Medicine from the heart . . . Hugh Silk

On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.

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My turn again—I have been so flush with submissions that I have not written for awhile. However, occasionally I need the outlet as well, so here are some thoughts after a very engaging experience with a longstanding patient.—Hugh Silk, MD

On Patience

I was recently reminded of the power of the wisdom that mentors pass along: listening is a form of treatment; the trick to primary care is to be patient; relationships enhance care more than we know.

A patient of mine recently became pregnant. She is a diabetic and despite her recent sincere efforts to get her sugars under control for this pregnancy, they were still quite high. On her first visit to the high risk OB clinic at nine weeks she was diagnosed with a miscarriage. She was having a difficult time with the news. One minute, they were admitting her to aggressively help her get her sugars under control and the next minute they were telling her that there was no heart beat so there was no need for an admission.

I was called. "Dr. Silk, we need you to talk to your patient." Three different people had done an ultrasound to confirm there was no heartbeat and that this was not a viable pregnancy. "Can you convince her? We feel she needs a D and C."

I spoke to her over the phone. What did she feel was going on?

"I can't accept that this has happened. I still feel pregnant; I am nauseous, my breasts are tender, I am sure I am pregnant. I have no cramps, no bleeding. I have miscarried before; it did not feel like this."

Who was I to argue? I have seen crazy things happen in this situation and resentment against a provider mounts quickly as the one who broke the bad news callously, the one who did not listen to what the patient's body was saying all along, the one who needed to shepherd the patient through whatever was going to happen.

"I am very worried about your pregnancy. Everything I have heard from the doctors says that your pregnancy is not going to make it. But I also hear you. You feel there is a chance. That chance may only be 1 percent or less, but you need more time."

"Yes, I need to be sure."

Some people, many people, may have been sure with three ultrasounds. She was not. And she was my patient. I was not offering false hope. I stressed that I was very concerned but that we could check her pregnancy hormone blood levels today and then again on Monday.

She was grateful.

I asked her to prepare for both outcomes. I told her I was most concerned for a miscarriage.

The weekend passed and her number went up minutely. I told her the news. She still felt the same physically. She was not having any bleeding or cramping; she still felt pregnant. She still was not convinced. She had wanted this baby badly. We could repeat the test in a few more days. She needed more time. She was not convinced yet. I did not see harm in waiting a bit longer. I explained the grim situation to her. I did not talk about praying for a miracle—I did not want her to feel like she had not prayed hard enough. I have had two patients in my career who were told they had miscarried by their OB providers, only to have the pregnancy be okay, and then they transferred to me deeply frustrated. I knew that would not be the case here at this point. But I also knew she was not ready. At least, she was not ready to admit that out loud.

We talked two days later. This call was different.

"The lab test number didn't go up, did it?"

"No," I replied.

"I knew it. I still feel pregnant but I know I am not."

I let her talk. She didn't need me to say anything. She didn't need my medical expertise to confirm what she knew. She cried. She vented. She talked about the past and the future. She talked about her daughter, her partner, and the baby that would not be.

She came in to get some misoprostol. She had a heavy bleed within 24 hours. She is moving forward. Slowly. As expected. I don't know if this could have gone any better for her—this awful thing, this hard thing. But I think it went better than it was about to go when I first talked to her. I think it went the way she could tolerate it to go. And for that I am grateful. We can start to plan soon for the next time. Our trust in one another deepened. Our relationship is a little stronger.