Room 441

It was my first year of residency and my first week of night float. The term “floater” theoretically depicted the role well, as my job was to cross-cover for 30 or more patients throughout the night. However, it’s doubtful my ungraceful movement from the call bed to a patient’s room at two in the morning would ever be described as akin to a “float.” To prevent these ghostly runs, I always tried to get most of my tasks done prior to midnight.

That night, I was to follow up on a page from one of the floor nurses regarding a patient with end-stage renal disease who had recently received a kidney transplant. His body was now silently rejecting it. Room 441. Patient 441.

The task was simple: obtain his allergy information. For whatever reason, this information had to be recorded by a physician. And this patient had nothing on file. I arrived at his room and peaked in. What I saw caught me off guard–he was young. Too young. At first glance, he appeared relaxed as he lie on the bed in his hospital gown. I fidgeted with discomfort, and stepped back behind the door.

I find it odd that patient doors always seem to be open. Is this an effort by the patient to preemptively stave off feelings of loneliness and isolation? Or that of a rushed clinician, mentally distracted by thoughts of the next patient by the time they’re on their way out of the room? Regardless, consciously or not, privacy seems to become less of a priority in the hospital to both patient and provider. 441 was no exception to this oddity.

I pushed the door further open and shuffled into the room. My bloodshot eyes met his. He was curled up under a blanket, phone wedged between the pillow and his ear. Still unsure of myself, I double-checked my paper to verify I was in the correct room. The paper read “441.”

“I have to go, Mom. The doctor is here,” I heard him mumble into the phone. I hesitated, hoping he wouldn’t hang up. That he wouldn’t notice me. That he would finish his phone call and I could come back later. Not everything has to be done prior to midnight–or even by the night shift, I thought to myself. Before I could reconcile these thoughts, 441 had already hung up the phone and was looking up at me with anticipation. The youth in his face mirrored mine.

“441: pls document pt’s allergy information.” The brief page echoed in my mind. Suddenly, this felt like too simple of a task. Surely there were more pressing things I could be doing for this patient. I swallowed my frustration and introduced myself, quickly jumping into collecting the information that I came for. (Allergies: none). Making eye contact with the door, I told him to let me know if there was anything I could do for him overnight and turned to go. “Is that all?” he asked. I froze up. I knew what he was really trying to say: aren’t you going to do anything about this? He sighed with justified exasperation.

I had no extensive information about 441’s diagnosis or treatment plan. He was a late admission and a brief sign-out. I was clueless, helpless, useless. Uncertain of how to proceed, I asked him about how the transplant rejection was diagnosed. Biopsy, he explained. Uncomfortable silence. He didn’t know much else other than that, but it was clear he hoped I would. Once again I averted my eyes from his gaze, as I read and re-read the tiny sign-out I had scribbled on the paper in front of me. Upon further questioning, it was clear the knowledge of his plan was limited to names of medications and a vague hospital timeline. And yet, even that was more than I knew about 441 in that moment.

“Patient-centered care” is a concept that we’re introduced to in medical school. The goal is for the patient to always be informed about the ongoing plan and to be an active partner in the decision-making process. It’s our responsibility to make sure we practice in this way.

Yet, time and time again, many of the patients I meet are unaware of the specifics of their diagnosis and treatment plan. Often, all of these conversations happen behind closed doors without the patient present. As clinicians, we make presumptions about what’s best for the patient, and forge ahead without first consulting them to see if they agree. Many times, the patient is informed about these decisions only after the process of carrying them out has begun.

We tell ourselves (I tell myself): time is of the essence. If 441 knew what I knew, had the training and experience that I had, he, too, would make the same decision. 441 would understand, I say, and forge ahead.

In my intern handbook, there’s an excerpt on how to properly conduct morning rounds. The author encourages the reader to engage in bedside rounding. And by this, he literally means bedside rounding—to discuss the patient’s new findings, diagnosis and ongoing care plan at the bedside, where the patient can hear and engage in the discussion. However, clinicians often have this discussion outside of the patient’s room. Many decisions are made before the attending even sets foot in the room. Only then is  the patient informed of the plan, without the opportunity to hear the reasoning behind such decisions.

The Picker Institute, founded by Harvey Picker, is an organization that aims to promote patient-centered care. It details eight facets of patient-centered care: access to care; continuity and transition; involvement of family and friends; emotional support; physical comfort; information and education; coordination and integration of care; and respect for patients’ preferences. Within these principles there’s an emphasis on direct communication between the patient and their medical team.

I encourage us all to put the patient at the center of our thoughts until they are at the center of their care, too. I will put 441 at the center of mine. I will do so until he becomes more than a number, more than a four-line assessment and plan, more than a four-day hospital admission, and more than a one-minute sign-out.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.