Some years ago, the San Francisco General Hospital (SFGH) ER staff printed up really cool T and sweatshirts that read: San Francisco General Hospital—As Real As It Gets. Though I’ve been quietly coveting those shirts, wishing there was a nice silk blend button-down version I could wear with my slacks in the clinic, I imagine the Highland Hospital ER in Oakland gets just as real if not realer. I did my internal medicine/primary care residency training at Highland Hospital. For my very first month out of Duke medical school as a brand new intern, I was assigned to the ER. Highland. Hospital. E. R. Now, in case you’ve forgotten or you are new to my blog—I’m just a country girl from Spring Lake, North Carolina. I had never in my life seen anything like Highland’s ER. And it wasn’t the pretty new one featured in The Waiting Room; it was the old, not even close to pretty one crammed with so many patients they were spilling out of the rooms into the one long hallway occasionally tied to gurneys with four-point restraints and a nylon mesh bag over the heads of “spitters.” I was a fish out of water for sure. (Or, in city-fied translation—I was in a setting extremely unfamiliar to me, and uncomfortably so.)
Still, I grew to really enjoy my time in the Highland ER, so much so that I contemplated switching to the emergency medicine residency program. I liked the laid back, yet intense personality of the people who worked there. I liked the variety of things you would see in a given 12-hour shift. I liked to sew deep cuts closed.
A primary reason I ultimately decided to stay put was that I was drawn to the concept of “patient continuity.” I liked the idea of seeing Ms. Jones, Ms. Chen, Mr. Smith over time. Over years.
One would think nephrology would easily lend itself to “patient continuity”—with its chronic kidney disease that usually takes years, even decades to worsen to end-stage disease. And even then, if a patient so chooses, there are years, even decades of dialysis. Or, if a patient is one of the chosen, there are years, even decades of transplant. I think this is mostly the case in some settings, but in my clinic at SFGH, I often find myself in the situation of meeting someone for the first time and maybe never seeing them again, or if I do see them again, they’ve seen my colleague, the physician assistant, and a monthly rotating nephrology fellow or three in between. Such is the nature of a specialty clinic… in a public hospital… with a teaching program.
This is a particularly bad thing in our clinic dedicated to taking care of patients with advanced chronic kidney disease. People often come to the clinic for the first time with less than 15% of kidney function left, sometimes less than 10%, sometimes already having symptoms of kidney failure.
There’s not a whole lot of time for getting to know one another. Me learning how they see themselves in the world. Them coming to see that I am a doctor who will provide the best care that I know how to provide to them, that I am trying to do right by them. This naturally comes from seeing a person over time. Over years.
Here it’s time to talk about getting ready for dialysis…or not. Or it’s time to talk about starting dialysis next week…or not.
It’s hard to have to have these literally life and death discussions with someone on first meeting. Like you’re meeting a blind date for a drink just to see if you like each other enough to move on to dinner—and he tries to grab your goodies.
Sometimes I feel like I am able to quickly convey my sincerity in such a way that garners some patients’ trust that I at least know what I’m talking about, in such a way that allows them to follow my advice.
But sometimes, I feel zero connection. Like my words are perceived as part of some larger scheme to make money off of them or to simply kill them off. Like they want to look me squarely in the eyes and say what they appear to be thinking:
“Bitch, I don’t know you!”
Or maybe that’s just what I would say.