A Case of Miscommunication

October 19th, 2010 by Danielle Ofri

A doctor lets a pushy patient get on her nerves before an emergency makes her realize medical care is a shared endeavor.

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The sun was already setting on Thursday when Diallo Amadou called me. “I not feeling well,” he said. “I need to see you, Dr. Ofri.”

I already had one foot out of the clinic door, and I knew that Mr. Amadou lived 45 minutes away. The whine in his voice was apparent even through his thick West African accent. “I need see you now,” he repeated.

In the few months I’d known Mr. Amadou, I probably had fielded fifty calls from him. He seemed to be always complaining, always wanting something, and always needing it right now. He always showed up without an appointment.

But, at only 43 years old, he also had a severe heart condition. At our first visit, he’d hauled in a stack of papers from a cardiologist in Pittsburgh. The papers detailed a severely malfunctioning heart, one that had required a pacemaker and a defibrillator and had entailed several stays in the ICU.

So when he called on a Thursday evening, I took his concerns seriously, despite the irritating tone of his voice. I questioned him about his symptoms to see if he might be experiencing congestive heart failure or an arrhythmia—in which case I would send him to the emergency room immediately. But he reported nothing specific, just a vague sense of not feeling well. I wasn’t scheduled to be in the clinic the next day—Friday—but because of his poor heart I didn’t want him to wait until Monday.

I called back and left a message. “Please come to the clinic tomorrow,” I said. “I won’t be here, but you can be evaluated by one of my colleagues in our urgent-care section.”

On Monday there was an indignant message from Mr. Amadou. “I come Friday, but you no there, so I go home. I need to see you!” My hands slapped into my lap with frustration. Either he hadn’t understood what I’d said, or he was simply being stubborn.

The next three days were a series of missed phone messages between us. If he was feeling sick, I told him, he should come to urgent-care right away. If he didn’t feel too bad, I could give him an appointment for the following week, as my schedule was already hopelessly overbooked for this week. He left repeated voicemails saying, “I need to see you, Dr. Ofri,” seeming not to acknowledge my messages to him. Whenever I called back, I only got his voicemail.

On Thursday in the waiting room, just as I was saying goodbye to my last patient of the morning, contemplating the possibility that I might actually have five minutes for lunch, Mr. Amadou popped into my line of sight. Tall and lanky, dressed in a powder-blue track suit, he signaled anxiously at me. “I need to see you Dr. Ofri,” he called out. “It is very important.”

I was unprepared for the rush of anger that flooded over me. It wasn’t just that I was about to lose that rare opportunity to eat lunch after an exhausting morning, but that Mr. Amadou would walk into my clinic and assume that I would drop everything and give him a medical evaluation at that instant. Yes, he had a bad heart, but that didn’t give him a free pass to be so demanding. Obviously, whatever was bothering him couldn’t be so bad, since he’d chosen to spend the week trading messages with me rather than come to the urgent-care clinic. I needed to draw a line.

“Mr. Amadou,” I said tautly, “you cannot just show up to the clinic without an appointment.”

“I come here to see you Dr. Ofri,” he said.

“Yes, I know,” I said, growing more exasperated. “But I have other patients with scheduled appointments, and there also are some days when I am not here. If it’s something that can’t wait, you can use the urgent-care clinic. Otherwise, you need to make an appointment like everyone else. I can give you an appointment for next week.”

“I no see other doctor,” said Mr. Amadou. “I only want to see you. I need to see you today.”

I knew that if I gave Mr. Amadou a medical visit then and there, I’d reinforce the idea that he could simply walk in to my office at any time. He’d be at my doorstep every week! But I also understood the severity of his cardiomyopathy—this was the type of patient I couldn’t take a chance on, annoying or not.

“Okay, Mr. Amadou.,” I said, sighing heavily, “just a quick visit. Next time you must have an appointment.”

Mr. Amadou smiled broadly as I led him from the waiting room and I knew I was going to regret this decision. Mr. Amadou had now figured out how to get an instant appointment, simply by being irritatingly persistent.

The medical assistant was about to leave for lunch also, but I gave him a beseeching smile. “Could you do a quick set of vital signs for Mr. Amadou?” I asked. He hesitated, raised an eyebrow, and then finally assented. With relief, I gestured Mr. Amadou into the assistant’s room.

Mr. Amadou took two steps, and then collapsed to the floor with a heart-stopping thud. There is always that dreadful moment of silence—which feels like an hour—when you realize that something terrible has occurred, when your body and mind are shocked from the ordinary to an emergency.

I dropped to my knees and grabbed his wrist to check for a pulse. “Mr. Amadou,” I shouted. “Can you hear me?” Mr. Amadou was breathing rapidly, his upper back slumped against the door frame, the rest of his lengthy body stretched out in the hallway. “Tell me what’s going on. Are you having any pain?” He placed his right hand over his chest. “My heart,” he said faintly, and I was swamped with a horrific wave of guilt.

By now a crowd had gathered around. The nurse was checking his blood pressure. His pulse was an alarming 130. His fingers were so cold that the oxygen saturation monitor could not pick up a reading. I listened quickly to his lungs, but there was no fluid build-up. I wasn’t sure what was going on, but it was obviously bad. I called for oxygen and a stretcher. We loaded Mr. Amadou’s listless body onto it and began wheeling him to the emergency room.

I held Mr. Amadou’s hand as we walked down the hall, striding briskly to keep my disconsolate pangs of remorse at bay, praying that he was going to be okay.

I felt horrible that I had upbraided him in the waiting room. How could I have been so harsh to berate him about acting entitled? But the truth was, he had been acting entitled. Mr. Amadou wasn’t willing to settle for anything less than what he wanted. Should his illness give him dispensation for selfish behavior?

We rolled Mr. Amadou into the triage bay of the emergency room. I explained the situation to the ER doctor while the nurses hooked up monitors and started an IV. As we finished the handoff of medical care, I turned back again to Mr. Amadou. I took his cool, clammy right hand in my two hands and gave it a squeeze. His fingers were frigid.

“Mr. Amadou, I’m sorry for how harshly I spoke to you in the waiting room,” I said. “And I’m sorry if we had a miscommunication last week.” He opened his eyes to my words, but was too breathless to speak. He nodded slightly and then squeezed my hand weakly.

I trudged back to the clinic, staring down at the linoleum floor the whole way. Despite my efforts not to, I couldn’t hold back from dissecting the events that had just transpired, trying to sort out the mistakes. Mr. Amadou had been demanding, probably unreasonably so. And I had put my foot down, perhaps a bit too decisively.

It was hard to know how much each had contributed to the current situation, but there was no doubt that our mutual missteps served to worsen Mr. Amadou’s medical condition. Had either or both of us been more flexible, perhaps Mr. Amadou would not have been on his way to the intensive care unit. Medical care is a shared endeavor and—as Mr. Amadou and I had just demonstrated—both doctor and patient share the blame when things turn sour.

I arrived at the clinic to see that the afternoon session was in full swing. Lunch was long since out of the question, but I’d lost my appetite entirely. Besides, there were already charts stacked in my box. The clerk handed me the first one. “Mrs. Velasquez doesn’t have an appointment for today, but she asked if you could squeeze her in.”

The impress of Mr. Amadou’s chilled hands still seemed to linger in mine. “Whoever shows up,” I said, “just add them to the schedule.” I took the chart from her hand and settled in for a long afternoon.

Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital, and editor-in-chief of the Bellevue Literary Review. Her most recent book, Medicine in Translation: Journeys with My Patients, is about the care of immigrants and Americans in the U.S. health care system.