Striking a Balance in Patient Care

One of my earliest LP experiences was with a teenage girl who had just been diagnosed with Type 1 Diabetes. Her mother was with her, and they were both distraught over the diagnosis and were overwhelmed with trying to decide how to proceed. My LP preceptor, unaware of this dynamic, sent me in to take a HPI and get some background, and the girl quickly broke down crying as I tried to gather information about her situation. Her mother was answering every question that I directed at the girl, and I was struggling to get a clear picture of what they wanted out of that visit besides knowing that this diagnosis was clearly very upsetting to the both of them. I refocused the conversation on what the girl wanted, and she was eventually able to relay that her primary concern was how this diagnosis of T1D was going to affect her life. She saw it as a monumental shift in her ability to live a normal life, and so I spent the rest of my time with them trying to assuage some of those concerns and getting them to enumerate what they wanted and how best we could help. Eventually my LP preceptor came in, and the four of us established a plan of care and followup, including setting the girl up with a T1D support group for new diagnoses.

This patient care experience was very challenging for me, as I had to navigate both my own nervousness with being so new to this type of encounter as well as work to balance and manage a very complicated patient relationship and problem. By working slowly and not talking a whole lot, I was able to get the patient and her mother to arrive at some actionable steps themselves, and it made the second half of the encounter, when my preceptor entered, more manageable.

Throughout this year I think I’ve improved the most in patient care when it comes to knowing when to listen and knowing when to direct the conversation. Initially, as in the story above, I was all about listening to the patient and their story. I quickly realized that striking a balance between the patient-centered and physician-centered approach was crucial to both getting the information I needed as well as making sure the encounter was efficient and the patient had all of their concerns addressed (and not just the ones that were weighing most heavily on their mind). I’m naturally a problem-solver, so my gut instinct with every patient is to try to solve their problems – whether it’s offering advice or directing them towards next steps. I’m always trying to tie off each encounter neatly with a clear set of action steps. I have slowly been learning, and am still struggling to really grasp, the notion that not every encounter will result in a neat set of patient instructions and next steps that make everyone happy. Sometimes, as I have seen in clinic and in hearing with the patient panels, there isn’t a good solution and the only next steps are to continue with the status quo and reevaluate later on. I’m learning to put the problem-solving instincts to rest sometimes and just work on slow, gradual improvements to patients’ health.

In my interactions this year, the hardest patient population to care for are the noncompliant ones. Not only because their health progresses more slowly than their compliant counterparts, but because as a member of the healthcare team, it’s so hard for me to feel the empathy and compassion for this population that I feel for the compliant patients. It’s so easy to play the blame game and scold patients for their inability to take their medications or watch their diet, and yet this population is also the kind that is so easily lost from the healthcare system for exactly that reason – providers that spend the entire encounter scolding and preaching rather than pivoting to a new plan or a different approach. It’s still very much a work in progress for me, but coming to terms with these noncompliant patients and remaining compassionate in those encounters is so important to my future as a physician and I want to continue to focus on that aspect of my patient care.