June 23, 2011

Matters of the heart

My sketch of the human heart during first year anatomy.
She whispered to me with bulging eyes of urgency, “something is not right, I’ve been in pain all night.” Her chief complaint was chest pain.  She had a routine work-up and some care with little relief.  The news came that all of her test results were normal.  Her body appeared tense, she looked panicked and afraid.  At bedside, the attending suggested endoscopy offering that her pain may be related to a gastrointestinal condition.  I introduced myself immediately as a medical student and quickly advocated for a cardiologist consultation. I mentioned that a few months prior she had been rushed to this hospital by ambulance with what had been determined as idiopathic ventricular fibrillation. The attending shook his head, he started moving toward the nurse’s station and I followed behind.  He reviewed her case with me again and then he shouted, “endoscopy” then I said “cardiology consult.” I left quickly without waiting for a response because I was trembling with fear.
As I sat outside trying to figure what my next steps would be, my phone rang and it was the nurse, she said that the attending had agreed to the cardiology consult. I returned to our house to care for my grandmother, in the absence of my mom she had no caregiver.  In the afternoon the cardiologist called me to express his concern with mom’s condition. He recommended, pending insurance approval that she be transferred to another hospital (the one that I had told her to go in the first place) for more tests and further observation.  This hospital did not have a full cardiology service and would be closing for good within next 72 hours.
Mom was transferred that night, additional test results showed significantly block coronary arteries. Early the next morning she had cardiac catheterization to open her blocked blood vessels. After a short hospital stay in she returned home. 
For a medical student learning to observe in clinical settings is a skill that comes with practice, time as well as teaching.  Furthermore, bearing witness involves seeing the whole patient taking aim at focus beyond the chart to examine the situation. The recently released book by Dr. Augustus White, Seeing Patients: Unconscious Bias in Health Care (Harvard University Press, 2011) offers the following:
“...the race and sex of patients [influences] physicians’ decisions about whether to refer patients for catheterization...If you were black, the report (Schulman et.al) concluded, you were less likely to be referred.  If you were a woman, you were also less likely to be referred.  And if you were a black woman, you were especially less likely to be referred.”
While some have criticized Dr. Schulman’s research as “exaggerating the disparities” inequalities in treatment and care are demonstrated in his efforts providing evidence for the need to improve health care as discussed in the report  Unequal Treatment Confronting Racial and Ethnic Disparities in Healthcare by Brian Smedley et. al.  As an African American woman who is a physician-in-training, I’m glad to witness good medicine as well as mom’s progress.

Cross-posted  at KevinMD.com

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