“I like you, that’s why I come here. You talk nicely.”
She flatters me, but my patient’s warm words are cold comfort.
This is her 14th hospital visit in a month that has yet to end. Not to mention the dozen visits over the last few months and many before that.
The presentations are identical. She wakes up, gets dressed, eats and gets a lift to emergency, where she reports dizziness, headaches, odd sensations or similar vague symptoms.
The emergency doctors find no discernible emergency and refer her to the physicians, who take a detailed history and examine her all over again and conclude the same.
Her medical record is littered with a concerning number of normal blood tests and scans. If the copious documentation from social worker to specialist doctor were on paper, she would need her own storage shed.
On this visit, it is my turn to meet the elegant elderly widow who laments that no one takes her seriously. When patients insist on the same symptoms, doctors owe them an open mind lest they miss a rare diagnosis through assumption, or worse, arrogance. But the diligent professionals before me have not missed a beat.
I probe gently. Does she have friends? She grumbles that her children could do more. Would she consider resuming her antidepressant? No. Could she join a community group? She doesn’t drive. Would she consider a retirement village? Absolutely not.
Indignantly, she says she recently tried her luck at a private hospital. They did nothing and charged her $500 for “a bag of water”.
“So I came to you, at least you’re nice.”
Down the corridor, there is a man in renal failure, swollen from ankle to abdomen. Next to him, a woman with cancer painfully boring into her pelvis.
A young guy with schizophrenia is growing more agitated by the hour. With all these patients waiting for a ward bed, my job is to be judicious with hospitalisation.
Explaining that skilled doctors have found nothing dangerous, I politely suggest she go home. Not today, she pleads. There is nothing we can do here, I press.
Her response wrings my heart.
“Darling, sit and talk to me.”
If I got the diagnosis, she has found the cure.
Sitting down and talking to her is the thing she needs, but if frontline professionals began to remedy loneliness, who would tackle accidents, heart disease and asthma? Who would organise dialysis and chemotherapy?
The Australian Institute of Health and Welfare considers loneliness a “subjective unpleasant or distressing feeling of a lack of connection to other people, along with a desire for more, or more satisfying, social relationships”. Loneliness is an emotional experience, distinct from isolation, which is a lack of social contact.
Globally, more than 30% of adults report feeling lonely often, always or sometimes. From Brazil (50%) and China (26%) to Australia (30%) and India (43%), loneliness transcends boundaries.
The physical health effects of loneliness include a striking elevation in the risk of heart disease, stroke and dementia. Indeed, loneliness rivals obesity and physical inactivity as a risk factor for premature death. The US Surgeon General made headlines when he compared the health impact of loneliness with that of smoking.
No wonder so many sick patients are lonely patients. The perennial ones we colloquially call “frequent fliers” don’t get respect as much as neglect. How can I tell my patient that of everyone on my list she might be the most at risk and the least likely to get attention?
When medicine can’t fix social problems, it’s tempting to redirect our ire towards the family but her tired children say they are doing their best. And why does the sister keep answering her requests to drive her to hospital? Because she doesn’t know how else to help.
Why doesn’t the public hospital turn her away? Because it’s not how we work. Patients can discharge themselves against medical advice, but doctors can’t force them out. Most people, of course, can’t stand being in hospital, but there are always those who are content to stay. It is easy to judge them until you consider what kind of home environment makes a noisy public hospital with ordinary food and harried staff a more attractive prospect.
My patient eventually goes home, implying I was unhelpful. My regret is replaced by guilt and then surrender when she returns the following day on my watch. At least she didn’t come back that same day, I think.
She insists she is not lonely, depressed or isolated (yet she is all of those). I tell her that I am not diminishing her symptoms but don’t have new solutions.
We are both frustrated, but now, with more time spent seeing her, I feel accountable to the patients waiting in ambulances and strewn in the corridors, so I wonder whether the hospital can create a plan for her future, inevitable presentations. Such plans are sufficiently rare that I propose it with a tinge of guilt until a draft arrives in my inbox.
Listing her numerous presentations “at a glance”, the plan advises doctors to reassure the patient about existing symptoms but investigate any new ones. It suggests reiterating past recommendations to enable social connections and access community services. Far from being punitive as I had feared, the document stands out for its sheer decency, reminding professionals to bear witness to the patient’s vulnerability and deem her worthy of care and deserving of empathy. In my view, it fulfils the goal of “first, do no harm”.
I regret that the patient has many futile hospital visits left in her, all at a tremendous cost to society at a time when doctors are being asked to turn off the lights to save money.
But while we hold our breath for an “all of government” or an “all of society” approach to this most insidious issue of our times, I can’t help thinking there is something very heartening about a public hospital system that will never turn its back on such patients even when we know that our capacity to help them is constrained.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
