensibilities suggested yes.