By Ella Eisinger
Ella Eisinger is a fourth-year medical student at the University of Pennsylvania Perelman School of Medicine. The essay below was a winner in this year’s American Board of Internal Medicine Foundation’s Building Trust Essay Contest, which explores the projects and initiatives by students in health professions around the theme of trust. “This essay really zooms in on a very formative moment of my clinical training,” Eisinger writes. Whether a patient ultimately follows their provider’s recommendations, she says, “this piece is meant to celebrate the process of building trust and … the core principle of patient autonomy.”
It was 11 p.m. on my Internal Medicine sub-internship when a new admission was paged out from the ED.
“67-year-old male, history of alcohol use disorder, presenting after a fall. He had a pint shortly before the incident.” My resident and I sigh. “Watch him, give him the vitamins––same deal as when he was here a few weeks ago. Probably just the classic ‘alcohol-induced ambulatory dysfunction.’”
I trudge to the exam room, prematurely irritated by the Sisyphean plan of a vitamin cocktail rolling down the mountain of substance use.
He lay in bed, somnolent, his downcast eyelids like lampshades masking provider scrutiny. His diffuse tremors work through Ativan’s sedating effects. [Ativan is commonly used to ease the symptoms of alcohol withdrawal, one of which is tremors, but in this case, the medication’s effect was transient due to the severity of withdrawal.]
“Mr. Hutson!” I yell, trying to get his attention. His eyelids droop further shut.
I haphazardly solicit a history from his mumbles, ultimately deciding to just consult his chart. After all, would this encounter truly be any different from the last five?
When presenting all of his electrolyte derangements, cardiac arrhythmias, and nutritional deficiencies to my attending, I let Mr. Hutson’s bottle count drench his entire problem list and, in effect, his personhood. The problem is alcohol, the solution is sobriety, and the perceived infeasibility of the latter leaves me ill motivated to probe any deeper.
Later in his room, I watch my attending lower herself to his eye level. She sits back on her heels, takes his tremulous hand in hers, and stares earnestly into his eyes. She asks him who he likes to drink with and why. He replies that he drinks alone, that it is the one-year anniversary of his son’s death, that the alcohol soothes his hurt. She asks if he would be open to quitting, to which he says that yes, yes he would but no, no he would not wait in the hospital for rehab placement. She gently presses further, citing her concerns about relapse and invoking the worries of his daughter, who lives too far away to act upon the falls recorded on her self-installed home monitors. With several more minutes of teary-eyed conversation, he acquiesces, agreeing to stay inpatient as a bridge to rehab.
I am internally slack jawed, awed by the power of a clinician’s authentic care to guide a patient toward a decision that will benefit their health. Over the next few days, I practice getting down on one knee, speaking to the person and not the pathology, and creating space for vulnerability. We talk about March Madness brackets, he agrees to starting Vivitrol injections [a medication used to reduce cravings associated with substance use disorders], and I watch his eyes light up as he tells me about his daughter. The trust between us builds, and I start to write a happy ending.
And then, over 80 hours since his last drink and in the absence of any signs of worsening withdrawal, he seizes.
With a multi-day Ativan taper, he emerges from the grip of complicated withdrawal, still set on pursuing rehab, although now with steadfast intent to first return home. The precise timeline of rehab center referral, interview, and acceptance remain uncertain; we fear that each minute spent alone in his home would compound his vulnerability to relapse.
I kneel at his bedside, I call his daughter, I voice our concerns about the electrolyte-related ventricular arrhythmias captured on telemetry, imprudently grasping at fear tactics to catalyze a change of heart. But he refuses, adamant about returning home to have his living will be notarized. He is fixated on this affair, almost eerily so, as though he knows that life itself now delicately hangs in the balance.
And ultimately, who am I to deny this grown man the right to part from this life on his preset terms? To refute his desire to pack clean clothes for the courageous journey ahead? To question his wish to visit his son’s grave for fear of whatever sadness it might stir?
In the success story of patient trust, I had naively expected the patient to ultimately accede to provider recommendations. But trust is neither a thing to be “won” or an active “winning” of patient compliance. Trust is to meet a patient halfway, to walk alongside them, and to encourage them forward while never abandoning them should that journey grow circuitous.
And so I stop trying to persuade, again kneeling by his bed as I had done every day.
“Don’t worry about me. I’m a tough one,” he smiles.
I take his now-steady hand in my own and look into his now-open, mournful, yet hopeful, eyes.
“You are.”