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The holy grail of patient care

In the legend of quest for the Holy Grail, soon after leaving King Arthur’s court, the young knight seeking the grail finds himself riding through a wasteland towards a castle. 

Different stories have Percival or Galahad or Gawain, surrounded by withered fields. Nothing grows, and even the birds are silenced. As he nears the castle, he sees a man fishing in a stream. The old man greets him warmly and offers to host him for the night. The old man tells him that he is the Fisher King, the lord of the castle and king of this land. The knight, let’s call him Percival, accepts. The king rises and Percival notices that he is wounded in his groin and the wound smells horrible and foul. Percival says nothing, not wanting to be rude.

That night, there is a banquet. Everyone at the feast seems excited and happy. All eyes are on Percival. He is embarrassed to be the center of attention. As the trumpets sound, a beautiful woman enters the room carrying a tray. On the tray there is a lance that is dripping with fresh red blood and a cup that is overflowing with wine and fruit and all manner of good food. All eyes turn to him, but again, not wanting to be rude, he says nothing. Everyone is polite, but sad, as they eat and drink from the cup’s bounty. He goes to bed, and wakes up far away in a trackless forest. It takes him 10 years to get back to the castle. 

I watch my student through the video camera system. The pregnant patient is huddled in on herself. Even through the camera I can hear the tears in her voice. Her misery is palpable. My student is running through the long checklist of questions that makes up the first prenatal visit. She is using our online interpreter. The patient speaks no English or French. Her belly looks way too big for a first prenatal visit. She answers the questions in a flat mechanical tone. I look at the chart and see that she is a refugee claimant, just arrived in Canada at 25-weeks pregnant. 

My student comes in to review. They meticulously, but somewhat mechanically, review the history. “Did you notice anything unusual about her?” I ask. The student looks at me quizzically. “How about her affect?” I hint. “Well,” says the student, hesitantly, “she does seem very anxious and sad.” 

“Yes!” I say. “Did you ask her why?”

“Should I do that?” my student asks again. “It seems kind of intrusive.” 

I restrain my eye roll. I remind myself that the “pandemic born,” as I call this generation of students, has come of age with a lot more online learning, and a lot less clinical observation. 

“Yes, it would be rude if you were meeting at a party,” I say. “But in this clinical context it is an essential part of the process. You have to recognize and name the big emotions in the room. Big emotions are like demons, if you name them you get power over them.” The student looks skeptical. Maybe I am being too “woo woo” for them. 

“OK,” I ask. “Where is she from?” 

They tell me. “Why did she choose to come here in the middle of her pregnancy?”

“I don’t know,” is the response.

“Where is her husband?”

“I don’t know.”

“Well, let’s go find out.”

We walk into the room; get a new interpreter on the screen. In all my years of practice, I have seldom seen anyone who looks so frightened and miserable. A few minutes later, much is revealed. We find out that she had left her native country because her husband’s family disapproved of their marriage. They found out that he had married, out of love, someone that they didn’t approve, and that she was pregnant. They threatened that they would find her, cut the baby from her belly and slit her throat. The young couple escaped across the country. They managed to get visas to Canada but could only afford one ticket. Now she is here, frightened and alone. 

Once we understand what is happening, I am able to put proper plans in place and hook her up with our social worker and maternal-child nurse. At the end of the interview I kneel in front of her, hold her hand and I promise her that I will do my best to take care of her and her child. She clasps my hand, gives a weak little smile and leaves to see the social worker.

After the clinic, I debrief with the student. “I guess I did have to ask those questions, and ask her how she felt,” they say. “But I would never be as emotional as you were. I’m just not like that.”

“You don’t have to be,” I say. “I don’t need you to copy my sappy style. You can do it in a way that suits your personality as long as you respond to what the patient is showing you and it gets done. Just remember you have to ask “why.” We are trying to reach the holy grail of good patient care here. If you don’t ask, you could be wandering in the wilderness for a very long time.”