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As soon as my stethoscope makes contact with her chest wall, I can hear the wheezing. Not quite as loud as last time, but still there, persistently announcing itself with every exhale. I step back and look into her brown eyes, which are searching mine, filled with a mixture of hope and fear.
"How is your breathing?" I ask Greta (name changed).
"A little worse," Greta admits. She goes on to tell me that her pulmonologist recommended she be evaluated at the university hospital for a lung transplant. He also prescribed her a new medication, which he told her might slow the progression of her pulmonary fibrosis for a while. Greta confides in me that she has the medication at home but didn't start it -- she is nervous about the side effects.
I listen to Greta's fears and ask her if she thinks she could give the medication a try and stop it if she cannot tolerate the side effects. She considers this for a second and then tells me she'll think about it.
As our visit ends, I encourage Greta to carve out some time to take care of herself. Greta's entire world is caring for others -- her ailing mother, her children who are now fledgling adults, and the patients she manages as a home care agency owner. Greta laughs, and the smile lines around her eyes become visible for the first time today. After some prodding, Greta commits to spending one hour a month just for her.
That night, after my kids are in bed, I sit in my home office, finishing up the documentation for the day and reflecting on my encounter with Greta. I look at the diagnosis, see that I've placed no orders, and think about the level of medical decision making. I realize that to coders and insurance companies, the most the visit would count as is low complexity. And all too often, that code is enough to convince me that I actually didn't do anything and that the patient is no better off for having seen me.
As a primary care provider in a location that thankfully has good access to specialist services, this is often a pitfall for me, as I suspect it is for many PCPs. I'm not the interventional cardiologist placing the stent that saves the heart or orthopedist who can offer joint lubricant injections that alleviate chronic pain. I sometimes fall into the trap of feeling as though I am a conduit for my HMO patients -- nothing more than a signpost pointing the way to the appropriate physician who can fix the problem.
Thankfully, I was recently reminded by a coach that caring is half of what we, as physicians, are called to do. While this is obvious and for most of us a primary motivation for a career in healthcare, it is something I had forgotten in the midst of RVUs [relative value units] and Press Ganey reviews and the ever-increasing number of electronic medical advice requests.
For the past few years, Greta has reminded me at each visit that I saved her life, a statement I have silently discounted to myself in my head. Early on in the pandemic, she had contracted COVID, and I had recommended she go to our local emergency department (ED) to receive a monoclonal antibody infusion. With her history of pulmonary fibrosis, this is something I am certain any physician would have recommended.
Recently, I have come to see her praise in a new light. She saw that I cared, and that I took the time to listen, something she has not always received from her specialists.
Long before I became a physician, I was a tech in the ED. My favorite part of that job was bringing blankets from the warmer to patients -- it was remarkable how that small kindness could ease the pain or uncertainty a patient was feeling. Being a physician requires much higher cognitive tasks but still allows us the opportunity to comfort or be with our patients in their suffering. Although there may not be a billable code we can attach to it, it may be a key part of the care the patient needs. And it may increase our sense of fulfillment in this demanding field.
Monica Ball-Zondervan, MD, is a family physician.
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