Sam’s plans

Writing on the theme of ‘that one patient’, runner-up in Pulse’s writing competition Dr Fatima Anwar reflects on gap between clinical plans and patients’ own plans

‘My wife needs the car, can I go to hospital tomorrow instead?’

I looked up from my hurried referral letter. ‘Sorry, I’m afraid your liver isn’t working very well, you could become seriously unwell. You need to go to hospital immediately for some tests, you may be there for some time.’

Something made me feel uneasy. A telephone appointment had been booked for a gentleman called Sam, regarding a ‘sick note extension’. He described worsening symptoms – some worrying – and I felt an examination would be useful. He seemed surprised and reluctantly agreed to attend.

Sam arrived at the end of my session and took a seat as I apologised for the delay. ‘I need to get the car back to my wife, she needs to get to work’ he said, seeming distracted. 

Noting obvious visible signs of serious acute liver pathology, I asked again about his medical history and scrolled through his medical record. No recent pathology results, no medications, no past medical history. Aside from some telephone appointments, Sam had not been to the surgery in years.

His presentation suggested acute liver failure – admission and same day tests were essential. I turned to Sam, taking a moment before speaking. Conveying urgency and gravity was vital, and I only had moments to do this. I handed Sam a printout of his medical record and a letter for the medical assessment unit, as I explained the situation. Sam looked unconvinced and somewhat disappointed; he was worried about how his wife would get to work. We went over the possible diagnoses again, the importance of attending hospital as soon as possible. He nodded and quietly agreed with the plan.

I found myself thinking of Sam over the next week while away from the surgery. I wondered what his investigations showed and looked forward to reading the discharge paperwork, hoping he was OK. 

At my next session, I discovered that Sam had decided not to go to hospital that day. Following some collapse episodes at home and two separate 999 ambulances, he went from MAU to ICU, and sadly passed away in intensive care within two weeks of our encounter. 

I was in shock and thought of Sam often; he had a family, job, plans, obligations. I spoke to my medic friends, my family, my husband, my appraiser and to myself on drives between work and my son’s nursery. I read about health belief models, reflected in my portfolio, and tried to make sense of it all. Could I have spent more time explaining, more time listening? What did I miss? 

‘Why? Why didn’t he go to hospital?’ I debriefed with a close friend, a medical registrar. She told me stories of patients from her ward, who regularly declined treatments and admissions, against medical advice. She told me that she had learnt patients have their own journey, and make their own decisions, some with which we may not agree. ‘It’s hard to accept, but we don’t know what they’re going through.’

Sadly, the circumstances surrounding this gentleman’s last weeks will remain a mystery, I can’t learn what was stopping him going to hospital and intervene, or address his concerns. A missed opportunity for understanding. 

Our patients are people with their own plans, responsibilities and obligations. The psychosocial context of the person sitting opposite us in the consulting room is of equal importance in determining outcomes.

Sometimes there is a gap between our clinical plan and the patients plans and expectations. Trying to understand the person as a whole, their life outside of the clinic room, their concerns, is essential in bridging this gap

Dr Fatima Anwar is a locum GP in Milton Keynes