I received “Pulse: Voices from the Heart of Medicine” this Friday and was an struck by an essay entitled The End of Nice. In this essay, the author remembers an experience that occurred 20 years ago when she was in training and working in the Emergency Department. The beginning of the essay is as follows:

“Mouse bite, one year ago” read the Chief Complaint entry on the chart I picked up from the “nonurgent” pile.

I was a second-year medical resident, on an eight-week stint in the Temple University Hospital emergency room. It was 3:50 am, the beginning of the end of the night shift. All hell could still break loose before my shift ended, but for now we were in a lull, and the less serious cases got our attention.

I looked at the time of triage for the mouse-bite patient. Five o’clock the previous afternoon.

“Mouse bite one year ago! And the patient’s been here eleven hours!” I exclaimed aloud to no one in particular. “What the fuck? What idiot sits here all night for that?”

“Nice potty-mouth, Kaplan,” commented Dave, the other resident on duty, as he wrote in a chart. “And where’s your compassion? Remember, that’s a suffering person you’re talking about.”

The author, Rosilind Kaplan, goes on to describe the gradual loss of compassion that occurred over the 6 years of medical training but culminating in this Emergency Department experience where people arrived with knives stuck in their chest with the explanation “I slipped and fell on it” as well as people cursing her for saving their life. She points out in narrative form what we know all too well. Many who seek care in the Emergency Department have limited capacity and often suffer from mental as well as physical illness. They are difficult folks to care for and the care providers often suffer from burnout.

In the case of the mice bite it turns out that  the patient was excessively worried (even obsessing)  about possible damage to her body festering unseen and so came at 4:15 in the morning:

“Sometimes I just worry. I start thinking about something and it gets bigger and bigger in my head, you know?” She spoke quietly, looking down.

I did know. But I wasn’t going there at 4:15 am.

“I started thinking about this yesterday and how it might have been a rat and I could have rabies. I never went to a doctor, and what if I die from this because I was stupid? So I came.”

I, too, remember some very similar experiences from my training. When I was a second year medical student at Tulane, I was working in the Emergency Department at 3:30 one night and was given a patient to evaluate who had been waiting to have a cyst evaluated for 4 hours. Being a 24 year old with not much life experience and no experience draining cysts (so he would have to wait for a real doctor anyway) I asked him what had made him seek care in this setting at this time.

He said ” My wife and I had a fight, my kids are out of control, and I felt that the Charity Hospital Emergency Department was as good a place as any to think through my problems. Oh yeah, and I can get a cyst taken care of in the mean time as well.”

While rounding in the hospital this weekend, I encountered a patient who suffers from somatization disorder. I was struck not by her lack of insight into her illness (multiple symptoms with no physiologic explanation), nor by the damage that had been done to her by the medical system (multiple surgeries for pain type symptoms with no clear pathology identified). I was struck by the certainty that she has rejected multiple opportunities to develop a trusting relationship with a doctor. She described for me multiple visits to    faceless Emergency Physicians who she felt could certainly be able to fix her wiring and stop her persistent though transient pain and weakness.  As we discharged her, making her an appointment in our office that I knew she wouldn’t keep, I thought back to my days as a student and attending in the Emergency Department.  I hope someone talks to her before ordering another MRI and neurosurgical consult.

20 years away from these experiences offers perspective. Practicing primary care, we use relationships to ferret out the real cause of our patient’s symptoms. In concluding her essay, Dr Kaplan says, and I concur, that while “real disease” may be causing the symptom, situational anxiety and depression are never far down our differential. Our patients, though, seek out our brand of care. I chose to work in this setting because I want to know who is in the exam room before I knock on the door. Health care reform offers opportunities to move some of these difficult to reach patients into primary care as well, as described here by Atul Gwande. Are we ready for them?