As I sat before my computer screen reviewing Ms. Washington’s sign-out note–the summary of a patient’s clinical course shared between two doctors when one begins caring for the other’s patients–I felt compelled, but overwhelmed. 68 year old female. Living with HIV. Survivor of non-Hodkgin’s lymphoma. Survivor of ovarian cancer, but radiation therapy left her with urinary tract strictures that caused persistent, complicated urinary tract infections. She was here now with another UTI, and due for surgery to stent open her constricted ureters. Her medical journey was full of twists and turns, and I was impressed with her strength before even meeting her.
“And what’s this about a new inflamed lymph node in her groin?” I asked her outgoing physician, clicking through screen after screen of her medical record. “It’s probably just reactive,” my colleague noted to me, meaning it was likely just a physical response to her urinary infection that would go away once we treated her with antibiotics. After a few more clicks and confirmations, through her latest labs and imaging results, it was time to meet my patient.
Now, one of my favorite parts of being a physician is the first time meeting a patient after reviewing their sign out note. For all the clinical detail packed into those typed-up summaries, there are inevitably a treasure trove of characteristics that are deemed irrelevant to medical documentation, and are thus only discovered, delightfully, at the patient’s bedside. Ms. Washington did not disappoint.
I found her lying in bed, deeply engaged in a crossword puzzle, looking weathered but resilient. Her pale hands, riddled with the small scabs and deep bruising of constant blood draws, gripped the small book. Though the room was buzzing with the moans and mumblings of 3 other patients, each hidden behind a curtain of faded fabric, their nurses beginning to give out morning medications, Ms. Washington’s focus was uninterrupted. Her face looked tired, with ringed shadows beneath deep brown eyes, but also looked as though she had been through this hospital routine a million times over, and, while objectively ill in the moment, was aware that this was, indeed, just a moment.
I had budgeted more time than usual on this morning for my rounds, given that it was my first time meeting my new patients, my first chance to get to know them beyond their medical record documentation. And so, after reviewing the details of her health dilemma, and after a physical exam that was very concerning for an enormously large and painful lymph node, I pulled up a chair to her bedside, and transitioned our conversation in another direction.
“Who is important to you in your life?” I began. It a question I always try to get at one way or another upon meeting a patient, because social support determines so much of a patient’s recovery process. She hesitated, at first. “Well… I love my dog, Dexter,” she joked, her voice raspy and rich, detailing a few funny anecdotes about her fluffy pal and his loyal tendencies. It’s about this time when a doctor might look at their watch and feel pressured to move on to the next patient. I saw hospital staff beginning to bring in breakfast trays, and I felt a nudge of temptation to hurry along the conversation. But I had the time. I sat, and waited.
“And of course there’s my partner, Rita,” she finally offered up, pushing her plastic tray aside as though to not lose focus on her next statements. “I wouldn’t have gotten through this all without her.” Over the next few minutes I had the privilege of hearing their long and touching love story; they had met as nurses in this very hospital, decades ago, and though they remained committed through difficulties like her HIV and cancer diagnoses, they were only able to be officially married in 2011, once marriage equality was established legally in New York. She told me, with sadness in her voice, about other friends who had also received an HIV diagnosis, but had committed suicide during a time when medication was unavailable or inaccessible; she took credit for her own person resilience in surviving these moments, but also gave thanks to Rita for fostering her through her darkest times. “I really wouldn’t have gotten through it all without her,” she emphasized, again.
We shared another few minutes together going over her goals of care: she was ready to fight anything that came her way this hospitalization, she had an unshakeable sense of self and considered herself a survivor with many years of life ahead. With a warm smile she me to push her breakfast tray closer–“Not that this is any five star meal”, she joked–and as she began digging into her hospital hash browns, I waved and headed out into the hallway.
Over the next few days, I had the chance to meet Rita at Ms. Washington’s bedside every evening when she visited after work. They would deliberate over cross-word puzzles together, flip through mindless reality TV episodes, or just sit and talk, all the while drowning out the beeps of heart monitors and chattering of other patients around them. Rita was sturdy and tall, yet unassuming; she never interrupted into conversations, instead sitting and listening while Ms. Washington spoke urgently and at length with her doctors and nurses, as if an invisible timer was running out of time to share all she wanted to share. In contrast, Rita’s presence was quiet, though powerful in the way she could create a separate world for Ms. Washington, as if they weren’t sitting in a busy public hospital but were relaxing on the couch at home.
Her peaceful presence was crucial when, over these same few days, Ms. Washington’s lymph node biopsy results came back, not as a “reactive” lymph node responding to the infection, but as a new cancer manifesting itself in her lymph nodes–bladder cancer–making this her third separate cancer diagnosis.
Sharing this bad news with Ms. Washington was a difficult conversation, though it was made far less painful having Rita by her side to cushion the blow. Ms. Washington sighed, and looked first to Rita, who offered her a hand squeeze and a “we-can-do-this” look of confidence in return. She then turned to me, in silence.
“My body makes so much noise all the time,” she finally said, softly. “I’ve been hearing it, lately, between all the noise, whispering: ‘Get ready‘.” Her eyes wandered around, settling on the sheets in front of her. “I’m really not totally surprised by this.” Her hand, still bruised and scabbed, clutched Rita’s tightly. “I’m ready to fight. We’re ready to fight.”
And fight, she did. Throughout my one-month rotation on Ms. Washington’s floor, she recovered from her infection, she stabilized enough to receive her urinary stents to avoid future infections, and she was set up with an oncologist to help tackle this new beast. All with Rita by her side.
It struck me that, despite Rita’s powerful, positive influence on Ms. Washington’s health and well-being, there was barely a mention of her name in our medical record. So, when it came time for my sign-out to the next physician, after reviewing the key medical details in front of our aging computer screens, I knew what would come next.
“You’ll have to meet Rita,” I insisted. “You might not get through it all without her.”
During my time with Ms. Washington and Rita, I thought often about how crucial a life partner must be to one’s health and well being. A multitude of clinical studies have examined in some way the effect of relationships on health, but perhaps one of the most robust and important studies among them is a 2013 study in the American Journal of Public Health, titled “Social Isolation: A Predictor of Mortality Comparable to Traditional Clinical Risk Factors.” (1) This study tapped into a national database of nearly 17,000 individuals to study the relationship between social isolation and mortality, and comparing the effect of social isolation on your chances of dying to the effects of behaviors like smoking, having high blood pressure, and being obese.
How, exactly, was “social isolation” measured? This is a crucial question for any research that attempts to draw conclusions about the effects of isolation on health, given that it can mean different things to different people. In this case, researchers used a well-known survey tool called the Berkman-Syme Social Network Index (SNI), which focuses on marriage status, frequency of social interactions, church attendance, and club memberships. They then defined social isolation in the following way:
“Participants received 1 point for each of the following: being married or living together with someone in a partnership at the time of their interview, averaging 3 or more interactions per week with other people (assessed with the questions “In a typical week, how many times do you talk on the telephone with family, friends, or neighbors?” and “How often do you get together with friends or relatives?”), reporting that they attended church or religious services 4 or more times per year, and reporting that they belonged to a club or organization such as a church group, union, fraternal or athletic group, or school group. Scores ranged from 0 to 4, with 0 representing the highest level of social isolation and 4 representing the lowest level.
Now, many people will surely disagree with these measures, and argue that they feel completely socially connected despite being unmarried, not a phone-talker, not a church-goer, and not a club member. You could also argue that one could feel isolated in a marriage if it is unhappy or abusive, or isolated despite frequent social contact if one feels depressed or otherwise subjectively isolated. However this study used these SNI measures to quantify a difficult-to-quantify concept of “isolation”, and I found Ms. Washington and Rita’s partnership to be so compelling that I wanted to see the outcomes of studying the “partnership” factor.
What did the researchers find? In general, they found that low SNI scores (extreme isolation, having no partner) were predictive of mortality among men and woman (analyzed as separate populations), and were associated with mortality risks similar to that of smoking and, for men, higher than that of high blood pressure.
Meaning: not having a “Rita” around is as bad for your health as smoking or having high blood pressure.
It is striking to me, as a physician, that we have such a robust field of science and pharmaceuticals built up around the identification, prevention, and treatment of high blood pressure, and no corollary field of science dedicated to the identification, prevention, and treatment of social isolation, given that it correlates even more strongly with death than hypertension. Yes, it is easier to pinpoint and treat an objective physiologic process like elevated blood pressure, than to intervene in complex social notions of “community” and “belonging”. And yes, it’s still critical to continue advancing fields that study how to better manage high blood pressure, obesity, and other chronic conditions.
However as a medical field, we have to start somewhere with better understanding social isolation, and the power of a “Rita” in our lives. One simple place to start, and a tenant of good medical care, is to always ask about relationships when meeting a new patient, and communicate to patients the importance of having a sense of connection with a trusted partner, whether it’s a spouse, best friend, or close confidante. It’s equally as important to advocate for laws like marriage equality that allow all human beings to be in loving, supportive relationships free from stigma and discrimination by the wider population.
What do you think? Do you have a “Rita” in your life? Do you think having a partner–whether spouse, best friend, or confidante–makes you healthier? Has your doctor ever asked about this before, and how would you feel about it if s/he did? Interested to hear your thoughts!
Photo Credit: Fouquier ॐ
- Pantell M, Rehkopf D, Jutte D, Syme SL, Balmes J, Adler N. Social Isolation: A Predictor of Mortality Comparable to Traditional Clinical Risk Factors. American Journal of Public Health. 2013;103(11):2056-2062.