Last Patient of the Day

Johanna Shapiro, PhD

It was late in the afternoon and the family medicine clinic had been unusually busy – filled with medically complicated patients whose life circumstances were even more complex. And it was the start of July, when yesterday our learners were medical students somewhere, and today they were our doctors.
As a behavioral health specialist who participates in the training of residents, I was observing one of the new interns as he started his final interview of the day. It appeared a straightforward case – according to the chart, the patient had “a cold.” The intern, visibly exhausted and also visibly relieved that he was almost home free, at least for today, began his interrogation.

When did the symptoms first present? Were they getting better or worse? Had the patient had similar symptoms before? His patient was compliant and eager to help. She answered all of the intern’s questions in a soft but clear voice. She was not tangential or nonresponsive. She knew her dates and times. She was, in short a perfect patient.

At the end of a sentence describing her cough, the patient said in exactly the same tone of voice, “I’m thinking of killing myself.”

I just about fell off my chair, alarm bells jangling in my head, my heart thudding like a heavy boot hitting the pavement. I glanced at the intern, the suicide assessment protocol already racing through my mind.

The intern was typing his note. He glanced up with a mildly concerned expression.

“Any fevers?”

Wait, what? Before I could collect my thoughts, the intern stood up to leave.

“Nice meeting you,” he said.

This story has a happy ending. The intern and I debriefed outside the exam room, he went back inside, evaluated the patient for suicIdality, judged that she was not immediately in danger of harming herself, and made an appropriate mental health referral. He was kind, thorough, and desperate to prove he knew how to handle the situation. And he did.

During that follow-up conversation with the patient, initially both she and the intern were awkward and embarrassed. The patient struggled with her sense of stigma about mental illness. The intern worried that, through inattention and excessive reliance on algorithmic medicine, he could have killed his patient. At the same time, they seemed to bond over their mutual distress. They saw each other and they saw each other’s suffering. And as the sun sank, casting ever-deepening shadows, in that room there was a kind of joy that each of them, at least for today, had averted disaster.