MISSED CONNECTIONS, DISTANT PLACES | Niharika Sathe
Like many relationships, ours began with awkward pauses. “You won’t see me until this is done, doc,” my patient told me, her face becoming pixelated and sharpening into focus again. The pandemic had begun, and she was terrified of the dangers lurking in the waiting room of our clinic, opting for telemedicine instead. I had just finished my residency training and was trying to get my bearings when Covid came on the horizon. I was terrified too.
We began meeting virtually to review my patient’s sugar logs. I hoped to closely adjust her medications and keep her out of the emergency room and hospital, where she was sometimes admitted with the complications that come with uncontrolled diabetes.
Had my patient tapped into the market of diabetic TikTokers, she would have gone viral. Like any good influencer, she made the mundane details of her diet and glucose values riveting. Our telemedicine visits became a “What I Eat in a Day” vlog of sorts, narrated with a dry wit and social commentary on what it was like to be living in a food desert where her only vegetable option was often the iceberg lettuce on her sandwich. She seemed to inherently know, without having read the literature, that so much of one’s health is determined by one’s zip code.
Primary care fosters a deeply intimate connection between patient and doctor. I’ve heard the crescendo-decrescendo of my patients’ heart murmurs, noted the play-by-play of their bowel movements, uncovered the insidious habit of the glass of wine that has become a bottle and tracked the mole on the backside whose borders were ominous. For all these personal details, and despite obtaining a detailed social history, these miscellaneous facts sometimes felt like the pieces of an IKEA bed frame—odds and ends that you knew fit as a set but couldn’t quite piece together to make a final product.
For all their technical difficulties, video visits filled in these gaps, providing a brief window into patients’ homes. Hers was humble but immaculate. She was perpetually ready for a dinner party; her background was often a table setting complete with fine china and doilies. I once asked if anyone was coming, and she looked tired. “No one’s coming. They’re all busy with their own lives. I always loved when company was coming, so I like to hold onto that feeling.” She changed the subject and asked about my son, squealing as I showed her his latest picture.
Initially, our check-ins did not seem to make a difference in her sugar. I asked if she’d be willing to show me how she injected her insulin. She jabbed the needle without piercing her skin and we paused as a spray of insulin shot into the air. Nerve damage from her diabetes was making it difficult to perform even simple tasks. I put in a request for a home health nurse; home visits were in short supply during the pandemic. We were lucky to be approved. I got a call a few weeks later from a frantic nurse who went to her home on multiple occasions but wasn’t let in. My patient was too scared to see anyone who might have Covid, even if it meant her other medical conditions were ignored.
When the pharmacy missed her home delivery of insulin, I tried bringing it to her house myself. “You’ve got a little boy at home and other patients who need you,” she declined. “You can’t waste time on an old lady like me.” Long gone were the days of house calls; like most doctors of my generation, I kept my work and home life separate, convinced that these boundaries were the key to my wellness and job satisfaction. Still, here I was, thinking of my patient when I was building Lego towers and folding piles of laundry. Here I was, offering to bring her medications to her door and feeling oddly jilted when she declined. I wasn’t sure if this newfound attachment made me an exceptionally caring doctor or an incredibly naive one.
I wonder what the insurance company thought of our visits. On paper they were of questionable utility, but we needed each other. She wore her church clothes and makeup for our tele-visits. Normally I would interpret this as a sign of respect for the medical profession, but I knew this signified a level of comfort, that I’d become part of the community she had built around her. Our visits ameliorated the palpable loneliness she was unable to hide on screen. These visits gave me meaning too, in a time where I felt useless. My colleagues were true front-line workers battling Covid in the ICU and ER, while my work in primary care, adjusting blood pressure medications or treating back pain on a finicky screen felt trivial in comparison. We managed to avoid hospital admissions, though I suspected her down-trending glucose values had more to do with worsened food insufficiency and less my medical expertise.
When the Covid vaccines became available, I was elated about the end of her solitude. With protection from the vaccine, she could re-enter society and get the help she needed. I was dismayed when she vehemently declined it. The vaccine was sanctioned by the government, and what had the government ever done for poor Americans like her? They never cared about her community before, and trust was important to her, a two-way street.
I let her in on a little secret; I was pregnant again and had just gotten the Covid vaccine. When the vaccine was first approved, inoculating pregnant women was controversial because they were not included in the trials. I weighed the benefits with my obstetrician and received the shot early in my first trimester, with the first wave of essential workers. I hoped sharing this big risk I had taken would convince her of its safety. She was overjoyed about the baby and would continue to get her other vaccines as I had recommended, but she was not getting this shot.
Soon after this news, she appeared at my office in person requesting a walk-in visit. She’d lost weight, and it was clear that every step caused immense discomfort. She handed me a gift bag, and I lifted a baby blanket. I suppressed the lump in my throat as I pictured her gnarled hands painstakingly crocheting the brightly colored yarn. “You need to sit, honey,” she said, glancing at my swollen ankles. “You work too hard. Just close your eyes. I won’t tell anyone.” She grabbed a pair of latex gloves, slowly donned one and handed the other to me. I understood I was to do the same. She reached over and held my gloved hand in hers in that harshly lit exam room, and I rested my eyes for a minute that felt like an hour.
It was then that I decided to press her about the Covid vaccine, worried for her safety, tripping over my own words in a rush to point out the statistics and efficacy. Shared decision-making is a delicate balance, trying to honor patient autonomy with evidence-based recommendations. I totally blew it, ruining the connection we just made and the human touch she had missed for almost two years. She drew back her hand, eyes tired above her mask. “I don’t need a vaccine,” she stated. “I can’t trust the government. If I get Covid, I leave it up to God to protect me.” I understood the underlying subtext— in pushing the vaccine, which she felt to be dangerous, I had broken the circle of trust we had worked so hard to build. Subsequent visits were formal, perhaps how our relationship should have been all along.
I’ve analyzed this moment searching for closure. Was this the irrevocable point when our relationship fell apart, or did we not have the rapport I assumed we did in the first place? One of the most effective tools in the physician’s tool belt is motivational interviewing, the slow tango of meeting the patient in their willingness to change, a median between simply listening and commanding—but we were in the middle of a pandemic and my patients were dying of Covid. Although I recognized the generational history of medicalized racism that led to her skepticism, I felt the urgency to provide professional recommendations to protect her.
Studying medicine is like taking the most complicated Rosetta Stone course. We have an entire lexicon of fancy sounding words like that for hiccups (singultus) and the achy pain between menstrual periods (mittelschmerz). We have inauspicious words really meant to signify good news and the absence of a disease (negative) and words that sound technical so we can avoid saying cancer (malignancy and neoplasm). We have a plethora of words and still, no adequate phrase to describe the doctor-patient relationship. It’s not quite family or friendship, and more intimate than an acquaintance. Perhaps the label for our relationship never mattered because what my patient needed was not a doctor at all, but a social worker, a friend, a system that instills trust.
I found out she had died because of a call from the funeral home, in the middle of a mundane and busy clinic day. They needed a physician to certify the cause of death and couldn’t locate her primary. There were no emergency contacts, and she hadn’t seen me in some time. The funeral director sounded more exasperated than relieved when I picked up. “Do you know her?” he asked. I hesitated. “I’m not sure,” I responded, “but I am her doctor.”
I hope my patient realized she was important to me, and although no one was around at the end, she was not alone. I wish I could show her pictures of my daughter, who naps with the blanket she crocheted. I carry her memory with me when I counsel my patients, trying to recommend without pressing, to feel comfortable with silence and listen. I hope she knew I supported her in any medical decisions she made. And if she had decided to get the shot, I would have accompanied her to the appointment, put on a pair of gloves, and held her hand.
Niharika Sathe is an internal medicine physician. She is grateful for her patients, whose stories make her a better doctor. She lives in Haddonfield, NJ with her husband and two children.