The Road through Residency:

Follow-up as Needed

The stacks of charts on the desk begin to resemble an art deco building, twisting in so many levels upon levels. The nurse passes by and plunks another chart down on the stack that is accumulating in front of me.

Now my view over the edge of the desk is obscured, effectively locking me into this prison of paperwork — each chart carrying a story, each level unique unto itself. A fax of skilled nursing orders on the ground floor gives rise to a couple of medication refills on the second, followed by a request for handicap placard on the third.

Filling the hours between the patient bedside and intense study is the sea of paperwork across which I must navigate. It often seems like a daunting and fearful task, but today I am reveling in the paperwork, hiding behind this wall of parchment to avoid doing what I have to. My citadel of manuscripts is not enough to hide me forever, and before long, the nurse again passes by and slides a chart directly into my view.

“Your next patient,” she said.

The handle of the door seems cold as I grasp it, and I glance down at the collection of studies and tests in manila folders and beige files, cloistered together by a thick rubber-band. As I open the door slowly

I stop for a slight moment before continuing, angry at myself that I had forgotten to knock on the door. This simple pleasantry and etiquette, drilled so hard into my brain as a medical student, has long been forgotten in the heat of the moment.

As I enter the room, the slight frame of a woman greets me, her eyes bright, her cheeks sunken and sallow. I sit down at the desk with the computer jutting out at me from the wall, demanding my attention. I shake her and her daughter’s hands, and sit down on the swivel chair, pulling the computer in between us, like a gate closing between two old friends.

Electronic medical records are the wave of the future. They are supposed to make documentation, billing and patient data, readily accessible and easily portable. They can streamline the history and physical to a point-and-click parade. They can increase productivity and decrease cost, all in a package that opens with the click of a mouse.

At least that’s what I have learned from various articles in the newspaper, medical journals, and from the technological faithful. It reminds of those news reels and cliffhanger serials of the 1950s.

I remember watching re-runs of Commando Cody on TV as a child, thinking how wonderful the future would be with flying suits, rocket ships and flying cars. Today I suppose I harbor a little resentment that I still don’t have that flying car. Now, as EMRs are thrust upon us, I wonder about how I’ll feel a decade from now about these “flying machines.”

Maybe they will bring a world of streamlined health care, and easily accessible medical records from across the globe, but today all I can see is a computer screen where my patient’s face should be.

I ask her how she’s feeling. She says she feels fine. I ask her about pain. No pain. I ask her about chest pain, shortness of breath, fever, chills, abdominal pain, bleeding. No, no, no, no, no and no, she said. I don’t feel very useful at the moment. Her daughter relates that no more chemotherapy is planned, and they are considering hospice.

Slowly, the once-vibrant lady that I saw three years back is now withering away from the mass in her pancreas that has invaded beyond the borders of a normal organ.

At the sound of her daughter saying hospice, my heart sinks. Not so much because I don’t feel this is a good decision. she would be comfortable in their care, but because I feel the unfairness of this situation more so than usual.

So many patients we see are quite ill from poor choices in life, angry at the world, themselves and us. And here this kindly lady, surrounded by a family who sings her praises as she walks through the hallways, is simply one of the sickest patients I have had the privilege of caring for. There is a saying I hear muttered throughout the hallways of the hospital, “Bad things always happen to nice people.”

I excuse myself to speak with the attending physician. There is nothing to discuss, but I present the patient to the attending physician from the beginning. I try to be thorough, feeling that treating her like a complex medical case is in some way being respectful. There is nothing complex about this, really. There simply is nothing more to offer at this point, except for supportive care, a synonym for everything else that doesn’t solve the problem.

I go back to the room and talk with the patient for a while and reminisce about our time together. I have seen her extensively over the past few years and have enjoyed our meetings. She smiles, shakes my hand, and walks out of the office with her daughter, who is calling to make arrangements for hospice at home. I hope to see her again, but I know deep down I probably won’t. I move back to the computer screen and type my note for the day, a simple note:

“Patient, 75-year-old with pancreatic cancer. Met today to discuss plans with patient and daughter. Plan for hospice at this time. No further invasive interventions. Follow-up as needed.”