Handoffs

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.

I'm used to feeling inadequate. Oftentimes, what ails my patients I'm not able to address, let alone fix. But one time I crossed the line from absorber of sorrows to active agent.

All set with my preconceived notions, I went into the hospital room to see Stan. He had severe hypertension and had had several previous transient ischemic attacks, and now he was back with another. His renal function was minimal, with dialysis coming soon. Despite our repeatedly having social work arrange outpatient appointments, he had never followed up. Last admission, they even gave him a month's worth of his antihypertensive medications, but here he was 6 weeks later off meds and admitted again.

I spoke with him but we got nowhere. He maintained that he could not afford his medication. I asked him why he didn't work. He said that he did do odd jobs, and besides, in a few months he would qualify for Social Security. I guess I was in a bad mood, so I heard myself ask, Do you realize you are playing with fire here? You will end up with a real stroke? Simply saying you want to wait for Social Security is not a plan.

Stan looked at me closely. Probably judging me to be about half his age, he said, Whatever, doc. Don't you have someone else to lecture? I sat down, took a deep breath, and tried to sound kind when I said, Do you realize that you will need dialysis soon? Stan replied that he had no intention of going on dialysis. We went in circles, with me trying to determine if he was delusional, suicidal, or trying to shock me. We left it as it was. The medical system would do its best, but his life was his to run.

Bending the HIPPA rules, I went to the nurse's station and called Stan's daughter to get some background, answers to questions like why she couldn't help him buy his medication. I was wholly in my righteous problem‐solving mode. Yet she was not alarmed by my dire prognostics. When the call was about to end, I asked if all of us could meet when she came to pick him up the next day. After a pause, she stated, I'm not coming up. Tell him to wait in the lobby for me. I'll be there to pick him up sometime after 5. Collecting her dad from the hospital on Christmas Eve, and she couldn't be bothered to enter the building? I hung up, sat back in my chair, and stared at my progress note.

I subsequently found out from the case manager that after being discharged, unlike before, he was going to a homeless shelter, not his daughter's house. I thought he must have been an awful father for a child to turn her own dad away on Christmas Eve.

Clearly, she had had no intention of picking him up from the hospital before my call; I had inadvertently shamed her into it.

I went back to talk with Stan. I decided to make inquiries of him based only on the information I was supposed to have. The case manager tells me you're going to the homeless shelter tomorrow. Don't you live with your daughter?

Not realizing that the doctors and case managers were on the same team, he seemed somewhat taken aback. I found a chair and sat down as he spoke. I wasn't always like this, you know. I'm not a drinker, nuts, or anything; I just was put out to pasture. I'm a computer programmer but not the new kind. I worked on those huge 1960s types. The personal computer revolution put me out of business. Before I had a chance to say anything, he continued, I know what you're thinking, I should have gotten trained or something to keep up, but I didn't, you know, I just didn't. I should've.

He must have seen a flicker of compassion on my face, as he went on, I've been staying with my daughter on and off for years. I'd get some job, get a place, but never for long. I don't like to stay with her. She has her own life, her own problems. She doesn't need me getting in the way, especially around Christmas. Around the holidays, I go to the shelter. My grandkids don't need me ruining the season.

He may well have been a lousy father, but I didn't see his medical noncompliance as a personal affront anymore. He should have made some different decisions in the past, but now he was a 64‐year‐old homeless man, alone. So, besides lecturing him on his blood pressure and work habits, could I do anything really helpful?

It didn't take me long to come up with something. The problem was how to approach it. Feeling like I was breaking some rule, I trailed him to the hospital lobby right after discharge. To my chagrin, he didn't so much as slow down. He saw his daughter's car, walked out, and got in her car before I knew what to do. Feeling like a fool, I stood at the window, noted how slate gray and dour the sky was, in complete contrast to the festive lobby, and thought about how useless I really was in the end. All my good intentions aside, he was no better off for having me as his doctor.

I bought myself a cup of coffee and while walking lost in thought, I literally bumped into Stan coming through the hospital's main doors. Laughing awkwardly, he said, I forgot my jacket in my room. He looked more scared now than he did after hearing my dire pronouncements of doom. He seemed like a child whose mother was angry at his forgetfulness. As he shuffled off, I couldn't stand it any longer. I didn't want him rushing around worried that his daughter would get fed up and leave. I told him to tell his daughter that I knew where his jacket was and that I'd be right back with it.

I got the coat, and when I approached him back in the lobby, I gave it to him. I then handed him the money I had set aside in my white coat. Trying to make myself sound casual, I said, Use this to take your grandkids out to dinner and buy them something. Neither wanting to give him a chance to say no nor wishing to make it more awkward for him, I quickly turned around and left without looking back.

As I resumed my $2 cup of coffee, I wondered if I had acted as a doctor, as a good Samaritan, or as an egoist? I was not deluded into believing I could buy his pride back for long with my pocket change. But maybe I could be a good person in addition to a caring, up‐to‐date doctor.

Later that day in the ER, a very sad place on Christmas Eve, I imagined Stan buying gifts or a fancy dinner for his family, just like he used to. He will need dialysis and probably will end up back in the shelter. I don't think he even knew my name, but maybe because I cared a little bit about what happened to him, he will, too.