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an online version of the magazine Fall 2009
Learning Curve

Time to Listen

By Daniel Munoz, M.D. '04


Learning Curve
Illustration by Sherrill Cooper

The concept of time is too often seen as a bad thing in our health care system. There are the number of days a patient stays in the hospital, with a myriad of financial pressures to shuttle patients rapidly through the system.

There are the work hours of residents, with regulatory pressures to ensure compliance with strict time limits. There is the time a patient waits for a test or procedure. And once that patient is undergoing the procedure, there is the time it takes the doctor to complete it. Sequencing tests and getting people through the gauntlet of hospitalization as efficiently as possible is a constant struggle. The health care system tries every day to minimize time, or at least make time more efficient.

This emphasis on efficiency, while admirable (and the basis for graduate degrees across multiple disciplines), can sometimes pervert the practice of medicine. And in an era of health care cost paranoia, it can actually inadvertently increase rather than decrease the costs we create. In some cases, we miss the bigger lesson.

Case in (almost) point: "Ms. Margaret." She is 53 years old, born and raised in a West Baltimore neighborhood that most of us have seen only on the local news. Maybe because of what she witnessed as a child, maybe because her youngest brother was killed in a drive-by shooting, or maybe just because it was the work she could find, Margaret took a job in 1990 as a prison guard for the State of Maryland. She loved the job, and the idea that she was in some small way giving back to her West Baltimore neighborhood.

Nineteen years later, on a blustery December night, she walked into the Johns Hopkins emergency room with chest pain. I met her 36 hours into her hospital stay. By that point, she had been assessed in the emergency room, observed in the ED’s acute care unit, and had undergone dozens of blood tests, a nuclear perfusion stress test to look for evidence of coronary artery blockade, and been admitted to my internal medicine service for further evaluation.

As an internal medicine attending, I have plenty of available data upon which to base clinical decisions. By the time I get a case, there have already been layers of thought and testing (blood tests, radiographic imaging, stress testing, etc.) applied to a patient. On the basis of the available data, and my own assessment of the patient, I help oversee a patient’s hospital course, be it a brief or lengthy stay.

When my senior resident and I entered Margaret’s room, she lay in bed gazing out her window toward a postcard-quality view of the Hopkins dome. Her face was expressionless. She turned in our direction and stared blankly as we pulled up chairs. With prodding, she introduced herself to us, in a volume barely above a whisper. We teased out details of her history and of the episode of chest pain that had prompted her trip to the hospital. "When did the pain start? How long did it last? What did it feel like?"

There were some things that just didn’t fit. Her description seemed inconsistent with classic angina, the sub-sternal chest pressure felt by patients with significant coronary artery disease. Something was wrong with Margaret. But my gut told me it wasn’t her coronaries.

Reading through her chart just prior to entering her room, we had stumbled upon the fact that Margaret’s mother had passed away this past summer. Now, sitting in her room 30 minutes into discussing her atypical chest pain, I was on the verge of calling it a day. For reasons still not clear to me, I looked at her and said, "And I am sorry about your loss. Were you and your mother close?" And with that, the floodgates opened. She wept in front of two perfect strangers. "I am a failure."

She must have said that half a dozen times in the ensuing conversation. Last January, she quit her job to care for her mother, who had Alzheimer’s disease. After five months of full-time selflessness, Margaret watched her mother go to sleep one night. She never woke up. Now, six months after her mother’s death, Margaret was convinced she was a failure. She could not find work. She was behind on bills. And her worst nightmare was the thought of being a burden on anyone.

Two nights ago, lying in bed, she wondered whether things would be better if she were to go to sleep and not wake up. She never fell asleep. Instead, she drove herself to the ER.

Wiping tears away, she looked me in the eye and said, "Doc, I just needed a break from my life. I just need some hope." For the next 20 minutes, we talked about how to find it. We talked about the courage inherent in asking for help. Not once did her chest pain again enter the conversation.

An hour after we met Margaret, she was ready to leave, and eager to start the outpatient counseling sessions we had set up for her. And that’s what it took. Sixty minutes.

Neither a battery of blood tests, nor a CT scan, nor a nuclear cardiac stress test (all done with blistering efficiency) changed her situation.

But I hope that hour did. *


— Daniel Munoz is a second-year cardiology fellow.
 Take Two Carrots and Call Me in the Morning
 Judgment Day
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
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