I just saw my internist for a preoperative exam for upcoming cataract surgery. This is my third encounter over the last year and a half. The care was medically sound and efficient. However, I later thought, “My physician doesn’t know me.” I know there have been many changes in the delivery of healthcare since I left my office internal medicine practice in 2005 to work exclusively in long-term care settings. However, I really enjoyed getting to know my patients as persons, which allowed me to contextualize the care I provided. 

Recently, I cared for an older patient in his early 90s who had already experienced metastatic cancer, pulmonary embolus, and other life-threatening illnesses in recent years. His Alzheimer's dementia had progressed to the point of needing 24/7 supervision. We were about to discharge him back home, where his wife was the primary caregiver, when he developed an acute GI bleed with hemodynamic instability. In the acute hospital, he was stabilized and was found to have a non-obstructing colon cancer too large to resect laparoscopically. His GI physician recommended resection of this cancer, telling his wife and daughter that this cancer could be cured with surgery and the risks were low. I am grateful that his wife had my cell phone. She first called his internist, who had become a trusted friend, and advised against the surgery. She and her daughter then called me, stating they thought surgery was too burdensome but also felt guilty for not wanting to take the GI physicians’ advice. I advised them that death was already likely within the next 2 years, with so many ways of dying.  In addition, the potential adverse effects of laparotomy and resection of a colon cancer were much greater than portrayed by this physician. I concurred with his internist that the best approach would be to discharge home on hospice with increased private home care, which is what happened. 

One of my frustrations when patients are referred to the acute hospital is that the wealth of information in my typed notes is seldom reviewed by the receiving physicians. In addition, I seldom receive a call from the ER or other hospital physicians regarding my reasons for sending a patient there, though my cell # is an integral part of each note. 

I fear we have normalized non-contextualized care in my community. In the interim, I am grateful to the families who trust me enough to contact me when faced with difficult medical choices.