Can I Trust You With This? How Pistis Left My Toolbox One Day

Female patient sitting on gurney in hospital gown, low section

Editor’s Note: Be sure to check out the collection of articles in the March issue and our new blog content for more on the patient voice in medicine.

By: Martina Rosenberg, PhD, assistant professor, Department of Biochemistry and Molecular Biology, University of New Mexico Health Sciences Center. Dr. Rosenberg teaches mostly undergraduate biochemistry majors and non-majors, including students in the combined BA/MD degree program. She is interested in barriers of learning in the STEM disciplines.

The view from the stretcher in an ambulance racing towards the ER is not particularly intriguing or interesting. Yet, it was what I focused on. I was trembling, with numbed, aching limbs, and almost no ability to speak. I was frightened because I felt unable to breathe. The EMT was trying his best to keep me engaged. And although I couldn’t see him, by talking to me, he threw me a literal lifeline (thank you, nameless EMT). I knew he was watching by his persistent encouragement to count to 3 on every breath in and out. It was then that I realized that, by slowing down my breathing, the pain at least did not spread.

“Can you move your arm?” he asked. My arm came up a few inches. “See, you can control this!”

Of course! Acid/base homeostasis, the blood buffer–I teach this stuff! The feeling of absolute helplessness evaporated as I stopped hyperventilating.

I have the privilege to work with the editor-in-chief of Academic Medicine, and we were discussing a set of articles on the importance of patient voices and the consequences if they are muted.1 One article resonated with me in particular. In a personal story featuring an elderly lady being asked the name of her cardiologist, the value of respectful communication is showcased.2 Aside from preventing a potential error, it also revealed the fragility of the patient-physician trust relationship.

By the time I got to see the ER physician, I could mumble short responses.
“Ah, you threw up and then you panicked, which was throwing off your breathing,” she concluded.
“Uh-uh…did panic after couldn’t breathe,” I whispered.
“Well, I wasn’t there, but you made your blood acidic and that caused your symptoms.”
“Alkaline.”
“No acidic. You were hyperventilating.”
“Alkaline…less acidic!”
“No, low pH means more acidic.”
“Yes, but…hyperventilating makes blood more alkaline.”
“Why would you say that?”
“Le Chatelier. Exhaling CO2 makes blood less acidic”
“No, it is still acidic. In any case, we will run some tests and get you some intravenous saline. Do you have an issue with that?”

It bothered me. The physician made a mistake then covered it with attitude. With my ability to speak only slowly returning, I didn’t feel able to communicate smarter. Most patients probably are not as insistent about the blood buffer, and ER constraints leave little time for a conversation. Nevertheless, for me–the patient–several emotions intersected in this moment. I became a medical case, not a person (symptom A, do B), and I felt like a nuisance in the clean working of the ER machinery and in the physician’s routine.

Most likely, she was very knowledgeable in many aspects for her work. In this instance, though, my effort to understand what had happened to me was not acknowledged, and the importance of my need to understand trivialized. The tone of our exchange troubled me. But above all, I lost trust in her ability. If she was not willing to hear me and, on top of that, didn’t recall her fundamental biochemistry, would she make the best decisions for my health? What if she attempted to balance my “acidosis” making everything worse?

Luckily, in the end, no harm was done. I was not dependent on a family member speaking up and catching a near miss as in Johnson’s article,2 but I too wished that my physician had encouraged me to talk frankly. I was trying to solve this puzzle with her and, from my perspective, she wasn’t interested in what I had to contribute. If she had nurtured my participation, including my questions, we could have been allies working towards a common goal.

The experience made me rethink our goals when educating medical students–to teach them to practice as we would like to be treated. When the EMT listened and encouraged my input, he was giving me an active part in my recovery. In contrast, the physician was trying to move forward a protocol. Violating some of the core concepts of person-centered care mentioned in the article by Johnson, she neglected the power that open lines of communication harbor. I didn’t tell her more about what happened just prior to the incident. What would be the point?

Instead, I was left to wonder how I, as an educator, could urge my physician hopefuls to pay attention to rapport building as well as knowledge building. Is modeling enough? The roles of the patient voice beyond trust building are discussed in the March issue of Academic Medicine. Please, take a minute and cultivate your ability to listen.

References

  1. Sklar DP. Giving voice to patient-centered care. Acad Med. 2016;91:285-287.
  2. Johnson BH. Promoting patient- and family-centered care through personal stories. Acad Med. 2016;91:297-300.

 

* In Greek mythology Pistis was the spirit of trust, honesty, and good faith, and one of the good spirits who escaped Pandora‘s box and fled back to heaven abandoning mankind.

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