American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, December 15, 2016

Without question

I was taking care of this grown man who was sick. His mama was at the bedside and she was worried about her manchild. Which makes sense because she's his mama.


This patient of mine has his own life, his own house, his own kids, and his own concerns about his health. And when I first rounded on him that first day, I was explaining everything that was happening to his body while his mama sat at on a chair holding her pocket book and nodding deferentially. She asked one or two super generic questions, but only if I paused and asked. There was a lot going on with him and I knew it was a big thing to get their heads around. His mom looked kind of like a deer in headlights.

“You sure you don't have any questions?” I asked them both. Even though I was mostly aiming my thoughts at the mother.

The patient answered, not his mom. “Um, no. I think you've explained it all to me.”

“What about you, ma’am?”

She simply smiled, lifted one hand and said she was fine. And all of it was pleasant and good. Albeit a little bit unsettling.


So after that first day, for whatever reason, I always seemed to round on him when no visitors were there. I'd come in and he'd say, “Dang. You just missed my mom!” That would make me feel like his mom had more questions for me. And I would reassure him that he could have the nurses page me when his mother was there if she wanted to talk to me. He said he would and that was that.

No one ever called.

The last hospital day came. I walked into his room early that afternoon and prepared to examine him. He was the last person I was planning to see before heading over to the medical school across town for a small group teaching session.

“What you know good, sir?” I asked. After three or four days in the hospital, we'd moved to more informal greetings.

“Nothing, Miss Manning! I'm just waiting on you to give me the verdict.”

“Okay. How are you feeling?”

“As well as I think I'm gon’ feel ‘fore I leave here. I'm ready to get up out of here.”

“Okay. Well it looks like we're in a place where it's safe to discharge you.” He pumped his fist when I said that. “Sounds like we're on the same page.”

“Good stuff.”

I asked if he had any questions and he said he had none. I reached out to shake his hand and my eyes wandered over to the window sill. What appeared to be a pair of multicolored reading glasses were resting there next to a McDonald's coffee cup. There was lipstick on the edge of the cup, too.

“Did I miss your mama again?”

“Man. She just can't win for losin’. She went to go feed the meter and I said, ‘Watch Dr. Manning come in soon as you go.’”

“Aww man.”

“She all worried ‘bout me and stuff.”

“I hear you. Being a mama is hard like that.” That made him chuckle when I said that.

We made a little more small talk and I headed out. I picked my tote bag up from where the clerk was hiding it for me in the nurses station and scuttled up the hall toward the elevators. I looked at my watch and I was making excellent time for my commute over to main campus.


I stepped onto the lift and took a deep breath as it stopped on what seems to be every single floor. After what felt like a million years, I finally make it out of the hospital. Checking the time once more, I smile since I know I'll make it with time to spare.

But then something happened.

I saw this man paying to meter for his car. And he looked relieved as he was doing it since the city of Atlanta will ticket you in less than one second if your meter dies. For some reason, I just sort of froze for a moment, watching him stick the “PAID” coupon on his dashboard. And, of course, imagining my patient's loved one doing the same.


I squeezed my eyes shut and gave and exaggerated sigh. My head swung to the right and stared up at the hospital. And then I made up my mind.

Five flights of stairs and five minutes later, I was back at my patient's room, panting and out of breath. Just as anticipated, as soon as I came trotting in I saw his mother settling back down into the chair--reading glasses in one hand and coffee cup in the other. And when she saw me huffing and puffing in that doorway, her eyes widened and a big smile erupted over her face.

You know? I'm not sure why but something made me feel intensely like I needed to go back to see her. Which, in a way, is pretty ridiculous, you know? I mean this patient was grown, man. And sure, he'd been handed a pretty heavy diagnosis, but still. This was not child.

But. He was her child. And, it appears, she was a big piece of his support team--a team he was definitely going to need.

And so. I came on in, pulled up another chair and sat down. I leaned on my elbows and tried not to look like I was in a hurry.

“Oh! I thought I'd missed you, Dr. Manning!”

“You know? I was leaving out and decided to come back. Just in case you wanted to talk.”

And you know what? She did want to talk. Talk about her son and his prognosis and how she could be of support. Of how she felt scared and how even when they are all grown up, they're still our babies. She wanted to know if I had kids and if they were boys or girls. And really, she just wanted to talk long enough to feel just a little less anxious about what her boy was up against. Not really questions. But there was more to discuss. There was.


So here's what I learned: I learned that sometimes people don't have questions. But that doesn't mean they don't want to talk. In that quick little instant, I shifted a piece of my practice based on a subtle new realization.


I will still finish my discussions with ”What questions do you have for me?” I sure will. But from now on, I'm going to start following up with one more question--”Is there anything else related to you hospitalization that you'd like to talk to me about?”

Yes. That.

And you know what? I've only been doing this for a couple of weeks now. But it's astounded me how many people bite on that second request. Questions? No. More you want to talk about? Yes.

Ah hah.

And no. The whole “listening to that hunch that you need to go back” lesson wasn't the take away for me. Although it is a very important thing to recognize when it happens and one that I've learned previously the hard way.


By the time we finished, there was only ten minutes remaining before my teaching session was to start. I texted my second year student small group and asked them for a last minute modification in our meeting plans. I apologized profusely and felt appreciative for their understanding. We ended up meeting outdoors on the patio of a local restaurant closer in than campus--which was easier for me coming from Grady. They were gracious and easygoing and that lightened my load.


When we finished, I said I'd stick around in case anyone had questions.

Or things they wanted to talk to me about.

You know what? No one had questions. But two people did have something they wanted to talk about. Important stuff, too.

Imagine that.

I'm so glad that I'm still learning, man. Still listening and learning and growing and trying.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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