A patient case illustrating elements of communication as a tool for equitable care
Fellow, Medical University of South Carolina, 2022
Compassion. We all have an idea of what it is and what it is not. Yet we have trouble defining it. We know that it is vital to the quality of the patient experience. Yet, it is not standardized practice. Review of literature attempts to capture compassionate care as a process that moves beyond expressing feelings. It is based on logical thought and evaluation. It does not necessarily mean performing magnificent deeds, but it consists of minute actions in order to provide comfort for patients and their family1. There is a need for more systematic investigation into elements of compassionate care. It is paradoxical that we are in a time when we can diagnose, treat, and manage so much more than ever. Yet, the doctor-patient relationship is the most strained it has ever been2. How can we create systems and practices that are geared to restore patient trust in not only providers, but the medical system as a whole institution? Arguably, compassionate communication increases equitable care systemically through establishing trust and making medical knowledge more accessible for patients. The following case is presented to continue further discussion.
A 70 y.o. male with a past medical history of mitral regurgitation s/p mitral clip placement, heart failure, atrial fibrillation on anticoagulation, lung cancer s/p lobectomy, chronic obstructive pulmonary disease, and gastroesophageal reflux disease presented to the emergency department with worsening dyspnea on exertion. When we came to get the history from him, it was not long before he made his wishes known. He interrupted the list of questions we were throwing at him, stating with utmost indignance that, “I am not leaving here until I can walk more than 3 ft without losing my breath”. He went on to tell us that this had been going on since his Mitraclip ™ was placed a couple of months ago. Once he returned home after the surgery, he focused on recovering and remained largely inactive. However, as time passed, he noticed his level of dyspnea persisted throughout the day. He distinctly noted an acute worsening of his breathing after medication adjustments at a recent cardiology appointment. At that time, his losartan 50 mg daily was discontinued due to hypotension and his metoprolol was increased to 50 mg twice a day for better rate control. He denied any increase in cough or sputum production, fever, chills, chest pain, palpitations, or weight gain. However, he had endorsed orthopnea, which resulted in him sleeping at an incline in the front seat of his truck for the last 4 nights. Lastly, he endorsed worsening lower extremity swelling that only became noticeable that morning upon waking. The patient was confident that he was complaint with his diuretic regimen and had not noticed any change in urine output. As the interview went on, he became so worked up that he was out of breath. His physical exam was notable for a soft systolic murmur at the apex, an irregularly irregular rhythm, trace pitting edema of the bilateral lower extremities, and diffuse excoriation with self-inflicted scabs. The resident told him that we would be admitting him for further work up. As we headed upstairs, I could tell from the look on her face that this was going to be a difficult case.
His initial labs were significant for a BNP (a measure of volume overload) greater than 2000 and his complete metabolic panel showed evidence of prerenal azotemia. His chest X-ray was benign. The results of his echocardiogram remained largely unchanged from a month ago; his ejection fraction was still the same. However, there was mention of a significant decrease in severity of mitral regurgitation. We started him on a diuretic as well as a rate control for his atrial fibrillation in efforts to stabilize him while we went through plausible reasons for his dyspnea. These interventions required obtaining morning labs. The next day during pre-rounds the nurse came over exasperated, saying that our patient was very difficult. He refused his lab draws and was so verbally aggressive that a public safety incident report was filed. The resident thanked the nurse and placed another order and wondered out loud, “How are we supposed to do our jobs if he won’t let anybody near him?” Before we even rounded with the attending, the whole floor had already formed a bias that was not in favor of this patient.
As the resident presented his case to our attending, with all of the negative connotations, I was surprised to hear the attending’s determination to get our patient compliant during his stay here. What would be her technique to re-establish trust with this patient? We went into his room, and after the introductions, the attending asked why he refused the labs this morning. He said he was not informed that they were coming beforehand, and it was so early when they came. He felt that he had the right to know what the plan was. The attending nodded her head and apologized for the experience he had. She looked at the window and noticed some Keurig® cups and asked whether he was a big coffee drinker. He nodded saying that he drank coffee more than water. She agreed, being a coffee addict herself. She then went on to recommend a Starbucks drink that had just came out. He shook his head vigorously, saying he didn’t even like the coffee they offered here in the hospital and that he actually preferred gas station coffee. He and the attending then went on to have a whole conversation about coffee, and by the end we were all smiling. He even had some chuckles. When she told him the plan to manage his dyspnea, he was much more agreeable. Every day, the attending would stop by the gas station near her house and pick up a cup of coffee for the patient. We never heard about problems during morning lab draws again. We were able to adjust his medications and decrease his edema. Every day when I went to see him, his work of breathing was noticeably improved and he was eventually able to pass the walking test.
In reflecting on this patient’s story, it was clear the role communication played in managing his disease: it established trust. I learned that patient-centered care is just as important as, and arguably a requirement for, guideline-directed medical therapy. We could come up with the cure to cancer, but if a patient does not trust the provider offering it, then it is rendered useless. It was more than a conversation about a cup of coffee that got our patient to adhere to his management regimen. It took human connection. Regaining trust in the patient-doctor relationship is about appealing to humanity, which is not as complex or daunting of a task as one might assume. This patient’s readmission taught me that compassionate care can be implemented by actively seeking common ground. It creates a space where the patient does not have to be defensive. Evidence demonstrates that when a patient trusts their health provider, they are more likely to have more positive outcomes than the patient who is skeptical3,4. That requires intentionally listening to patients when they describe their present illness, to not only better understand what their values are, but also what motivates them. For this patient, it was mobility. He had mentioned quite frequently how his father had the same heart condition he had but is still functioning on his own. For the patient, his dyspnea had robbed him of his mobility and diminished his sense of independence. For others it might be their ability to communicate or engage in certain hobbies. René Descartes famously said Je pense donc je suis ( I think therefore I am); it was the fundamental truth that tied him to reality that made him feel human. Patients’ perception of their disease has a lot to do with their day-to-day.
Towards the end of his stay, I asked the patient whether there was a learning lesson from his situation that he would share with students. He looked at me and without a skipped beat, he said, “Communicate... you know I had called the office up to three times after the procedure? Not one person returned my phone calls.” I walked away from that room wondering how things would have been different if someone had spoken with him initially about his concerns. Unforeseen readmission to the hospital is an indicator or poor quality of care, hence the incentive for hospitals to prevent such events6 . What would have happened if the medical system had fostered dialog between provider and patient? For instance, what if that practice had virtual follow up visits with all patients who had underwent a procedure? Would my patient’s story have turned out differently?
When I think of health equity I think of a particular picture. It is the one of three different people trying to watch a baseball game. They are all standing on boxes to see over the fence, but there is a stark height difference. The tallest person can see over the fence and watch the baseball game just fine with or without standing on the box. The medium height person can see just above the fence, but they have to stand on their toes. The shortest person sits in a wheelchair and is unable to see above the fence, even though they have a box like everyone else. Equity looks like having the shortest person not only use two boxes, but also building a ramp for them, to make the view of the baseball field accessible. In this analogy the goal of equity is for everyone to have the same view. Further, each person could come to their own conclusions of what was happening in the baseball game. Well, the same thing goes for health equity. Access to information is vital for patient’s overall health and is often limited for certain people by literacy or language barriers. These are social determinants of health that often impede equitable health. A 2021 meta-analysis demonstrated that communication interventions (for example: teach back, decision aid, etc.) at discharge were significantly associated with lower hospital readmission rates6. As demonstrated above in this patient’s case, compassionate communication can be used as a ramp to make health care information accessible and equitable.
This case I hope sparks discussion, because at the end of the day what is worse than a broken heart is a broken medical system that does not hold itself accountable. Unfortunately lack of proper communication in the clinical setting is a systemic issue. Oftentimes it results in negative outcomes, such as lack of patient adherence7. Action needs to be geared towards the implementation of components of compassionate care. Research already indicates that empathy begins to decline during the third year of medical school,5 so in efforts to increase patient advocacy, it is important to teach medical students tools of compassionate care. Medical students are members of the health care team with essential roles because we have the most time to spend with patients. That is why it is encouraged to take ownership. While we may not necessarily conduct direct clinical care, we certainly can impact its quality.
1. Tehranineshat B, Rakhshan M, Torabizadeh C, Fararouei M. Compassionate Care in Healthcare Systems: A Systematic Review. J Natl Med Assoc. 2019;111(5):546-554. doi:10.1016/j.jnma.2019.04.002
2. Miles, S. H. (2004). The Hippocratic Oath and the ethics of medicine. Oxford: Oxford University Press.
3. Hu L, Bai L, Zhao S, Lu R. Analysis of Doctor-Patient Relationship in Post-COVID-19 Period: Perspective Differences Between Citizen and Medical Staff. Inquiry. 2021;58:469580211060300. doi:10.1177/00469580211060300
4. Birkhäuer J, Gaab J, Kossowsky J, et al. Trust in the health care professional and health outcome: A meta-analysis. PLoS One. 2017;12(2):e0170988. Published 2017 Feb 7. doi:10.1371/journal.pone.0170988
5. Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996-1009. doi:10.1097/ACM.0b013e318221e615
6. Becker C, Zumbrunn S, Beck K, et al. Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021;4(8):e2119346. Published 2021 Aug 2. doi:10.1001/jamanetworkopen.2021.19346
7. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834. doi:10.1097/MLR.0b013e31819a5acc