Friday Before Christmas
On the Friday before Christmas, I received an unusual gift.
Like any job, being a primary-care physician has both challenges and rewards. The challenges are many, and the rewards are often fleeting--a smile or a "thank you" from a patient or coworker, for instance. And I've found that being a teacher of medical students and residents brings an additional layer of rewards and challenges.
One Friday before Christmas, these arrived in an especially potent mix.
The afternoon started simply enough; I met with the three senior residents to review their patient schedules. We identified a few problems: Beth had a patient who was demanding more tests than Beth believed were warranted; Rebecca was struggling to sort through the medical and cultural issues involved in an elderly Chinese woman's treatment; Mark was seeing Melissa, a middle-aged, HIV-positive woman recently moved from out of state and experiencing a number of confusing symptoms.
We discussed, planned and prepared; the office was full of cookies and cheery decorations. With three highly competent residents on hand, I hoped that I might complete enough of my own work to free up time on the long holiday weekend ahead.
Towards day's end, Mark came into my office, looking anxious. He plopped down on a chair facing me.
"There's a problem," he said. "Melissa, the HIV patient? She wants me to lie for her."
"Really?" I asked, stalling in hopes of giving him time to think through the situation and come up with his own solution.
"She was in the emergency room last night," Mark said. "When she was discharged this morning, they gave her discharge papers to her boyfriend Todd, and he read them. The papers show her HIV-positive status. He's demanding to know if it's true, and she's afraid of him. She wants us to tell him that she's not HIV-positive, no matter what the papers say."
As Mark talked, my thoughts swirled: How can someone in the ER have been so careless? If Melissa files a grievance for this breach of privacy, what will my role be? If I back her up, an ER nurse might lose his job. But if we tolerate this violation, how can we keep our patients' trust? More alarmingly, how could Todd not know about Melissa's infection? Although he's not our patient, what are our obligations to him?
Feeling lost, I fell back on a standard technique.
"What do you think we should do?" I asked.
"I'm a terrible liar," Mark responded. "And I don't know what's best for her. She says she's afraid of what Todd might do if he learns that it's true. She's in the exam room, hiding from him."
I took a deep breath, unsure of what to say. As staff members packed up, put on their coats and cheerfully wished each other good holidays, Mark and I sat together, speculating about Melissa's fears and trying to anticipate Todd's reactions. Meanwhile, the office manager and the security guard were reminding us that it was time for all patients to leave the building.
Finally, still without a plan, we went to talk with Melissa.
In the face of her desperate distress, our apologies for the ER's breach of confidentiality seemed pitifully inadequate. Her fear of abandonment, her anger, her denial filled the room. If we didn't tell Todd the truth, she would have to; but she refused. For now, she was safe in the exam room, but Todd was still waiting, and the long holiday weekend loomed. We didn't know if he would become violent now, later or never.
I knew that I wasn't providing meaningful solutions, and I feared that I wasn't modeling skillful crisis management, either.
Finally, Mark turned to Melissa.
"Here's the deal," he said. "Todd knows something. While we're all here, either you can tell him the truth or we can tell him. If we don't tell him now, it'll be hanging over your head all weekend, and it's a long weekend. I feel very bad that you're in this situation, and I want to make it better. How can we handle it together?"
After a pause, Melissa spoke, her voice thin and defiant: "Okay, you can tell him that it's true."
We walked with her out to where Todd stood waiting. From the corner of my eye, I saw the security guard, alert, shoulders tense. Behind the snowflake-festooned door of the exam-room area, I knew, the office manager was poised to call for any help we might need--a taxicab, a psychologist, an ambulance or a police officer.
Before anyone else could say a word, Melissa burst out, "It's true--I am HIV-positive. But it's being treated."
Todd sank into a chair, tears streaming down his face. He stood, took a few steps, collapsed into another chair, then rose again.
He began to talk, his voice rising to a near-yell then falling to a sobbing whisper: "But I love you--how could you not tell me?...How can you doctors just sit there and let her kill me?...I don't know what to do...For my birthday you gave me chlamydia; is HIV my Christmas present?"
Melissa was by turns angry, pleading, defiant. "I love you, baby. I was scared. This is hard for me, too! I meant to tell you, but I didn't know how. I love you, too...and I'm scared." Betrayal, abandonment, anger and fear roiled the air.
By turns, Mark and I tried to offer comfort, information and reassurance. We gave Todd the names of clinics that did HIV testing; we scheduled Melissa to return after the holiday; we gave them both a crisis-intervention hotline number.
We watched as Todd's role changed from villain to victim, and as his mood turned from frightened anger to resolute acceptance. Eventually, emotions spent, shoulders sagging, footsteps uncertain, Melissa and Todd walked out into the night together.
Feeling equally exhausted, Mark and I stayed behind to talk. I was hoping that I'd helped Melissa and Todd begin to face the rough road ahead; Mark seemed relieved that the crisis was over and that he hadn't had to handle it alone.
Before leaving, I reflected on the gifts of the season. I remembered again how one of the deepest rewards of medical practice is the privilege of seeing people at their most vulnerable--and their most human.
On this day, I realized, I'd received a rich, terrible, fragile and beautiful gift indeed.
About the author:
Deborah Pierce is a clinical associate professor of family medicine at the University of Rochester, NY. Her story Concierge Care appeared in Pulse a year ago. "I love the richness of primary care and write sporadically as a way to process the intensity of clinical medicine. I'm especially glad to have a chance to reflect on these events in writing without causing any further harm, because so many identifying details have been changed to protect the individuals' privacy."