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Roe v. Wade overturned: A family medicine resident reacts
I remember how small and shy she looked, curled into herself in her too-large hospital gown. I remember thinking that it was autumn, and she should have been at her first homecoming dance, not sitting in the ER staring mutely at the hospital-issued safety socks on her feet. Her mother, puffy-eyed from crying, was sitting on the bed beside her, stroking her hair.
Together, my patients and I talked about the pregnancy. She told me how scared she was, how she didn’t want to “kill her baby”, but that she also wasn’t sure she could take care of a child. She told me that she was terrified of childbirth, that she didn’t want her friends at school to know and to judge her. We talked about how she was a victim; how she was an innocent child, too. I reassured her, and her mom emphatically agreed – her body was still her own.
The man who hurt her did not take that from her. She could make any choice she wanted, and it would be the right choice.
Eventually, she was able to make a decision which was best for her. I don’t know what became of her, but I hope she is well now, and I hope she’s thriving and happy. I also hope that she doesn’t see the news about Roe v. Wade and feel stripped of her personhood, as many women did.
When I heard about the Supreme Court decision I thought of her, and how important our conversation was to the trajectory of her life. I wondered if across the country these conversations might be silenced, and patients might be left to navigate this important facet of their health alone.
Some version of the conversation I had with my young patient occurs in exam rooms across the country countless times a day. Sometimes these conversations are cut and dry. Other times, they are accompanied by heartbreak and tears.
These conversations are common – one in four women in the United States have had an abortion. I have had many friends who were faced with deciding what to do after an unexpectedly positive pregnancy test. The reasons were different for each person – one was raped at a party, another’s birth control failed, the boyfriend of a third friend wouldn’t wear a condom – but the underlying sentiments were the same for each woman. They thought: “This is a difficult choice, but it’s a choice I’m ready to make. I’m not ready to have a baby at this point in my life.”
My friends talked to their doctors, who assisted them in making an informed choice. Some of them chose abortion. Others chose to deliver their baby. All were helped along in their decision by a physician who was there to support them and assist them in making a well-considered choice for their individual circumstance.
Economic and health consequences of restricting access to abortion
The facts are clear: Nearly half of all pregnancies in American women in 2011 were unplanned, and about 4 in 10 of them ended in an elective abortion, according to the Guttmacher Institute.1 Restricting access to abortions does not stop abortions from happening; it limits the opportunity for women to seek advice from trusted friends and professionals and it reduces access to safe abortions.
The people who will be most harmed by these restrictions are the most socially and economically vulnerable. Wealthy, mobile women with the ability to travel to other states or countries will always be able to access abortion care; low-income, work-tethered women and women with other children to care for at home will struggle to do so.
Denying women abortion services puts them at increased risk for lifelong, multigenerational economic hardship. Women who sought abortions but were unable to obtain them experienced an increase in household poverty which lasted years relative to women who were able to receive an abortion, according to the authors of The Turnaway Study.2 They were less socially, geographically, and economically mobile, and were less likely to go on to receive a higher education.
In a country where citizens do not have paid maternity leave, affordable and accessible childcare services, or universal health care, raising a child is an enormous financial burden. Women who are denied abortions also are much more likely to end up as a single parent, shouldering that burden alone.
Additionally, low socioeconomic status is associated with increased all-cause mortality. People who live in poverty are disproportionately affected by diabetes and other chronic health conditions, and have lower life expectancies overall.
The reversal of Roe v. Wade is not only going to lead directly to patient death by decreasing access to safe abortion, causing women to pursue unsafe alternatives; it will also indirectly result in more women being driven into and remaining in poverty and suffering the health consequences.
In addition to risking a woman’s life medically, pregnancy also significantly increases that individual’s risk of being a victim of intimate partner violence. The number one cause of death in pregnant women is homicide, most often by their sexual partner, said an article published in Nature in 2021.3 Therefore, restricting a woman’s ability to control if and when she has children could put her at risk for death from serious pregnancy-related complications and unsafe abortion consequences and increase her likelihood of dying by domestic violence.
Patient-physicians interactions are changed
As a physician I hope that I am able to convey my intense respect for and support of a woman’s autonomy into every family planning visit I conduct. Unfortunately, this ruling will not only have an immediate impact on the lives of women across the country – it will also alter the way many of us interact with our patients on a day-to-day basis. When patients can report doctors to authorities in some states for offering terminations, and doctors can report patients for seeking them, there will be absolutely no trust in the therapeutic relationship.
With this ruling, the content of private and protected conversations between patients and their physicians will be subject to censure and potentially criminal consequences.
Regardless of where I eventually practice medicine, I should not be in the position of talking to a patient and telling them that they do not have any agency over their body unless they have the money and resources to travel to a state where abortion is legal. I should not have to tell a child that she must carry and birth another child just to appease the often-fickle whims of lawmakers.
The conversation I had with my pediatric patient was important to her health and to her future, and she deserved to have the chance to discuss her feelings with a trusted physician. Every woman has the right to make her own decisions within the sanctity of the exam room, not from the distance of a courtroom.
Dr. Persampiere is a resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
References
1. Unintended pregnancy in the United States. Guttmacher Institute. 2019 Jan 9. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states
2. Foster D et al. The harms of denying a woman a wanted abortion - ANSIRH. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf
3. Subbaraman N. 2021 Nov 12. Homicide is a top cause of maternal death in the United States. Nature News. https://www.nature.com/articles/d41586-021-03392-8
I remember how small and shy she looked, curled into herself in her too-large hospital gown. I remember thinking that it was autumn, and she should have been at her first homecoming dance, not sitting in the ER staring mutely at the hospital-issued safety socks on her feet. Her mother, puffy-eyed from crying, was sitting on the bed beside her, stroking her hair.
Together, my patients and I talked about the pregnancy. She told me how scared she was, how she didn’t want to “kill her baby”, but that she also wasn’t sure she could take care of a child. She told me that she was terrified of childbirth, that she didn’t want her friends at school to know and to judge her. We talked about how she was a victim; how she was an innocent child, too. I reassured her, and her mom emphatically agreed – her body was still her own.
The man who hurt her did not take that from her. She could make any choice she wanted, and it would be the right choice.
Eventually, she was able to make a decision which was best for her. I don’t know what became of her, but I hope she is well now, and I hope she’s thriving and happy. I also hope that she doesn’t see the news about Roe v. Wade and feel stripped of her personhood, as many women did.
When I heard about the Supreme Court decision I thought of her, and how important our conversation was to the trajectory of her life. I wondered if across the country these conversations might be silenced, and patients might be left to navigate this important facet of their health alone.
Some version of the conversation I had with my young patient occurs in exam rooms across the country countless times a day. Sometimes these conversations are cut and dry. Other times, they are accompanied by heartbreak and tears.
These conversations are common – one in four women in the United States have had an abortion. I have had many friends who were faced with deciding what to do after an unexpectedly positive pregnancy test. The reasons were different for each person – one was raped at a party, another’s birth control failed, the boyfriend of a third friend wouldn’t wear a condom – but the underlying sentiments were the same for each woman. They thought: “This is a difficult choice, but it’s a choice I’m ready to make. I’m not ready to have a baby at this point in my life.”
My friends talked to their doctors, who assisted them in making an informed choice. Some of them chose abortion. Others chose to deliver their baby. All were helped along in their decision by a physician who was there to support them and assist them in making a well-considered choice for their individual circumstance.
Economic and health consequences of restricting access to abortion
The facts are clear: Nearly half of all pregnancies in American women in 2011 were unplanned, and about 4 in 10 of them ended in an elective abortion, according to the Guttmacher Institute.1 Restricting access to abortions does not stop abortions from happening; it limits the opportunity for women to seek advice from trusted friends and professionals and it reduces access to safe abortions.
The people who will be most harmed by these restrictions are the most socially and economically vulnerable. Wealthy, mobile women with the ability to travel to other states or countries will always be able to access abortion care; low-income, work-tethered women and women with other children to care for at home will struggle to do so.
Denying women abortion services puts them at increased risk for lifelong, multigenerational economic hardship. Women who sought abortions but were unable to obtain them experienced an increase in household poverty which lasted years relative to women who were able to receive an abortion, according to the authors of The Turnaway Study.2 They were less socially, geographically, and economically mobile, and were less likely to go on to receive a higher education.
In a country where citizens do not have paid maternity leave, affordable and accessible childcare services, or universal health care, raising a child is an enormous financial burden. Women who are denied abortions also are much more likely to end up as a single parent, shouldering that burden alone.
Additionally, low socioeconomic status is associated with increased all-cause mortality. People who live in poverty are disproportionately affected by diabetes and other chronic health conditions, and have lower life expectancies overall.
The reversal of Roe v. Wade is not only going to lead directly to patient death by decreasing access to safe abortion, causing women to pursue unsafe alternatives; it will also indirectly result in more women being driven into and remaining in poverty and suffering the health consequences.
In addition to risking a woman’s life medically, pregnancy also significantly increases that individual’s risk of being a victim of intimate partner violence. The number one cause of death in pregnant women is homicide, most often by their sexual partner, said an article published in Nature in 2021.3 Therefore, restricting a woman’s ability to control if and when she has children could put her at risk for death from serious pregnancy-related complications and unsafe abortion consequences and increase her likelihood of dying by domestic violence.
Patient-physicians interactions are changed
As a physician I hope that I am able to convey my intense respect for and support of a woman’s autonomy into every family planning visit I conduct. Unfortunately, this ruling will not only have an immediate impact on the lives of women across the country – it will also alter the way many of us interact with our patients on a day-to-day basis. When patients can report doctors to authorities in some states for offering terminations, and doctors can report patients for seeking them, there will be absolutely no trust in the therapeutic relationship.
With this ruling, the content of private and protected conversations between patients and their physicians will be subject to censure and potentially criminal consequences.
Regardless of where I eventually practice medicine, I should not be in the position of talking to a patient and telling them that they do not have any agency over their body unless they have the money and resources to travel to a state where abortion is legal. I should not have to tell a child that she must carry and birth another child just to appease the often-fickle whims of lawmakers.
The conversation I had with my pediatric patient was important to her health and to her future, and she deserved to have the chance to discuss her feelings with a trusted physician. Every woman has the right to make her own decisions within the sanctity of the exam room, not from the distance of a courtroom.
Dr. Persampiere is a resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
References
1. Unintended pregnancy in the United States. Guttmacher Institute. 2019 Jan 9. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states
2. Foster D et al. The harms of denying a woman a wanted abortion - ANSIRH. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf
3. Subbaraman N. 2021 Nov 12. Homicide is a top cause of maternal death in the United States. Nature News. https://www.nature.com/articles/d41586-021-03392-8
I remember how small and shy she looked, curled into herself in her too-large hospital gown. I remember thinking that it was autumn, and she should have been at her first homecoming dance, not sitting in the ER staring mutely at the hospital-issued safety socks on her feet. Her mother, puffy-eyed from crying, was sitting on the bed beside her, stroking her hair.
Together, my patients and I talked about the pregnancy. She told me how scared she was, how she didn’t want to “kill her baby”, but that she also wasn’t sure she could take care of a child. She told me that she was terrified of childbirth, that she didn’t want her friends at school to know and to judge her. We talked about how she was a victim; how she was an innocent child, too. I reassured her, and her mom emphatically agreed – her body was still her own.
The man who hurt her did not take that from her. She could make any choice she wanted, and it would be the right choice.
Eventually, she was able to make a decision which was best for her. I don’t know what became of her, but I hope she is well now, and I hope she’s thriving and happy. I also hope that she doesn’t see the news about Roe v. Wade and feel stripped of her personhood, as many women did.
When I heard about the Supreme Court decision I thought of her, and how important our conversation was to the trajectory of her life. I wondered if across the country these conversations might be silenced, and patients might be left to navigate this important facet of their health alone.
Some version of the conversation I had with my young patient occurs in exam rooms across the country countless times a day. Sometimes these conversations are cut and dry. Other times, they are accompanied by heartbreak and tears.
These conversations are common – one in four women in the United States have had an abortion. I have had many friends who were faced with deciding what to do after an unexpectedly positive pregnancy test. The reasons were different for each person – one was raped at a party, another’s birth control failed, the boyfriend of a third friend wouldn’t wear a condom – but the underlying sentiments were the same for each woman. They thought: “This is a difficult choice, but it’s a choice I’m ready to make. I’m not ready to have a baby at this point in my life.”
My friends talked to their doctors, who assisted them in making an informed choice. Some of them chose abortion. Others chose to deliver their baby. All were helped along in their decision by a physician who was there to support them and assist them in making a well-considered choice for their individual circumstance.
Economic and health consequences of restricting access to abortion
The facts are clear: Nearly half of all pregnancies in American women in 2011 were unplanned, and about 4 in 10 of them ended in an elective abortion, according to the Guttmacher Institute.1 Restricting access to abortions does not stop abortions from happening; it limits the opportunity for women to seek advice from trusted friends and professionals and it reduces access to safe abortions.
The people who will be most harmed by these restrictions are the most socially and economically vulnerable. Wealthy, mobile women with the ability to travel to other states or countries will always be able to access abortion care; low-income, work-tethered women and women with other children to care for at home will struggle to do so.
Denying women abortion services puts them at increased risk for lifelong, multigenerational economic hardship. Women who sought abortions but were unable to obtain them experienced an increase in household poverty which lasted years relative to women who were able to receive an abortion, according to the authors of The Turnaway Study.2 They were less socially, geographically, and economically mobile, and were less likely to go on to receive a higher education.
In a country where citizens do not have paid maternity leave, affordable and accessible childcare services, or universal health care, raising a child is an enormous financial burden. Women who are denied abortions also are much more likely to end up as a single parent, shouldering that burden alone.
Additionally, low socioeconomic status is associated with increased all-cause mortality. People who live in poverty are disproportionately affected by diabetes and other chronic health conditions, and have lower life expectancies overall.
The reversal of Roe v. Wade is not only going to lead directly to patient death by decreasing access to safe abortion, causing women to pursue unsafe alternatives; it will also indirectly result in more women being driven into and remaining in poverty and suffering the health consequences.
In addition to risking a woman’s life medically, pregnancy also significantly increases that individual’s risk of being a victim of intimate partner violence. The number one cause of death in pregnant women is homicide, most often by their sexual partner, said an article published in Nature in 2021.3 Therefore, restricting a woman’s ability to control if and when she has children could put her at risk for death from serious pregnancy-related complications and unsafe abortion consequences and increase her likelihood of dying by domestic violence.
Patient-physicians interactions are changed
As a physician I hope that I am able to convey my intense respect for and support of a woman’s autonomy into every family planning visit I conduct. Unfortunately, this ruling will not only have an immediate impact on the lives of women across the country – it will also alter the way many of us interact with our patients on a day-to-day basis. When patients can report doctors to authorities in some states for offering terminations, and doctors can report patients for seeking them, there will be absolutely no trust in the therapeutic relationship.
With this ruling, the content of private and protected conversations between patients and their physicians will be subject to censure and potentially criminal consequences.
Regardless of where I eventually practice medicine, I should not be in the position of talking to a patient and telling them that they do not have any agency over their body unless they have the money and resources to travel to a state where abortion is legal. I should not have to tell a child that she must carry and birth another child just to appease the often-fickle whims of lawmakers.
The conversation I had with my pediatric patient was important to her health and to her future, and she deserved to have the chance to discuss her feelings with a trusted physician. Every woman has the right to make her own decisions within the sanctity of the exam room, not from the distance of a courtroom.
Dr. Persampiere is a resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
References
1. Unintended pregnancy in the United States. Guttmacher Institute. 2019 Jan 9. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states
2. Foster D et al. The harms of denying a woman a wanted abortion - ANSIRH. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf
3. Subbaraman N. 2021 Nov 12. Homicide is a top cause of maternal death in the United States. Nature News. https://www.nature.com/articles/d41586-021-03392-8
My experience as a family medicine resident in 2021
I did not get a medical school graduation; I was one of the many thousands of newly graduated students who simply left their 4th-year rotation sites one chilly day in March 2020 and just never went back. My medical school education didn’t end with me walking triumphantly across the stage – a first-generation college student finally achieving the greatest dream in her life. Instead, it ended with a Zoom “graduation” and a cross-country move from Georgia to Pennsylvania amidst the greatest pandemic in recent memory. To say my impostor syndrome was bad would be an understatement.
Residency in the COVID-19-era
The joy and the draw to family medicine for me has always been the broad scope of conditions that we see and treat. From day 1, however, much of my residency has been devoted to one very small subset of patients – those with COVID-19. At one point, our hospital was so strained that our family medicine program had to run a second inpatient service alongside our usual five-resident service team just to provide care to everybody. Patients were in the hallways. The ER was packed to the gills. We were sleepless, terrified, unvaccinated, and desperate to help our patients survive a disease that was incompletely understood, with very few tools in our toolbox to combat it.
I distinctly remember sitting in the workroom with a coresident of mine, our faces seemingly permanently lined from wearing N95s all shift, and saying to him, “I worry I will be a bad family medicine physician. I worry I haven’t seen enough, other than COVID.” It was midway through my intern year; the days were short, so I was driving to and from the hospital in chilly darkness. My patients, like many around the country, were doing poorly. Vaccines seemed like a promise too good to be true. Worst of all: Those of us who were interns, who had no triumphant podium moment to end our medical school education, were suffering with an intense sense of impostor syndrome which was strengthened by every “there is nothing else we can offer your loved one at this time,” conversation we had. My apprehension about not having seen a wider breadth of medicine during my training is a sentiment still widely shared by COVID-era residents.
Luckily, my coresident was supportive.
“We’re going to be great family medicine physicians,” he said. “We’re learning the hard stuff – the bread and butter of FM – up-front. You’ll see.”
In some ways, I think he was right. Clinical skills, empathy, humility, and forging strong relationships are at the center of every family medicine physician’s heart; my generation has had to learn these skills early and under pressure. Sometimes, there are no answers. Sometimes, the best thing a family doctor can do for a patient is to hear them, understand them, and hold their hand.
‘We watched Cinderella together’
Shortly after that conversation with my coresident, I had a particular case which moved me. This gentleman with intellectual disability and COVID had been declining steadily since his admission to the hospital. He was isolated from everybody he knew and loved, but it did not dampen his spirits. He was cheerful to every person who entered his room, clad in their shrouds of PPE, which more often than not felt more like mourning garb than protective wear. I remember very little about this patient’s clinical picture – the COVID, the superimposed pneumonia, the repeated intubations. What I do remember is he loved the Disney classic, Cinderella. I knew this because I developed a very close relationship with his family during the course of his hospitalization. Amidst the torrential onslaught of patients, I made sure to call families every day – not because I wanted to, but because my mentors and attendings and coresidents had all drilled into me from day 1 that we are family medicine, and a large part of our role is to advocate for our patients, and to communicate with their loved ones. So I called. I learned a lot about him; his likes, his dislikes, his close bond with his siblings, and of course his lifelong love for Cinderella. On the last week of my ICU rotation, my patient passed peacefully. His nurse and I were bedside. We held his hand. We told him his family loved him. We watched Cinderella together on an iPad encased in protective plastic.
My next rotation was an outpatient one and it looked more like the “bread and butter” of family medicine. But as I whisked in and out of patient rooms, attending to patients with diabetes, with depression, with pain, I could not stop thinking about my hospitalized patients who my coresidents had assumed care of. Each exam room I entered, I rather morbidly thought “this patient could be next on our hospital service.” Without realizing it, I made more of an effort to get to know each patient holistically. I learned who they were as people. I found myself writing small, medically low-yield details in the chart: “Margaret loves to sing in her church choir;” “Katherine is a self-published author.”
I learned from my attendings. As I sat at the precepting table with them, observing their conversations about patients, their collective decades of experience were apparent.
“I’ve been seeing this patient every few weeks since I was a resident,” said one of my attendings.
“I don’t even see my parents that often,” I thought.
The depth of her relationship with, understanding of, and compassion for this patient struck me deeply. This was why I went into family medicine. My attending knew her patients; they were not faceless unknowns in a hospital gown to her. She would have known to play Cinderella for them in the end.
This is a unique time for trainees. We have been challenged, terrified, overwhelmed, and heartbroken. But at no point have we been isolated. We’ve had the generations of doctors before us to lead the way, to teach us the “hard stuff.” We’ve had senior residents to lean on, who have taken us aside and told us, “I can do the goals-of-care talk today, you need a break.” While the plague seems to have passed over our hospital for now, it has left behind a class of family medicine residents who are proud to carry on our specialty’s long tradition of compassionate, empathetic, lifelong care. “We care for all life stages, from cradle to grave,” says every family medicine physician.
My class, for better or for worse, has cared more often for patients in the twilight of their lives, and while it has been hard, I believe it has made us all better doctors. Now, when I hold a newborn in my arms for a well-child check, I am exceptionally grateful – for the opportunities I have been given, for new beginnings amidst so much sadness, and for the great privilege of being a family medicine physician.
Dr. Persampiere is a 2nd-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
I did not get a medical school graduation; I was one of the many thousands of newly graduated students who simply left their 4th-year rotation sites one chilly day in March 2020 and just never went back. My medical school education didn’t end with me walking triumphantly across the stage – a first-generation college student finally achieving the greatest dream in her life. Instead, it ended with a Zoom “graduation” and a cross-country move from Georgia to Pennsylvania amidst the greatest pandemic in recent memory. To say my impostor syndrome was bad would be an understatement.
Residency in the COVID-19-era
The joy and the draw to family medicine for me has always been the broad scope of conditions that we see and treat. From day 1, however, much of my residency has been devoted to one very small subset of patients – those with COVID-19. At one point, our hospital was so strained that our family medicine program had to run a second inpatient service alongside our usual five-resident service team just to provide care to everybody. Patients were in the hallways. The ER was packed to the gills. We were sleepless, terrified, unvaccinated, and desperate to help our patients survive a disease that was incompletely understood, with very few tools in our toolbox to combat it.
I distinctly remember sitting in the workroom with a coresident of mine, our faces seemingly permanently lined from wearing N95s all shift, and saying to him, “I worry I will be a bad family medicine physician. I worry I haven’t seen enough, other than COVID.” It was midway through my intern year; the days were short, so I was driving to and from the hospital in chilly darkness. My patients, like many around the country, were doing poorly. Vaccines seemed like a promise too good to be true. Worst of all: Those of us who were interns, who had no triumphant podium moment to end our medical school education, were suffering with an intense sense of impostor syndrome which was strengthened by every “there is nothing else we can offer your loved one at this time,” conversation we had. My apprehension about not having seen a wider breadth of medicine during my training is a sentiment still widely shared by COVID-era residents.
Luckily, my coresident was supportive.
“We’re going to be great family medicine physicians,” he said. “We’re learning the hard stuff – the bread and butter of FM – up-front. You’ll see.”
In some ways, I think he was right. Clinical skills, empathy, humility, and forging strong relationships are at the center of every family medicine physician’s heart; my generation has had to learn these skills early and under pressure. Sometimes, there are no answers. Sometimes, the best thing a family doctor can do for a patient is to hear them, understand them, and hold their hand.
‘We watched Cinderella together’
Shortly after that conversation with my coresident, I had a particular case which moved me. This gentleman with intellectual disability and COVID had been declining steadily since his admission to the hospital. He was isolated from everybody he knew and loved, but it did not dampen his spirits. He was cheerful to every person who entered his room, clad in their shrouds of PPE, which more often than not felt more like mourning garb than protective wear. I remember very little about this patient’s clinical picture – the COVID, the superimposed pneumonia, the repeated intubations. What I do remember is he loved the Disney classic, Cinderella. I knew this because I developed a very close relationship with his family during the course of his hospitalization. Amidst the torrential onslaught of patients, I made sure to call families every day – not because I wanted to, but because my mentors and attendings and coresidents had all drilled into me from day 1 that we are family medicine, and a large part of our role is to advocate for our patients, and to communicate with their loved ones. So I called. I learned a lot about him; his likes, his dislikes, his close bond with his siblings, and of course his lifelong love for Cinderella. On the last week of my ICU rotation, my patient passed peacefully. His nurse and I were bedside. We held his hand. We told him his family loved him. We watched Cinderella together on an iPad encased in protective plastic.
My next rotation was an outpatient one and it looked more like the “bread and butter” of family medicine. But as I whisked in and out of patient rooms, attending to patients with diabetes, with depression, with pain, I could not stop thinking about my hospitalized patients who my coresidents had assumed care of. Each exam room I entered, I rather morbidly thought “this patient could be next on our hospital service.” Without realizing it, I made more of an effort to get to know each patient holistically. I learned who they were as people. I found myself writing small, medically low-yield details in the chart: “Margaret loves to sing in her church choir;” “Katherine is a self-published author.”
I learned from my attendings. As I sat at the precepting table with them, observing their conversations about patients, their collective decades of experience were apparent.
“I’ve been seeing this patient every few weeks since I was a resident,” said one of my attendings.
“I don’t even see my parents that often,” I thought.
The depth of her relationship with, understanding of, and compassion for this patient struck me deeply. This was why I went into family medicine. My attending knew her patients; they were not faceless unknowns in a hospital gown to her. She would have known to play Cinderella for them in the end.
This is a unique time for trainees. We have been challenged, terrified, overwhelmed, and heartbroken. But at no point have we been isolated. We’ve had the generations of doctors before us to lead the way, to teach us the “hard stuff.” We’ve had senior residents to lean on, who have taken us aside and told us, “I can do the goals-of-care talk today, you need a break.” While the plague seems to have passed over our hospital for now, it has left behind a class of family medicine residents who are proud to carry on our specialty’s long tradition of compassionate, empathetic, lifelong care. “We care for all life stages, from cradle to grave,” says every family medicine physician.
My class, for better or for worse, has cared more often for patients in the twilight of their lives, and while it has been hard, I believe it has made us all better doctors. Now, when I hold a newborn in my arms for a well-child check, I am exceptionally grateful – for the opportunities I have been given, for new beginnings amidst so much sadness, and for the great privilege of being a family medicine physician.
Dr. Persampiere is a 2nd-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
I did not get a medical school graduation; I was one of the many thousands of newly graduated students who simply left their 4th-year rotation sites one chilly day in March 2020 and just never went back. My medical school education didn’t end with me walking triumphantly across the stage – a first-generation college student finally achieving the greatest dream in her life. Instead, it ended with a Zoom “graduation” and a cross-country move from Georgia to Pennsylvania amidst the greatest pandemic in recent memory. To say my impostor syndrome was bad would be an understatement.
Residency in the COVID-19-era
The joy and the draw to family medicine for me has always been the broad scope of conditions that we see and treat. From day 1, however, much of my residency has been devoted to one very small subset of patients – those with COVID-19. At one point, our hospital was so strained that our family medicine program had to run a second inpatient service alongside our usual five-resident service team just to provide care to everybody. Patients were in the hallways. The ER was packed to the gills. We were sleepless, terrified, unvaccinated, and desperate to help our patients survive a disease that was incompletely understood, with very few tools in our toolbox to combat it.
I distinctly remember sitting in the workroom with a coresident of mine, our faces seemingly permanently lined from wearing N95s all shift, and saying to him, “I worry I will be a bad family medicine physician. I worry I haven’t seen enough, other than COVID.” It was midway through my intern year; the days were short, so I was driving to and from the hospital in chilly darkness. My patients, like many around the country, were doing poorly. Vaccines seemed like a promise too good to be true. Worst of all: Those of us who were interns, who had no triumphant podium moment to end our medical school education, were suffering with an intense sense of impostor syndrome which was strengthened by every “there is nothing else we can offer your loved one at this time,” conversation we had. My apprehension about not having seen a wider breadth of medicine during my training is a sentiment still widely shared by COVID-era residents.
Luckily, my coresident was supportive.
“We’re going to be great family medicine physicians,” he said. “We’re learning the hard stuff – the bread and butter of FM – up-front. You’ll see.”
In some ways, I think he was right. Clinical skills, empathy, humility, and forging strong relationships are at the center of every family medicine physician’s heart; my generation has had to learn these skills early and under pressure. Sometimes, there are no answers. Sometimes, the best thing a family doctor can do for a patient is to hear them, understand them, and hold their hand.
‘We watched Cinderella together’
Shortly after that conversation with my coresident, I had a particular case which moved me. This gentleman with intellectual disability and COVID had been declining steadily since his admission to the hospital. He was isolated from everybody he knew and loved, but it did not dampen his spirits. He was cheerful to every person who entered his room, clad in their shrouds of PPE, which more often than not felt more like mourning garb than protective wear. I remember very little about this patient’s clinical picture – the COVID, the superimposed pneumonia, the repeated intubations. What I do remember is he loved the Disney classic, Cinderella. I knew this because I developed a very close relationship with his family during the course of his hospitalization. Amidst the torrential onslaught of patients, I made sure to call families every day – not because I wanted to, but because my mentors and attendings and coresidents had all drilled into me from day 1 that we are family medicine, and a large part of our role is to advocate for our patients, and to communicate with their loved ones. So I called. I learned a lot about him; his likes, his dislikes, his close bond with his siblings, and of course his lifelong love for Cinderella. On the last week of my ICU rotation, my patient passed peacefully. His nurse and I were bedside. We held his hand. We told him his family loved him. We watched Cinderella together on an iPad encased in protective plastic.
My next rotation was an outpatient one and it looked more like the “bread and butter” of family medicine. But as I whisked in and out of patient rooms, attending to patients with diabetes, with depression, with pain, I could not stop thinking about my hospitalized patients who my coresidents had assumed care of. Each exam room I entered, I rather morbidly thought “this patient could be next on our hospital service.” Without realizing it, I made more of an effort to get to know each patient holistically. I learned who they were as people. I found myself writing small, medically low-yield details in the chart: “Margaret loves to sing in her church choir;” “Katherine is a self-published author.”
I learned from my attendings. As I sat at the precepting table with them, observing their conversations about patients, their collective decades of experience were apparent.
“I’ve been seeing this patient every few weeks since I was a resident,” said one of my attendings.
“I don’t even see my parents that often,” I thought.
The depth of her relationship with, understanding of, and compassion for this patient struck me deeply. This was why I went into family medicine. My attending knew her patients; they were not faceless unknowns in a hospital gown to her. She would have known to play Cinderella for them in the end.
This is a unique time for trainees. We have been challenged, terrified, overwhelmed, and heartbroken. But at no point have we been isolated. We’ve had the generations of doctors before us to lead the way, to teach us the “hard stuff.” We’ve had senior residents to lean on, who have taken us aside and told us, “I can do the goals-of-care talk today, you need a break.” While the plague seems to have passed over our hospital for now, it has left behind a class of family medicine residents who are proud to carry on our specialty’s long tradition of compassionate, empathetic, lifelong care. “We care for all life stages, from cradle to grave,” says every family medicine physician.
My class, for better or for worse, has cared more often for patients in the twilight of their lives, and while it has been hard, I believe it has made us all better doctors. Now, when I hold a newborn in my arms for a well-child check, I am exceptionally grateful – for the opportunities I have been given, for new beginnings amidst so much sadness, and for the great privilege of being a family medicine physician.
Dr. Persampiere is a 2nd-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
Smart watch glucose monitoring on the horizon
Earlier this year, technology news sites reported that the Apple Watch Series 7 and the Samsung Galaxy Watch 4 were going to have integrated optical sensors for checking interstitial fluid glucose levels with no blood sampling needed. By the summer, new articles indicated that the glucose sensing watches would not be released this year for either Apple or Samsung.
For now, the newest technology available for monitoring glucose is continuous glucose monitoring (CGM), which involves a tiny sensor being inserted under the skin. The sensor tests glucose every few minutes, and a transmitter wirelessly sends the information to a monitor, which may be part of an insulin pump or a separate device. Some CGMs send information directly to a smartphone or tablet, according to the National Institutes of Health.
In 1999 the Food and Drug Administration approved the first CGM, which was only approved for downloading 3 days of data at a doctor’s office. Interestingly, the first real-time CGM device for patients to use on their own was a watch, the Glucowatch Biographer. Because of irritation and other issues, that watch never caught on. In 2006 and 2008, Dexcom and then Abbott released the first real-time CGMs that allowed patients to frequently check their own blood sugars.1,2
How CGM has advanced diabetes management
The advent of CGM has advanced the field of diabetes management in many ways.
It has allowed patients to get real time feedback on how their behavior affects their blood sugar. The use of CGM along with the ensuing behavioral changes actually leads to a decrease in hemoglobin A1c, along with a lower risk of hypoglycemia. CGM has also resulted in patients having a better understanding of several aspects of glucose control, including glucose variability and nocturnal hypoglycemia.
Affordable, readily accessible CGM monitors that allow patients to intermittently use CGM have become available over the last 3 years.
In the United States alone, 34.2 million people have diabetes – nearly 1 in every 10 people. Many do not do self-monitoring of blood glucose and most do not use CGM. The current alternative to CGM – self monitoring of blood glucose – is cumbersome, and, since it requires regular finger sticks, is painful. Also, there is significant cost to each test strip that is used to self-monitor, and most insurance limits the number of times a day a patient can check their blood sugar. CGM used to be reserved only for patients who use multiple doses of insulin daily, and only began being approved for use for patients on basal insulin alone in June 2021.3
Most primary care doctors are just beginning to learn how to interpret CGM data.
Smart watch glucose monitoring predictions
When smart watch glucose monitoring arrives, it will suddenly change the playing field for patients with diabetes and their doctors alike.
We expect it to bring down the price of CGM and make it readily available to any patient who owns a smart watch with that function.
For doctors, the new technology will result in them suddenly being asked to advise their patients on how to use the data generated by watch-based CGM.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. They have no conflicts related to the content of this piece. Dr. Persampiere is a second-year resident in the family medicine residency program at Abington Jefferson Health. You can contact them at [email protected].
References
1. Hirsh I. Introduction: History of Glucose Monitoring, in “Role of Continuous Glucose Monitoring in Diabetes Treatment.” American Diabetes Association. 2018.
2. Peters A. The Evidence Base for Continuous Glucose Monitoring, in “Role of Continuous Glucose Monitoring in Diabetes Treatment.” American Diabetes Association 2018.
3. “Medicare Loosening Restrictions for Continuous Glucose Monitor (CGM) Coverage,” Healthline. 2021 Jul 13.
Earlier this year, technology news sites reported that the Apple Watch Series 7 and the Samsung Galaxy Watch 4 were going to have integrated optical sensors for checking interstitial fluid glucose levels with no blood sampling needed. By the summer, new articles indicated that the glucose sensing watches would not be released this year for either Apple or Samsung.
For now, the newest technology available for monitoring glucose is continuous glucose monitoring (CGM), which involves a tiny sensor being inserted under the skin. The sensor tests glucose every few minutes, and a transmitter wirelessly sends the information to a monitor, which may be part of an insulin pump or a separate device. Some CGMs send information directly to a smartphone or tablet, according to the National Institutes of Health.
In 1999 the Food and Drug Administration approved the first CGM, which was only approved for downloading 3 days of data at a doctor’s office. Interestingly, the first real-time CGM device for patients to use on their own was a watch, the Glucowatch Biographer. Because of irritation and other issues, that watch never caught on. In 2006 and 2008, Dexcom and then Abbott released the first real-time CGMs that allowed patients to frequently check their own blood sugars.1,2
How CGM has advanced diabetes management
The advent of CGM has advanced the field of diabetes management in many ways.
It has allowed patients to get real time feedback on how their behavior affects their blood sugar. The use of CGM along with the ensuing behavioral changes actually leads to a decrease in hemoglobin A1c, along with a lower risk of hypoglycemia. CGM has also resulted in patients having a better understanding of several aspects of glucose control, including glucose variability and nocturnal hypoglycemia.
Affordable, readily accessible CGM monitors that allow patients to intermittently use CGM have become available over the last 3 years.
In the United States alone, 34.2 million people have diabetes – nearly 1 in every 10 people. Many do not do self-monitoring of blood glucose and most do not use CGM. The current alternative to CGM – self monitoring of blood glucose – is cumbersome, and, since it requires regular finger sticks, is painful. Also, there is significant cost to each test strip that is used to self-monitor, and most insurance limits the number of times a day a patient can check their blood sugar. CGM used to be reserved only for patients who use multiple doses of insulin daily, and only began being approved for use for patients on basal insulin alone in June 2021.3
Most primary care doctors are just beginning to learn how to interpret CGM data.
Smart watch glucose monitoring predictions
When smart watch glucose monitoring arrives, it will suddenly change the playing field for patients with diabetes and their doctors alike.
We expect it to bring down the price of CGM and make it readily available to any patient who owns a smart watch with that function.
For doctors, the new technology will result in them suddenly being asked to advise their patients on how to use the data generated by watch-based CGM.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. They have no conflicts related to the content of this piece. Dr. Persampiere is a second-year resident in the family medicine residency program at Abington Jefferson Health. You can contact them at [email protected].
References
1. Hirsh I. Introduction: History of Glucose Monitoring, in “Role of Continuous Glucose Monitoring in Diabetes Treatment.” American Diabetes Association. 2018.
2. Peters A. The Evidence Base for Continuous Glucose Monitoring, in “Role of Continuous Glucose Monitoring in Diabetes Treatment.” American Diabetes Association 2018.
3. “Medicare Loosening Restrictions for Continuous Glucose Monitor (CGM) Coverage,” Healthline. 2021 Jul 13.
Earlier this year, technology news sites reported that the Apple Watch Series 7 and the Samsung Galaxy Watch 4 were going to have integrated optical sensors for checking interstitial fluid glucose levels with no blood sampling needed. By the summer, new articles indicated that the glucose sensing watches would not be released this year for either Apple or Samsung.
For now, the newest technology available for monitoring glucose is continuous glucose monitoring (CGM), which involves a tiny sensor being inserted under the skin. The sensor tests glucose every few minutes, and a transmitter wirelessly sends the information to a monitor, which may be part of an insulin pump or a separate device. Some CGMs send information directly to a smartphone or tablet, according to the National Institutes of Health.
In 1999 the Food and Drug Administration approved the first CGM, which was only approved for downloading 3 days of data at a doctor’s office. Interestingly, the first real-time CGM device for patients to use on their own was a watch, the Glucowatch Biographer. Because of irritation and other issues, that watch never caught on. In 2006 and 2008, Dexcom and then Abbott released the first real-time CGMs that allowed patients to frequently check their own blood sugars.1,2
How CGM has advanced diabetes management
The advent of CGM has advanced the field of diabetes management in many ways.
It has allowed patients to get real time feedback on how their behavior affects their blood sugar. The use of CGM along with the ensuing behavioral changes actually leads to a decrease in hemoglobin A1c, along with a lower risk of hypoglycemia. CGM has also resulted in patients having a better understanding of several aspects of glucose control, including glucose variability and nocturnal hypoglycemia.
Affordable, readily accessible CGM monitors that allow patients to intermittently use CGM have become available over the last 3 years.
In the United States alone, 34.2 million people have diabetes – nearly 1 in every 10 people. Many do not do self-monitoring of blood glucose and most do not use CGM. The current alternative to CGM – self monitoring of blood glucose – is cumbersome, and, since it requires regular finger sticks, is painful. Also, there is significant cost to each test strip that is used to self-monitor, and most insurance limits the number of times a day a patient can check their blood sugar. CGM used to be reserved only for patients who use multiple doses of insulin daily, and only began being approved for use for patients on basal insulin alone in June 2021.3
Most primary care doctors are just beginning to learn how to interpret CGM data.
Smart watch glucose monitoring predictions
When smart watch glucose monitoring arrives, it will suddenly change the playing field for patients with diabetes and their doctors alike.
We expect it to bring down the price of CGM and make it readily available to any patient who owns a smart watch with that function.
For doctors, the new technology will result in them suddenly being asked to advise their patients on how to use the data generated by watch-based CGM.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. They have no conflicts related to the content of this piece. Dr. Persampiere is a second-year resident in the family medicine residency program at Abington Jefferson Health. You can contact them at [email protected].
References
1. Hirsh I. Introduction: History of Glucose Monitoring, in “Role of Continuous Glucose Monitoring in Diabetes Treatment.” American Diabetes Association. 2018.
2. Peters A. The Evidence Base for Continuous Glucose Monitoring, in “Role of Continuous Glucose Monitoring in Diabetes Treatment.” American Diabetes Association 2018.
3. “Medicare Loosening Restrictions for Continuous Glucose Monitor (CGM) Coverage,” Healthline. 2021 Jul 13.
The Cures Act: Is the “cure” worse than the disease?
There is a sudden spill of icy anxiety down your spine as you pick up your phone in your shaking hands. It’s 6 p.m.; your doctor’s office is closed. You open the message, and your worst fears are confirmed ... the cancer is back.
Or is it? You’re not sure. The biopsy sure sounds bad. But you’re an English teacher, not a doctor, and you spend the rest of the night Googling words like “tubulovillous” and “high-grade dysplasia.” You sit awake, terrified in front of the computer screen desperately trying to make sense of the possibly life-changing results. You wish you knew someone who could help you understand; you consider calling your doctor’s emergency line, or your cousin who is an ophthalmologist – anybody who can help you make sense of the results.
Or imagine another scenario: you’re a trans teen who has asked your doctor to refer to you by your preferred pronouns. You’re still presenting as your birth sex, in part because your family would disown you if they knew, and you’re not financially or emotionally ready for that step. You feel proud of yourself for advocating for your needs to your long-time physician, and excited about the resources they’ve included in your after visit summary and the referrals they’d made to gender-confirming specialists.
When you get home, you are confronted with a terrible reality that your doctor’s notes, orders, and recommendations are immediately viewable to anybody with your MyChart login – your parents knew the second your doctor signed the note. They received the notification, logged on as your guardians, and you have effectively been “outed” by the physician who took and oath to care for you and who you trusted implicitly.
How the Cures Act is affecting patients
While these examples may sound extreme, they are becoming more and more commonplace thanks to a recently enacted 21st Century Cures Act. The act was originally written to improve communication between physicians and patients. Part of the act stipulates that nearly all medical information – from notes to biopsies to lab results – must be available within 24 hours, published to a patient portal and a notification be sent to the patient by phone.
Oftentimes, this occurs before the ordering physician has even seen the results, much less interpreted them and made a plan for the patient. What happens now, not long after its enactment date, when it has become clear that the Cures Act is causing extreme harm to our patients?
Take, for example, the real example of a physician whose patient found out about her own intrauterine fetal demise by way of an EMR text message alert of “new imaging results!” sent directly to her phone. Or a physician colleague who witnessed firsthand the intrusive unhelpfulness of the Cures Act when she was informed via patient portal releasing her imaging information that she had a large, possibly malignant breast mass. “No phone call,” she said. “No human being for questions or comfort. Just a notification on my phone.”
The stories about the impact of the Cures Act across the medical community are an endless stream of anxiety, hurt, and broken trust. The relationship between a physician and a patient should be sacred, bolstered by communication and mutual respect.
In many ways, the new act feels like a third party to the patient-physician relationship – a digital imposter, oftentimes blurting out personal and life-altering medical information without any of the finesse, context, and perspective of an experienced physician.
Breaking ‘bad news’ to a patient
In training, some residents are taught how to “break bad news” to a patient. Some good practices for doing this are to have information available for the patient, provide emotional support, have a plan for their next steps already formulated, and call the appropriate specialist ahead of time if you can.
Above all, it’s most important to let the patient be the one to direct their own care. Give them time to ask questions and answer them honestly and clearly. Ask them how much they want to know and help them to understand the complex change in their usual state of health.
Now, unless physicians are keeping a very close eye on their inbox, results are slipping out to patients in a void. The bad news conversations aren’t happening at all, or if they are, they’re happening at 8 p.m. on a phone call after an exhausted physician ends their shift but has to slog through their results bin, calling all the patients who shouldn’t have to find out their results in solitude.
Reaching out to these patients immediately is an honorable, kind thing to, but for a physician, knowing they need to beat the patient to opening an email creates anxiety. Plus, making these calls at whatever hour the results are released to a patient is another burden added to doctors’ already-full plates.
Interpreting results
None of us want to harm our patients. All of us want to be there for them. But this act stands in the way of delivering quality, humanizing medical care.
It is true that patients have a right to access their own medical information. It is also true that waiting anxiously on results can cause undue harm to a patient. But the across-the-board, breakneck speed of information release mandated in this act causes irreparable harm not only to patients, but to the patient-physician relationship.
No patient should find out their cancer recurred while checking their emails at their desk. No patient should first learn of a life-altering diagnosis by way of scrolling through their smartphone in bed. The role of a physician is more than just a healer – we should also be educators, interpreters, partners and, first and foremost, advocates for our patients’ needs.
Our patients are depending on us to stand up and speak out about necessary changes to this act. Result releases should be delayed until they are viewed by a physician. Our patients deserve the dignity and opportunity of a conversation with their medical provider about their test results, and physicians deserve the chance to interpret results and frame the conversation in a way which is conducive to patient understanding and healing.
Dr. Persampiere is a first-year resident in the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece. You can contact them at [email protected].
There is a sudden spill of icy anxiety down your spine as you pick up your phone in your shaking hands. It’s 6 p.m.; your doctor’s office is closed. You open the message, and your worst fears are confirmed ... the cancer is back.
Or is it? You’re not sure. The biopsy sure sounds bad. But you’re an English teacher, not a doctor, and you spend the rest of the night Googling words like “tubulovillous” and “high-grade dysplasia.” You sit awake, terrified in front of the computer screen desperately trying to make sense of the possibly life-changing results. You wish you knew someone who could help you understand; you consider calling your doctor’s emergency line, or your cousin who is an ophthalmologist – anybody who can help you make sense of the results.
Or imagine another scenario: you’re a trans teen who has asked your doctor to refer to you by your preferred pronouns. You’re still presenting as your birth sex, in part because your family would disown you if they knew, and you’re not financially or emotionally ready for that step. You feel proud of yourself for advocating for your needs to your long-time physician, and excited about the resources they’ve included in your after visit summary and the referrals they’d made to gender-confirming specialists.
When you get home, you are confronted with a terrible reality that your doctor’s notes, orders, and recommendations are immediately viewable to anybody with your MyChart login – your parents knew the second your doctor signed the note. They received the notification, logged on as your guardians, and you have effectively been “outed” by the physician who took and oath to care for you and who you trusted implicitly.
How the Cures Act is affecting patients
While these examples may sound extreme, they are becoming more and more commonplace thanks to a recently enacted 21st Century Cures Act. The act was originally written to improve communication between physicians and patients. Part of the act stipulates that nearly all medical information – from notes to biopsies to lab results – must be available within 24 hours, published to a patient portal and a notification be sent to the patient by phone.
Oftentimes, this occurs before the ordering physician has even seen the results, much less interpreted them and made a plan for the patient. What happens now, not long after its enactment date, when it has become clear that the Cures Act is causing extreme harm to our patients?
Take, for example, the real example of a physician whose patient found out about her own intrauterine fetal demise by way of an EMR text message alert of “new imaging results!” sent directly to her phone. Or a physician colleague who witnessed firsthand the intrusive unhelpfulness of the Cures Act when she was informed via patient portal releasing her imaging information that she had a large, possibly malignant breast mass. “No phone call,” she said. “No human being for questions or comfort. Just a notification on my phone.”
The stories about the impact of the Cures Act across the medical community are an endless stream of anxiety, hurt, and broken trust. The relationship between a physician and a patient should be sacred, bolstered by communication and mutual respect.
In many ways, the new act feels like a third party to the patient-physician relationship – a digital imposter, oftentimes blurting out personal and life-altering medical information without any of the finesse, context, and perspective of an experienced physician.
Breaking ‘bad news’ to a patient
In training, some residents are taught how to “break bad news” to a patient. Some good practices for doing this are to have information available for the patient, provide emotional support, have a plan for their next steps already formulated, and call the appropriate specialist ahead of time if you can.
Above all, it’s most important to let the patient be the one to direct their own care. Give them time to ask questions and answer them honestly and clearly. Ask them how much they want to know and help them to understand the complex change in their usual state of health.
Now, unless physicians are keeping a very close eye on their inbox, results are slipping out to patients in a void. The bad news conversations aren’t happening at all, or if they are, they’re happening at 8 p.m. on a phone call after an exhausted physician ends their shift but has to slog through their results bin, calling all the patients who shouldn’t have to find out their results in solitude.
Reaching out to these patients immediately is an honorable, kind thing to, but for a physician, knowing they need to beat the patient to opening an email creates anxiety. Plus, making these calls at whatever hour the results are released to a patient is another burden added to doctors’ already-full plates.
Interpreting results
None of us want to harm our patients. All of us want to be there for them. But this act stands in the way of delivering quality, humanizing medical care.
It is true that patients have a right to access their own medical information. It is also true that waiting anxiously on results can cause undue harm to a patient. But the across-the-board, breakneck speed of information release mandated in this act causes irreparable harm not only to patients, but to the patient-physician relationship.
No patient should find out their cancer recurred while checking their emails at their desk. No patient should first learn of a life-altering diagnosis by way of scrolling through their smartphone in bed. The role of a physician is more than just a healer – we should also be educators, interpreters, partners and, first and foremost, advocates for our patients’ needs.
Our patients are depending on us to stand up and speak out about necessary changes to this act. Result releases should be delayed until they are viewed by a physician. Our patients deserve the dignity and opportunity of a conversation with their medical provider about their test results, and physicians deserve the chance to interpret results and frame the conversation in a way which is conducive to patient understanding and healing.
Dr. Persampiere is a first-year resident in the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece. You can contact them at [email protected].
There is a sudden spill of icy anxiety down your spine as you pick up your phone in your shaking hands. It’s 6 p.m.; your doctor’s office is closed. You open the message, and your worst fears are confirmed ... the cancer is back.
Or is it? You’re not sure. The biopsy sure sounds bad. But you’re an English teacher, not a doctor, and you spend the rest of the night Googling words like “tubulovillous” and “high-grade dysplasia.” You sit awake, terrified in front of the computer screen desperately trying to make sense of the possibly life-changing results. You wish you knew someone who could help you understand; you consider calling your doctor’s emergency line, or your cousin who is an ophthalmologist – anybody who can help you make sense of the results.
Or imagine another scenario: you’re a trans teen who has asked your doctor to refer to you by your preferred pronouns. You’re still presenting as your birth sex, in part because your family would disown you if they knew, and you’re not financially or emotionally ready for that step. You feel proud of yourself for advocating for your needs to your long-time physician, and excited about the resources they’ve included in your after visit summary and the referrals they’d made to gender-confirming specialists.
When you get home, you are confronted with a terrible reality that your doctor’s notes, orders, and recommendations are immediately viewable to anybody with your MyChart login – your parents knew the second your doctor signed the note. They received the notification, logged on as your guardians, and you have effectively been “outed” by the physician who took and oath to care for you and who you trusted implicitly.
How the Cures Act is affecting patients
While these examples may sound extreme, they are becoming more and more commonplace thanks to a recently enacted 21st Century Cures Act. The act was originally written to improve communication between physicians and patients. Part of the act stipulates that nearly all medical information – from notes to biopsies to lab results – must be available within 24 hours, published to a patient portal and a notification be sent to the patient by phone.
Oftentimes, this occurs before the ordering physician has even seen the results, much less interpreted them and made a plan for the patient. What happens now, not long after its enactment date, when it has become clear that the Cures Act is causing extreme harm to our patients?
Take, for example, the real example of a physician whose patient found out about her own intrauterine fetal demise by way of an EMR text message alert of “new imaging results!” sent directly to her phone. Or a physician colleague who witnessed firsthand the intrusive unhelpfulness of the Cures Act when she was informed via patient portal releasing her imaging information that she had a large, possibly malignant breast mass. “No phone call,” she said. “No human being for questions or comfort. Just a notification on my phone.”
The stories about the impact of the Cures Act across the medical community are an endless stream of anxiety, hurt, and broken trust. The relationship between a physician and a patient should be sacred, bolstered by communication and mutual respect.
In many ways, the new act feels like a third party to the patient-physician relationship – a digital imposter, oftentimes blurting out personal and life-altering medical information without any of the finesse, context, and perspective of an experienced physician.
Breaking ‘bad news’ to a patient
In training, some residents are taught how to “break bad news” to a patient. Some good practices for doing this are to have information available for the patient, provide emotional support, have a plan for their next steps already formulated, and call the appropriate specialist ahead of time if you can.
Above all, it’s most important to let the patient be the one to direct their own care. Give them time to ask questions and answer them honestly and clearly. Ask them how much they want to know and help them to understand the complex change in their usual state of health.
Now, unless physicians are keeping a very close eye on their inbox, results are slipping out to patients in a void. The bad news conversations aren’t happening at all, or if they are, they’re happening at 8 p.m. on a phone call after an exhausted physician ends their shift but has to slog through their results bin, calling all the patients who shouldn’t have to find out their results in solitude.
Reaching out to these patients immediately is an honorable, kind thing to, but for a physician, knowing they need to beat the patient to opening an email creates anxiety. Plus, making these calls at whatever hour the results are released to a patient is another burden added to doctors’ already-full plates.
Interpreting results
None of us want to harm our patients. All of us want to be there for them. But this act stands in the way of delivering quality, humanizing medical care.
It is true that patients have a right to access their own medical information. It is also true that waiting anxiously on results can cause undue harm to a patient. But the across-the-board, breakneck speed of information release mandated in this act causes irreparable harm not only to patients, but to the patient-physician relationship.
No patient should find out their cancer recurred while checking their emails at their desk. No patient should first learn of a life-altering diagnosis by way of scrolling through their smartphone in bed. The role of a physician is more than just a healer – we should also be educators, interpreters, partners and, first and foremost, advocates for our patients’ needs.
Our patients are depending on us to stand up and speak out about necessary changes to this act. Result releases should be delayed until they are viewed by a physician. Our patients deserve the dignity and opportunity of a conversation with their medical provider about their test results, and physicians deserve the chance to interpret results and frame the conversation in a way which is conducive to patient understanding and healing.
Dr. Persampiere is a first-year resident in the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece. You can contact them at [email protected].