Narrative in Health Care – Telling

The Story of Quality Patient Care

Dr. Vincent Lam, CCFP

Emergency Physician, Toronto East General Hospital, Lecturer, University

of Toronto

Case 1: “Just can’t sleep”

• Patient: 81 year old South Asian woman

• History Present Illness: Unable to sleep, felt panicked last night, unwell this AM, no pain

• Other Stuff We Know: 3 months history exertional chest pain, suggestive of coronary artery disease, diabetes, hypertension, hyperlipidemia

• unable to meet target heart rate on recent stress test due to mobility issues, scheduled for Persantine scan (today!)

What’s The Story?

• Third visit to ER in similar scenario – ie:

unable to sleep prior to Persantine

• Son says: “The cardiologist says she must

have the test.”

• Daughter says: “This is the third time the

Persantine has been booked.”

• Patient says: “I’m scared of the test.”

Quality Options:

• A) ‘Standard of Care’: Tell patient there

she will have to do what her cardiologist

says.

• B) ‘Best Quality Health Care in World!’:

patient must not travel to India.

• C) ‘Quality Communication’: to weigh

options.

“Statistics cannot substitute for the human

being before you, statistics embody

averages, not individuals.”

Jerome Groopman,

How Doctors Think

Case 2: “It’s just a little cut”

• Patient: 18 month old boy

• History Present Illness: ran into coffee

table, smashed glass top, cut near eye

• Other Stuff We Know: waiting in ER for 6

hours, holding bag of cheesies, has

destroyed play room, WAY past bedtime

(11 PM)

What’s The Story?

• Mom: “Is this an emergency department? It’s

your fault! I’ve been waiting for hours! No one

told me not to feed her! you expect me not to

feed my child? I’m raising her on my own, do

you know how tough that is? I haven’t had a

good night’s sleep in months! You don’t

understand! You are an *%&hole! WHAT am I

supposed to do for three hours?”

• Patient: laughing hysterically, uncontrollable

The Story Continues…

• “You #*^%head, you @*&%ing (insert

racial slur), you can’t make me wait

around, I’m getting out of this @)(&hole!”

• Mother leaves with child.

• Observant nurse: “That’s a mom on the

edge.”

• Physician colleague: “Nicely done!”

Quality Options:

• A) ‘Duty of Care’, ‘Standard of Care’: Call Children’s Aid Services.

• B) ‘Mom-centered care’: Let the kid have a scar.

• C) ‘Quality Companionship’: Ask my supportive colleague for advice, then document his advice clearly in the chart, so that we can keep each other company in court.

Case 3: “She said she never

wanted life support…”

• Patient: 67 year old female

• History Present Illness: Unsteady on her

feet for several weeks, not seen several

days, found today unresponsive, in ER

with agonal respirations

• Other Stuff We Know: Living in basement

of relative’s home, husband died of

metastatic lung cancer within past year,

What’s The Story?

• Medical assessment: Critically ill, stroke,

pneumonia, needs intubation, aggressive

resuscitation for any chance at survival

• Family says: “She saw what her husband

went through. She said she never wanted

life support…”

• Meanwhile, in the overloaded emergency

department, “phew!”

The Story Continues…

• Sister: “It’s time.”

• Family, lots of family, “Come to say

goodbye to auntie.”

• Excellent internist: “Vincent, I just want to

see what you think about something…”

“Vincent, I just want to see what

you think about something…” • The words: I don’t know what’s going on here,

and I’d like your opinion.

• The subtext: You totally missed the boat, and I’d like to point that out in the nicest possible way.

• The upshot: This is going to be tricky…

• Medically: Intubation? Or…

• BIPAP? Chest tube? Is this life support?

Quality Options

• A) ‘Stick to Advance Care Directives’: No

further aggressive measures, because the

patient didn’t want life support anyways.

• B) ‘Highest Technical Quality’: Aggressive

resuscitation because we might save this

patient’s life.

• C) Is there a bio-ethicist on call?

???

“The practice of medicine is an art, not a

trade; a calling, not a business; a calling in

which your heart will be exercised equally

with your head. Often the best part of your

work will have nothing to do with potions and

powders.”

Sir William Osler