Family Medicine: Day 9, 10

The doctor with whom I am working asked me to see a patient who came in to talk about diabetes management. This patient, she had told me, was considerably non-compliant with our interventions and the importance of monitoring her blood glucose regularly. The patient was young, but had significant morbidity associated with poorly controlled Diabetes; she had some peripheral neuropathy, poor vision, and recurrent yeast infections. After looking through some items I planned to speak with her about,  I went into the patient’s room, and I introduced myself. The patient quickly asked me, “you have to follow them HIPPA rules, right?”, to which I hesitently responded,  “Yes, whatever you tell me will be held in complete confidentiality, aside from 2 exceptions: if you are planning to harm yourself or someone else, I must contact proper authorities to maintain the safety of yourself and others”. She then quickly began to tell me about her anxiety and depression, which has been causing her significant distress over the past several months. This patient has a child with developmental disabilities, who can be exceedingly challenging to care for at times. She also was suffering from many other stressors, including loss of employment, feelings of failure, mental abuse from her husband, and the lack of a good emotional support or friend. I listened to her empathetically, and I managed to slide in questions about the diagnostic criteria for depression (SIGECAPS), and I found that she met criteria for clinical diagnosis of depression, without thoughts of suicide or homicide. I felt really overwhelmed by the difficult situation this patient was in; I have completed my psychiatric clerkship, but the interaction felt a lot different in a family medicine office visit than in the psychiatrist's office, especially since this interaction was completely unexpected. The main concern that this patient had was the fact that she utilized an illegal substance in order to deal with the stress of caring for her developmentally disabled child, and she wanted to quit with help from us. We were able to prescribe to her an antidepressant and an anxiolytic for acute attacks, as well as referring her to our psychologist for further assistance, and we will follow up with her again in a week.

The whole interaction was so quick. The scheduled office visit was for 10 minutes, but we spent much longer than that with her. As it happened, I wish I would have spent more time with her, and directed the conversation a little bit more (I had allowed her to talk freely with empathetic statements to encourage her to speak freely - its what we do on psych, but not very time efficient for family medicine!). It’s never easy to ask about suicidal or homicidal ideation, and I hope I didn’t make her feel uncomfortable with my questions. I look forward to seeing her in the clinic for a follow up visit, knowing that I will have had some time to prepare for the encounter.  I do feel like I handled this situation fairly well, but it emphasizes the fact that you never know what to expect when you walk into a patient’s room, and it is best to remain open minded. I’m glad that I didn’t have this experience when I first started third year rotations, because I would have felt completely off-guard; it’s reassuring to know that I was able to handle this interaction without too much of my own anxiety!