Andrew Silverman

Nothing in medicine is routine or simple. As a second-year medical student, absorbing experiences and learning how to contribute were my primary goals. My encounter with EB as part of weekly medical rounds during visits to a clinic was anything but routine. I believed that I had learned a great deal during my first year and a half of school with regard to medical diagnosis, patient care and interviewing. However, meeting with EB gave me food for thought about the impact of cultural differences, social/economic/religious values, and the importance of safeguarding the therapeutic relationship.

I learned not to make assumptions about individuals and the way that they live their lives. I learned how to be aware of my biases but still listen to the person in front of me. EB appeared to be very affable and open in his communication. He wanted to assist with his treatment and I realized quickly that it was important to him to have some control during the medical examination. He denied having any medical issues except diabetes and vision issues. I quickly realized that he was having trouble with his memory and was not an accurate reporter, as he was having trouble with time, orientation, and remembering details of his past. Why was he not told to bring his wife or another supportive person along with him on the exam days to help with providing information? Perhaps he could have come back the next day with a relative who knew his medical history. Why did he not have a social worker who might have someone visit and check on his medication compliance and diet? These were some of my private questions as we examined EB. I felt disappointed that the clinic did not ensure that these measures were put in place for EB to ensure he would receive effective-as-possible care. I assumed that he would want someone to check on him at home. However, I learned later that my assumption was not correct. He did not want anyone interfering with his lifestyle at home. He was fiercely independent and would feel that his functioning as a man would be diminished if people were checking on his home care and medications. He was annoyed that I would even consider that he needed someone to check on him at home when I asked at the end of the interview. After speaking to the examining physician, we learned that EB had a stroke two years earlier which had led to dementia. He did not remember having a stroke and did not mention it to the medical students at the time of the examination.

I was inspired by his general attitude and demeanor. EB demonstrated respect for the medical community and he held a strong work ethic. During the examination, I was taken aback and somewhat shocked by the amount of information that we could not gather from EB. I had an uneasy feeling that we were not doing a proper job by him. He placed his trust in us and in some ways, we had let him down by not appreciating the degree of his dementia and how it might be affecting him on a daily basis. I was not sure he was accurate about the list of medications he was taking and his dosages. Who made sure that he was taking his medications properly and eating properly? I began to think about all the home care issues an individual with dementia might be having and ways to circumvent these issues. However, I realized after speaking to the medical director that EB was a proud man who did not want anyone overseeing him in his home. He worked six days a week as a laborer with his hands and went to church on Sundays. He was resistant to home healthcare from ancillary staff and denied having any difficulties except vision problems, primarily.

Also, I wondered, was there a social worker at the clinic who could sit down with EB and help him with support resources? I learned from my examination with EB that prior medical history, home care and the accuracy of current reporting from the patient or support person i.e. friend, neighbor, sister, wife, etc. is vital when dealing with a person with cognitive impairment. Although he tried his best to give an accurate history, I was not convinced that his reporting was accurate. I also understood that his feelings of competency were at issue here. He was self-employed and independent, working as a gardener around the island. I wanted to make sure that he felt respected at the same time that I began to question his reporting. As I have learned from previous courses and experiences in different hospitals and clinics as an undergraduate and medical student, patients thrive when they feel trust and respect from their physicians who are able to empathize with them and encourage transparency. It is of upmost importance to value the person in front of you and respect their feelings of self-worth. It is critical that patients feel that the physician is truly listening to them. I wanted EB to feel this way so I did not challenge his reporting at the time of the examination. I understand that a person with dementia may not remember significant medical events or even what they had yesterday to eat. However, I noticed my frustration growing as the interview went on. Now, I struggled with the question of just how much I should challenge his story, without hurting his pride and self-image as a strong, healthy individual. I was aware of the gaps in information and several inconsistencies in his story. I stayed quiet. In the future, I would gather as much information as possible before meeting the patient. I would specifically collaborate with my medical support team including the charge nurse. There may be one or more persons who have significantly bonded with EB and developed a good working relationship with him in his past medical visits. I might want that individual present during the examination to help him feel more comfortable. In addition, there is the issue of confidentiality. I would encourage a person such as EB to bring his significant other with him to future visits but only after making sure he is comfortable with this person and has signed the necessary paperwork allowing that person to be present during the examination and to be a part of the process.

In addition, I have learned from previous teachers that there are many individuals who are necessary and vital to the treatment team and care of the patients who come for medical treatment. Speaking to the physician who was working with EB altered my thinking about his care. I might have left him on his medication had I not spoken with the medical director. Since speaking with the physician, sending EB for surgery became one of many options I now considered in thinking about his future care. EB had been a strong, independent person who did not want to speak about his problems and seem as though he was complaining. His culture valued restraint and privacy as well as independence, as I learned from the medical physician in charge. My assumption that he would not opt for surgery as it was a risky choice, was not well-founded. Staying on medication for EB became a choice with its own risks.

Having a good and realistic prevention plan for EB so that his diabetes does not progress rapidly is another aspect of his care that we did not address that day. I felt that we had let him down. I began to feel let down as well and that EB could be getting more services than he was receiving at the time. There is very good high quality research and literature on what may assist in slowing down dementia and living a quality life with diabetes, including basics such as diet and exercise. Respect, empathy and good medical knowledge and care are also necessary ingredients here. Today I have learned that good medical support is essential. Perhaps I might have given him some drawings or easy to understand nutritional charts to hang in his kitchen. Understanding different cultural norms of food would be extremely helpful in planning a healthy lifestyle change for EB to take him away from any high salt, high-saturated fats in his diet which might contribute to worsening diabetes. Learning about the foods that are grown on the island and the availability of healthy food choices is critical to illness prevention and slowing down the course of an illness such as diabetes. Learning more about turning resistance around to help patients consider healthy options is a necessary part of the role of medical provider. Continuing to read quality research on dementia and asking questions about application are also important to my learning experience. ‘Routine' medical care and routine interviews, although an original assumption of mine, is no longer a belief of mine after meeting and interviewing EB. Nothing in medicine is routine.