Late one Thursday afternoon, toward the end of a hectic day of back-to-back patients, I stared through weary eyes at an unfamiliar name in the electronic record’s clunky blue font. The name belonged to an older woman who was last seen in clinic 6 months ago. She had uncontrolled diabetes, hypercholesteremia, and hypertension. She had immigrated to the United States from Jamaica 20 years ago without the benefit of a formal education. Somewhat frustrated that my last patient wouldn’t be easy, I furiously scribbled her history and a few lab findings onto a wrinkled sheet of printer paper before knocking on the door of her exam room.
On the other side of the door sat a woman, old but not elderly, the gray hairs just starting to outnumber the brown. She clutched a small, weathered purse between crossed arms. While her gaze was locked on the white tile floor beneath her feet, I introduced myself to her forehead, our eyes never quite meeting.
“I’m only here because my daughter is a nurse and she forces me to come,” she said matter-of-factly in a Caribbean accent.
“Are you still taking the metformin you were prescribed?” I asked.
She quickly replied, “I tried that stuff, and it made my bones hurt. I don’t think it’s good for me.”
“What about the atorvastatin or the valsartan?” I asked.
“I’ll never take a statin, but I do take the valsartan sometimes when I feel stressed.”
My breath became rapid and shallow with frustration, as if the day in clinic had been a marathon and breaking through to this patient was the last 100-meter sprint before the finish line. Despite the clinic thermometer always being set to 70 degrees, the air in the cramped exam room felt thick and suffocating.
Why won’t she open up? I thought to myself, staring at the patient whose eyes were still fixated on the floor.
Glancing at her lab values, with the ominous number 9.8 next to HgA1c, I could not help but think about what circumstances had led to the patient getting to this point. The last 100-meter stretch of the marathon was no longer a straight and narrow path, but rather one that branched out in multiple directions—the finish line looking different depending on which path I chose.
I could have chosen the straightest path, the one that would have gotten me out of the clinic and on my way to my studies the quickest. But what would the finish line have looked like on that path? Would it have been one where we were rewarded with well-managed and stable chronic health conditions? Rather, I realized, I could choose to take the more winding path—a path covered in roots and unfamiliar terrain, one that would make reaching the finish line a more treacherous undertaking. I thought, the finish line at the end of that path may not be the quickest to reach, but it may be the one the patient needs to reach.
“You mentioned you take the valsartan when you’re stressed. What did you mean by that?”
She sat there quietly for a few moments, nervously twiddling her thumbs. Her shoulders slumped down as her eyes, puffy and red, met mine for the first time.
“Well,” she started, “about 7 months ago my niece and her two daughters were killed in a car accident. I think about it sometimes, then feel like my blood pressure is going up, and I take one of my blood pressure pills. I hate takin’ pills so I gotta be feelin’ real bad to take one.”
The thick, suffocating air filling the cramped exam room was sucked out in an instant, replaced by the chill of guilt. Going into the encounter, I was pondering the quickest route to the finish line, the one that benefited me the most. The path that I, no we, needed to take was then soberingly obvious.
Navigating the maze of roots and debris covering this new path to the finish line, careful not to twist an ankle, I expressed my deepest condolences to the patient as well as my gratitude for her willingness to discuss her circumstances. Tears welled up, and she cried quietly for a few moments before retrieving a tissue from the weathered purse she no longer was clutching. The new path we had decided to take, albeit a more arduous one, led to a shared finish line that would reward us with a holistic understanding of the medical and nonmedical determinants of this patient’s health. This was the shared finish line that I would now strive for with all my patients, no matter how the marathon had progressed, and no matter the path needed to get there.
Note: Some details of this patient encounter were changed to preserve patient anonymity.
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