The Clinic, FIFE and rational-emotional incongruousness (Revised)

By Daniel Rosenbaum – Class of 2015

The following account describes a patient encounter during the mandatory Family Medicine Clinical Experience in my first year of McMaster’s undergraduate MD program. To protect patient confidentiality, certain elements of the encounter have been modified.

My family medicine experience in the fall provided a great introduction to clinical practice, an opportunity to apply some of the basic skills that were introduced in MF1, and a truly fascinating look at the variety provided by family practice. In my short time at the clinic, I learned a great deal from the doctor I shadowed, as well as, of course, the many patients I saw (for as the first patient from whom I ever took a history pointed out, “Never forget… that us patients know an awful lot about our health!”). In this piece, I’ll focus on one encounter in particular that I observed on my first day at the clinic that has stuck with me.

If time allowed – and I stress the if, as time seemed to be an exceptionally rare and valuable commodity in the family doctor’s office – after seeing a patient, my preceptor and I would take an opportunity, however brief, for both reflection (discussion of relevant or interesting points; concerns or questions I may have had; subtle pieces of advice he may have wished to pass on as they related to a specific case), as well as some background about who and what was to follow. In this instance of note, a nurse popped into the office and mentioned that she had nearly left the exam room in tears after checking in with the next patient, a young woman with an infant. “It’s heartbreaking…” I recall the nurse saying, “she’s really torturing herself.”

This woman was evidently struggling with issues related to her mood following the birth of her child. It was clear from the moment we entered the room that she was quite distraught: tissues in hand, mouth quivering, and with puffy, red eyes. Two broad things were remarkable for me about this visit. The first was how well, in my admittedly brief experience, I thought the family doc handled the situation given how much emotional weight this woman was clearly carrying. He used silence well. His tone matched hers. When appropriate, he kept things light, but reassuring, and never condescending. He employed the FIFE framework tremendously well, a point to which I will return. And ultimately, the two were able to arrive at some understanding of the woman’s complex situation and the possible trajectories towards turning it around, for as they both agreed, she could no longer go on like this (her worries were really quite heavy: she remarked that she would wake in the morning to the almost-immediate sensation that she could not bear to face the day); she was referred urgently to the social worker at the clinic for follow-up and commencement of counseling.

But I’ll return to the power of FIFE (the second broad thing of note from this encounter), less as a framework for patient interaction and more as recognition of how these factors, as they relate to illness, can affect one’s life. I am really fascinated by the potential incongruousness of rational thought and emotions. This patient presented as educated, insightful, and introspective; she was able to rationalize her worries, yet this ability was not helping her emotional difficulties. In fact, it was perhaps fueling the struggle by adding a sense of helplessness: this shouldn’t be happening… why can’t I control it?

This issue, of rational-emotional incongruousness, is one over which I have ruminated in terms of my own health. In dealing with unresolved pain related to a hip injury, I have gone through some emotionally challenging times. Stoic as I am, I can be reasonably good at getting through those times quickly, relying on the rational thought that my “suffering” ranks nowhere near the hardships faced by so many. Other times, though, it is not so easy to reconcile my feelings that way; emotions often don’t really work like that. Understanding a patient’s perspective, then, both the ideas and feelings about his or her situation, as opposed to merely the biomedical facts that would lead to a categorical prescription of course of action leading to outcome, really is critical to the prospect of good health.

I suppose these ideas will continue to develop as I continue to gain clinical experiences. For now, though, I am very glad that my exposure to FIFE came so early in my medical education, and I look ahead to MF5 eager to learn more about the mind, and the complex interplay between rationality and emotion taking place therein.

Edited by the author on November 2, 2014.

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