THIS ESSAY WON THE FIRST ANNUAL EXPRESSIONS IN HUMANISM CONTEST, SPONSORED BY THE UICOMP CHAPTER OF GHHS
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A Measure of Performance
by Matthew Chia, Class of 2015
Copyright Matthew Chia, 2013 All rights reserved.
If there is a common axiom to modern medicine, it is that performance is discretely measurable. Throughout our premed and medical school curricula, we are judged on exam performance, letters of recommendation, or research accomplishments, each of which represent milestones that are meant to quantify our abilities and our hard work. In medical practice, there seems to be an ever-increasing number of external forces that evaluate, score, and count. Hospital administrators deliver policies and performance metrics, while Associations, Societies, or Groups deliver countless publications and guidelines. The insurance companies deliver miles of red tape, living by the rule “deny, delay, and refuse to pay.” While a physician might praise or curse any one of these, you might think that above all, a physician’s performance has been anatomically dissected into its vital components.
And so, a patient presents with poorly-controlled diabetes mellitus and depression. A physician can take his or her vast experience and apply it thoughtfully, balancing each and every one of the external forces that would test a physician’s competence.
But here’s the trick. Today, this patient didn’t present at all. She existed, and was well known to my preceptor, but I still don’t even know her name. Today, we saw her family, who came to us frustrated, tired, but most importantly, near the edge of despair. Our patient, who I will call Mrs. D, had fallen into depression and was refusing to take her 500 daily units of insulin. Her condition declined, blood glucose rising so high that her glucometer failed to even produce a number. Even as her mental status deteriorated, she refused to seek care, refused to allow her daughter to call 911, and refused to allow her husband to take her to her primary care physician, who she knows and likes.
In my mind, I was starting to quantify our inability to care for Mrs. D. I wondered about the legal ramifications of DNR, about reimbursements for hospice care, and about why we still didn’t have her chart in the room. But my preceptor didn’t balk at any of these things. He first recognized the pain the family was in, and the hardships they tackled each and every day. He carefully asked about Mrs. D’s symptoms and behaviors, and what her family had tried to do. After further dialogue, he told them that Mrs. D should get to the hospital, by the husband’s legal consent, or when she fell into a coma. But what stunned me was what he said to them last;
“Make sure to bring her here. If the ambulance takes you to another hospital, I can’t be there to take care of her.”
If that seems underwhelming, consider how anybody would measure this visit. Mrs. D received no care, and thus fails to meet policies and performance metrics that a hospital might set for diabetes patients. Her quality of care is certainly outside what the American Diabetes Association guidelines recommend. In fact, because there was no proper patient encounter, my preceptor spent more than half an hour in a way that insurance would not pay for. Ultimately, I realized that he cared deeply about his patient, whether or not his patient cared about him, or about herself. Mrs. D’s family knew that he was there to support them through this critical moment, and that Mrs. D had a real advocate. She was a case that could have been punted to another hospital, given up on, or forgotten about. In fact, I am embarrassed to say that our jam-packed schedule for the rest of that day was already on my mind. But my preceptor was properly focused on giving Mrs. D the best care he could give her.
I should now spend the rest of tonight studying about the sequelae of prolonged ketoacidosis, and the inpatient management of severely hyperglycemic diabetes mellitus. But today I saw a performance that showed me medicine beyond the rubric, medicine that exceeded measurement. It is a lesson that I will carry not on another scribbled notecard, but in my head, and in my heart.
