A Patient’s Whole

Dear Ms. B,

I’m not sure if you remember the medical student who came in every morning at 6:30am for a week to check in on you. I, however, distinctly remember our daily interactions.

I was nervous during our first interaction – I had never taken care of a pregnant patient actively withdrawing from heroin use. Since you were anxious and irritated with your surroundings, I tried to be as brief as possible with my questioning, focusing on the usual vaginal bleeding, discharge, contractions, and fetal movement. Even though I was following the guidelines I have read over and over, and actively managing your recent heroin fix with Suboxone to help you come down, for me, the experience I shared with you was unforgettable.

As you were stabilizing on Suboxone over the next few days, I began discussing the possibility of discharging you on scheduled medications as you progressed with the pregnancy. That look on your face has stayed with me – I kept searching but couldn’t detect any emotions. You stopped. Then, the emotions began to flow through your tears. I remember being at a loss for words – you were doing so well that we stopped scoring your withdrawal symptoms. You were on minimal medications for symptom management. You were on the right path in a physician’s handbook for caring for patients with withdrawal.

After a long pause, you revealed that you really did not want to be discharged on Suboxone. Even if it was helping you improve day by day? Yes. Why? Your husband set an ultimatum for you regarding substance use. You had to be completely clean following delivery or he will take the other children with him and leave. Even if Suboxone can limit lapses and opiates’ influence on the brain and allow you to stop taking heroin? Yes.

That’s when I finally realized why you were so adamant with the medically assisted withdrawal treatment in the first place, and were reluctant with the usual Suboxone protocol. We should have had a discussion with you to understand where you were coming from when we initiated your treatment: your past heroin use, your goals for treatment, and your plans after treatment. I was so focused on your symptom management and ensuring that your baby was doing well, that I forgot to take care of you as a person and not just your symptoms. As doctors, we are adequately prepared to take care of symptoms with numerous medications and therapy. But when we have to dig deeper and figure out why a patient is acting the way he/she is or why he/she is feeling a certain way, we are often at a loss and unsure how to proceed.

In my eyes Suboxone is a medical treatment, a step towards overcoming addiction, and a method in which health professionals can do something for a patient. However, to you, Suboxone carries a completely different meaning: it equates to failure, a weakness in you, and lack of self-control. You saw using Suboxone to control withdrawal as an innate flaw in you. You chose to use heroin before, and therefore now, you should be able to choose to stop.

Through our brief interaction, you taught me that treating a patient’s physical symptoms are just part of a patient’s overall care. How can I adequately take care of you if I don’t know where you stand emotionally and what else is going on in your life? I can’t take care of the body and not take care of the mind. The mind-body connection is much stronger than we think. If you don’t want to take the medication, even if it’s the medication that is used to treat everyone else with your exact symptoms, you can’t possibly feel improvement if your mind doesn’t feel the same.

I am very grateful for the opportunity I had to take care of you. My treatment plan was inadequate because I didn’t know you – your thoughts, your bearings, your experiences, etc. Although my treatment plan can manage all your symptoms and keep your baby healthy, if you are not on board with the plan, that is still considered a treatment failure.

As the patient you should be at the center of all decisions regarding your health. I should be part of the support system ensuring that you are headed in the right direction. With you as my leading example, I will aim to try to understand who my patients are and what their goals are before prescribing a treatment plan. Going forward, I promise to try my best to take care of each patient beyond their physical symptoms and provide the honorable care that each one deserves.

With appreciation,

Emily Lee