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When medicine isn’t enough: Establishing a therapeutic relationship

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

I spent the last two months on my internal medicine rotation. Medicine is an interesting clerkship because we see medically complex cases, but also because we get to spend a lot of time with our patients. Patients can be in the hospital for days or weeks, and we have sustained exposure to them on a daily basis.

I developed good relationships with many of my patients, but one in particular stood out. I’ll call him Bill. Bill was sort of a stereotypical big, blue-collar, somewhat intimidating guy, but he ended up being easy to talk to. He came in to the hospital complaining of shortness of breath. His diagnosis was easy – he was having a congestive heart failure (CHF) exacerbation.

Heart failure is a term that encompasses many different conditions, but the fundamental problem is the heart is not beating properly. Without an adequate heartbeat, blood does not circulate well throughout the body. As a result, fluids can get backed up, leak out of the vasculature and pool in the lungs. The fluid buildup caused Bill to feel short of breath.

Bill presented with an uncomplicated CHF exacerbation, so we diuresed him (meaning we gave him medications that caused him to pee out the excess fluid). He no longer had any issues breathing after that so we sent him home.

After his discharge, I continued to see other patients without thinking about Bill. He was an open and shut case from a medicine perspective. But a few days later, my team got a call from the ED. Bill was back with another exacerbation.

CHF is a chronic condition with no cure, but can be well managed with medications and a low-sodium diet. Bill was not consistently taking his medications, nor did he follow his diet.

Admittedly, this wasn’t entirely his fault. He lived in a shelter where the diet was whatever was provided, and he mentioned that it was difficult to keep track of his medications. But he was still making choices that negatively affected his health. For example, he had just eaten an entire party-sized bag of pretzels. As you might imagine, party-sized pretzel bags don’t fit into a low-sodium diet. I wanted to understand why he ate them, and hopefully get him to stop.

Over the next several days, I spent a lot of time with Bill. As it turned out, we got along well. We talked about his life, about medical school, and even watched "The Dark Knight" on TV. He also tried to set me up on a date with my attending, which, despite being well-intentioned on his part, was one of the more awkward moments of my life.

During this time, Bill’s attitude towards his health started to change as well. When I had first asked him about why he was eating poorly, he responded angrily, saying, “I’m a man. I’ve given the orders my whole life. I’m in charge and I can eat whatever I want!”

But after I repeatedly brought it up amidst our other conversations, his attitude changed. The last day of the rotation, he finally told me, “You know, you’re right. Those pretzels f***ed me up. I’m not eating those anymore. And I’m going to take my medicines.” This was a breakthrough. He had finally admitted that he could do better and committed to doing so.

I was later told that this breakthrough was because I had established a “therapeutic relationship” with Bill. Essentially, he was more likely to follow my medical advice because he liked and trusted me.

Bill’s case made me think about how we as physicians approach patients who make poor health decisions. In my experience, there are two common schools of thought. One is that patients should be held responsible for their decisions. We can address medical conditions in the hospital, but we can’t force them to take care of themselves. If they don’t, it’s largely their problem.

The second line of thinking is that patients face crippling structural challenges. In a sense, patients can’t be held responsible for their decisions because their social situation dictates their poor decision-making. Their decisions are our problem.

The reality is likely somewhere in the middle. As health-care providers, we have to figure out how to set people up to succeed. But individuals have to make the decision to take care of themselves (starting with not eating salt-laden pretzels).

I would like to think Bill went on stay true to his word and change his diet. Patients don’t always follow instructions, but a therapeutic relationship can certainly help.

Akhilesh Pathipati is a third-year medical student at Stanford. He is interested in issues in health-care delivery.

Photo by nathanmac87

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