My 10 o'clock patient's name is Maria*. Her chart has three "health maintenance" flags that are bright red, indicating that she is more than 3 years overdue for a mammogram, more than 6 years overdue for a Pap smear, and has never had colorectal cancer screening. My job today is to close those care gaps.
But when I get to the exam room, Maria is stressed. Her blood pressure is 160/80, and the medical assistant is inflating the cuff to take it again. Maria meets my eye imploringly. "I just hate coming in here," she says, and then bites her lip in chagrin. "Nothing personal, I mean."
I channel my most calm self and shoo the medical assistant out of the room. "Let's not worry about the blood pressure right now," I say. "Tell me what's going on in your life."
An Array of Problems
It is a litany of issues. She is stressed out at her work. Her supervisor is "a jerk," she says, without elaborating. An old boyfriend is messaging her and she doesn't want to talk to him. One of her kids is flunking geometry, and she knows she should go in to meet with the teacher about it, but she hated school and she always feels like she's in trouble when she pulls up in front of the high school, even just to pick up her kid. I can feel my resolve to get that mammogram draining away.
These encounters -- in which physicians take care of patients but don't order the needed screening tests -- are often characterized as being a failure of organization and agenda-setting, as though a truly disciplined physician would be able to redirect the patient to suddenly caring about getting her mammogram done.
I can see the four previous orders in the electronic medical record representing the potential mammograms of years past and I know that while I might be able to get Maria to pretend she will go and accept the order, she won't follow through, and in fact, might not come back at all. I think the underlying cause is more than just disorganization. In many cases, I suspect it is mistrust and fear due to some kind of trauma.
This trauma can come from a wide variety of places. Take an example from one extreme end: a friend of mine who was raped. She tells people that she is safe now; she's lucky, she survived. But I know that she got Cs in college because she was afraid to go to office hours and be alone in a room with the professor. She won't take her trash out alone after dark. She sleeps with the lights on. One night, we watched a crime drama together, a rape and torture story that ended with a dramatic takedown, the suspect packed away in handcuffs, the victim tucked into the back of the attractive FBI agent's SUV while he told her, compassionately, that she was safe now. As the credits rolled, my friend spoke up.
"They always make it seem like that's the end," she said ruefully. "Like they put you in the car and say, 'You're safe now, and it's over.' They don't talk about the after." The after, of course, encompasses the limitations in her life now.
When she says this, I think of patients like Maria.
Effects of Trauma
Researchers know that sexual assault survivors are not only less likely to present for routine care and , but also tend to have a , which can be associated with . While all of these topics would merit further study, it is reasonable to deduce that survivors of other types of traumas -- whether personal or rooted in historical mistreatment -- might also be less likely to show up in a medical office unless they absolutely have to.
The difficult work of optimizing "care gaps" for patients with fear and mistrust also needs to be studied in more detail. But often I notice that reminding these patients, over and over, only seems to drive them further away.
Today, I decide I will talk to Maria a little more. About the people in her life who she can talk to, and the things she is proud of about her life and her kids. We go over the 15-minute limit, and I still haven't clicked the button for the mammogram.
Maria tells me about her unhappy childhood. Her father used to march her to the doctor's office every few months and demand that she be weighed because he thought she ate too many sweets. There were a lot of lectures about self-discipline. About how she should "do better." No one ever asked her what need she was trying to meet with the food. No one ever told her that they could tell she was trying, so hard, all on her own.
Devising Creative Alternatives
So that's what I'm going to tell her today. I can see she's working really hard to succeed at work despite her demanding supervisor, and to advocate for her daughter at school. I congratulate her for just making it in the door to her appointments, since coming to a doctor's office is obviously stressful. Could some of our visits be done over video -- would that be easier for her? She takes a deep breath and agrees that it probably would.
"I didn't know we could do it that way," she says, softly.
I make some notes for the next visit. Her friend who she grocery shops with -- might she be a good support to accompany Maria for the mammogram? Could Maria do her own self-swab for HPV instead of a Pap? Can we think creatively about alternate ways to meet her healthcare needs?
It took me 35 minutes to see Maria, and she leaves with zero health maintenance items checked off her list today. But she hugs me, impulsively, and says I am the only doctor she has ever felt comfortable with. This is not because I used high-tech medicine to cure her, but because I chose to ignore the electronic reminders for one day and reach out to the human being across from me. I can bring up the health maintenance items in a few weeks or months. For today, my only goal was to get her to return.
Of course, the screening tests I mentioned are important. They save lives. But when patients seem resistant to getting them done, we need to do better in looking beyond the red "care gap" flags and start to learn the story of the person before us, so that we can more effectively meet their healthcare needs, both in the short and long term.
*The patient's name has been changed.
is associate professor of family medicine at Brown University's Warren Alpert Medical School in Providence, Rhode Island. She researches health disparities for patients with a history of trauma and/or PTSD.