Her Father Thanked Me

I was a first-term registrar, getting my head around the process of working as a GP. Well-supported, but still feeling out of my depth sitting in a room with patients, no other doctor there to supervise. A telehealth consultation (one of my least favourite legacies of COVID-19) with a young woman I had never met, reporting increased symptoms of indigestion and needing a new script for a PPI. Discussed, given a new script, recommended review in person to examine and assess for other issues.

Another call, several weeks later, no improvement in indigestion, a red flag. Again exhorted the patient to present in person and provided a referral for a gastroenterologist closer to home to review. A few weeks later, another call, this time from the patient’s mother, reporting an admission to hospital for aspiration pneumonia, receiving antibiotics. I organised for a copy of my gastroenterologist referral to be given to the treating respiratory team and to organise an inpatient consult while admitted. Not actioned, patient sent home a few days later with oral antibiotics.

After discharge she saw the gastroenterologist, organised for endoscopy, but the patient did not have private health insurance so was placed on the waiting list at the public hospital in her area.

The patient finally presented in person to see me. I’ve rarely seen any patient look more unwell outside of a resuscitation or intensive care context. Barely able to walk 20 metres to the consult room due to shortness of breath and fatigue, pale and drawn. Heart rate elevated, oxygen saturation reduced, bloated and tender abdomen.

I called the ‘real doctor’ at the hospital to figure out when her endoscopy may happen, and was told that no public endoscopies are performed at this centre of excellence (definitely not true), and rudely dismissed. Organised with the patient for immediate emergency presentation, which she was reluctant to do as she had felt so dismissed with her recent pneumonia admission. Eventually convinced to go with family to the hospital again, and when I called later in the day she was waiting on CT results.

Calls to follow up with the patient after this went unanswered, no documentation available from the hospital.

Eventually I received a call from her mother: metastatic cancer, likely signet ring cell carcinoma, although she was too unwell for biopsy to establish an exact diagnosis. Discharged home for palliative care, a family member a nurse and able to administer medications at home. The palliative care team had asked if the GP could be organised to complete her death certificate with her eventual passing, and so her mother called me. I was the only GP she had seen in the last 12 months.

I agreed and provided my mobile number, if the patient were to pass overnight then to call in the morning and I could be there. A few short weeks later I received the call while on my way to work, blocked myself out for a few hours (it would be an hour’s drive to her parents’ house), and went to visit the family.

I felt so many emotions while driving, primarily guilt and questioning what could have been done differently. When I arrived, I sat outside in the car for a while, suddenly anxious as to how this would go. I’d certified many deaths before, but always within the safety of the hospital, very much contained within the walls of a health care setting. But here I was, in a normal street, outside a normal house.

The moment that sits with me most is going to the front door, being let inside, meeting her family. Her father shook my hand, looked me in the eye, and thanked me. Thanked me for being the person who took her seriously, who listened to her symptoms, who was worried for her.

She was more fragile than even the last time I had seen her (the only time I had met her in person alive), but peaceful in the hospital bed they had set up in her old bedroom, facing towards the large window with a view of the surrounding trees. I followed the old motions I had been taught and completed the documentation, sat with the family for a short while, and then left.

I know now that there really was nothing that could have been done between the first time I spoke to her and her eventual death. It took some time to get to that point, and I still wonder how her care may have been different if she had seen a regular GP sooner, or for other issues.

With any telehealth consultation now I think carefully through the symptoms and organise to examine patients promptly if they may need it. I try to always step outside my initial diagnosis and consider the differentials, consider what could be lurking and the steps that may (or may not) be required to figure out the problem.

But I will always come back to the gratitude and grace her father showed me. The importance of caring and listening and helping where we can. Most patients don’t expect us to know everything or do everything. They need us to listen, to take them seriously, and to care. It’s the most important thing we can do, and the rest can come from there.