THE ELDERLY man’s past medical history – the section of a patient’s medical chart that outlines all the diseases that the person has been diagnosed with in the past – read:
1. Extensive history of dementia with recurrent admissions to hospital.
2. Non-verbal at baseline.
3. Long-standing history of depression.
Then there was the rest (the nobler diseases):
4. Coronary artery disease.
5. Chronic kidney disease.
6. Prostate cancer, completed radiation therapy.
The resident, fresh out of medical school and in his first year of residency, started to read the patient’s past medical history to the consultant. The consultant was a tall, slim man who always wore a tie to work. He was a stickler for language. (He once corrected a student who had asked a patient for permission to examine his “tummy.” “Why do you talk to him as though he’s a child, doc? Do you think he does not know what the abdomen is?”)
The consultant interrupted the resident after coronary artery disease.
“What do you think about what you just said, doctor?”
The resident went blank. He was reading what someone else had written. He did not think much about it.
“What is non-verbal at baseline?”
“That’s what was in the chart.”
“That’s not a diagnosis, doc.”
“What about extensive history of dementia with recurrent admissions to hospital?”
“I guess he probably has advanced dementia.”
“Maybe. We don’t know. What would you say?”
“Say what he has: he has dementia. Say what he is able to do and not do. How capable he is would give us an idea of how advanced the dementia is. Remove recurrent admissions to hospital. Whoever put that there wants you to think that his current admission is due to the dementia. But we know that is laziness. What if his current admission is related to number four?”
“I will make that change.”
“So, what brought him in this time?”
“Sepsis, which has resolved. But his kidneys took a hit, and now they are wondering about dialysis and whether it’s appropriate.”
“What do you think about that?”
“I think considering that he may have advanced dementia, it’s probably not a good idea.”
“But I am not convinced that this man has advanced dementia.”
“He lives in a nursing home –”
The consultant interrupted him again.
“Have you ever visited a nursing home? Are all the residents the same? Do they all have advanced dementia?”
At this point the resident started to get annoyed. He thought the consultant was just being difficult now.
“I spoke to his daughter who used to visit him regularly at the nursing home. She said up to this admission he was still doing most of the basic activities of daily living on his own – like bathing, dressing, eating. He used a walker to get around. He took part in many of the group activities. She thinks he was having a reasonably good quality of life compared to some of the other residents there.”
“So, she thinks dialysis might be worth a shot?”
“Yes. But I am not sure she understands what it means to have long-term dialysis. I started to describe it to her: the three-times-a-week schedule, the duration, the complications. She said, based on what she knows about her father, he would want to give it a shot if it would allow him to maintain the quality of life he had prior to this admission.”
“And what did he say?”
“Well, he is not really able to communicate.”
“Right. He is non-verbal at baseline. Is that because of the dementia?”
“Could he say anything at all? Could he nod, yes or no? Could he understand instructions? Could he write? Could he read?”
“I am sorry, I didn’t do a full language assessment. I can go back and do it.”
“That’s OK. We can do it together.”
The resident felt less uneasy with those words.
They headed down the corridor toward the patient’s room.
“I went ahead and called nephrology to set up a meeting with the patient’s daughter and the social worker,” the resident said.
“I think that’s very reasonable. Thanks for doing that. It’s a complicated case.”
“Sorry about the vague past medical history. I should have dug deeper.”
“Shouldn’t we all? But alas, we prefer labels. We are too lazy to make an effort to understand. We have become specialists in lazy medicine. Modern medicine is lazy medicine. Time for me to retire.”
Taureef Mohammed is a geriatric medicine fellow. Email: firstname.lastname@example.org