Can team-based medicine prescribe trust?

Hospitals diligently sweep the specters of morbidity and mortality into darkened corners so that patients can walk through bright hallways of hope. Yet somehow, tendrils of doubt creep into Martin’s room and find refuge. The Venetian blinds deflect all evidence of the blazing summer sun. This is a grey, grey room. Martin’s mother remains a daily sentinel at Martin’s side, yet seems too worn to expect happiness for her son. I think of Dorothea Lange’s black and white dust bowl mother. A sunken darkness encircles Martin’s eyes, contrasting starkly with his general pallor. At only 19, he is far younger than me, but 10 years of chronic pain have drained something intangible, yet surprisingly evident, from him. He is, in his own words, a “parasite” on his mother. “Hopeless, helpless, and pointless.” And that is it: that is what I feel. The harpoon of his hopelessness dragging me to the bed where he stretches, pinned down by despair. I talk with Martin for hours about frustration, loneliness, and living with pain, visiting doctor after doctor without avail. He emigrated from Poland years ago to live with his mother here in New York City. Surely he arrived on a plane, yet I see him on a raft, unable to navigate the waters around him. He dropped out of school and work because of his symptoms, and now finds himself friendless and adrift in a foreign city. The psychiatrists tell him that he needs antidepressants, but Martin refuses to take drugs that will alter his mind. And how can I blame him? On that raft, his mind may seem like the only thing he has left. As a medical student, I am powerless to prescribe Martin anything to ease his pain. Rather, I scramble to understand for myself the medications and action plans already established for Martin by Psychiatry. By Neurology. Ophthalmology. Pediatrics. Pain Management. Luckily, I do have the time and wherewithal to recognize that Pain Management is telling him to take more of Medicine A, even as Neurology tells him they cannot diagnose his condition unless he weans himself off that very same medication. Ophthalmology states his situation does not warrant an inpatient evaluation, while Neurology presses for an immediate eye exam. Psychiatry recommends Antidepressant B, C, or D, but the last thing Martin will tolerate is clouding of his mind. Stormy waters to navigate indeed. I visit Martin for updates and to inquire about previous treatments. He focuses his gaze at a point in the stale air between us without committing to my eyes. With a sigh he launches in to a well-oiled rumble of speech accounting the history of his chronic headaches and the interventions other hospitals have tried. “It’s all the same,” he concludes. I return to see him every day. One morning I enter Martin’s room, my white coat pockets overstuffed with faxed records from other hospitals. I attempt to pull one paper out of my pocket only to release a tangled origami trap of documents onto his bed. A half smile tickles the corners of his mouth. I sit beside his bed and together we sort through the tests and procedures he has already endured. Together we read the contradictory advice. He slouches further into his bed as his faith in his “teams of experts” dwindles into a callow dream. I reassemble the pages, and as I stand to leave, our eyes meet. I anchor him here for a moment. I organize a multidisciplinary meeting, no small battle in this hive of buzzing consultants. Everyone arrives except the attending neurologist who sends a pair of residents in her stead. After deliberation, we arrive at a unified plan: inpatient eye exam, continue Medicine A, try to convince Martin to take Antidepressant C. This coherent plan agreed upon by each specialty, fuels my optimism. I return to Martin’s room after the meeting to talk about Antidepressant C. He stares into the corner where his mother is seated. “Chronic pain is already altering your mind,” I say. “We believe this medication will actually make you feel more like yourself again.” I add, “This is the single, best plan we came up with after talking with each other… You are in good hands.” I smile—an offering. Finally, Martin agrees to take Antidepressant C. He looks into my eyes, “Ok, I’m willing to try.” “You’ve made the right decision,” I declare. My chest fills with a rejuvenating wave of hope. Does my excitement lift his spirits a bit too? Is he sitting a little higher in his bed? I touch his shoulder for a moment before I leave and somehow his room seems less grey. His mother smiles when I say goodnight. The next day I am not on the ward. The attending neurologist reviews Martin’s file, comes to see him, and tells him to stop taking Antidepressant C—to take B instead. When I return, Martin is not taking either antidepressant. He barely talks. His mother turns to me and demands, “Why can’t you doctors get it together and figure out what is happening to my son?” Her knotted face of frustration deflects my feeble explanation that Antidepressants B and C are very similar. Statue-like, Martin and his mother stare back with a cold, marble resignation. The next day Martin takes Antidepressant B with a small sip of water, understanding that it is his fastest ticket out of the hospital. He turns his face askance to mine and looks instead toward the window and its blunted sunlight. I feel his trust in me untether. I hand Martin his weighty discharge summary, including the record we pieced together from other hospital admissions. He mumbles an unintelligible response and crams it into his backpack along with his new prescriptions, perhaps atop those written by the doctors before us and the doctors before them. They are useless pages, lacking the compass of trust that might point him toward recovery. As Martin wordlessly leaves our ward, I am left wondering if we have helped ease his pain, or if he leaves us as unmoored as ever, drifting on his raft—searching for hope.