January 13, 2022, 2:58 p.m. — I was in the middle of my afternoon clinic, teaching a third-year medical student, when the front desk called.
“Your 1:20 patient is here, but they are 30 minutes late. Is it OK to have him register?”
I looked at my schedule. I had already seen my 1:20 patient, so I asked the staff at the front desk more about who I would actually be seeing. I found out that it was a patient who had been scheduled for the next day and had accidentally come a day early. I knew right away who he was. I had delivered him two years ago, and his mom was one of my favorite patients. I told the front desk to check him in and hoped his mother had brought him.
I opened the chart, and an alert came up: “Grandparents are now guardians. Mother is dead. He is due for vaccines.”
My mind went quiet; then it started to swirl. A colleague was asking me a question, but I couldn’t answer. Things felt foggy.
I walked toward the patient room. I went in, and within a few seconds the grandmother looked at me and said, “No one told you.”
No, no one had told me. I sat down and apologized for looking so dazed. Seeing the patient felt like a hit to the chest.
The patient’s mom was someone I was always excited to see on the schedule. I’d first met her more than three years ago. We’d been through a lot together. I was her doctor when she first got sober, when she got a new job, when she got pregnant, when her partner relapsed and she distanced herself from him for her and her son’s health — and I was there when she delivered him. I had seen her and her baby for the next year and a half.
At her son’s most recent visit, when he was 18 months old, I could tell that something was off. The mom denied any recent drug use at the time, but she agreed to a toxicology screen. The screening test came back positive for cocaine. She didn’t answer my phone calls after that. She had also missed a number of scheduled appointments since then. I then went on maternity leave, and as a result, I had not seen her for over eight months.
I refocused on the child and started the physical exam. Usually I talk to the toddler’s adults first, to let the toddler feel the trust in the room. I find that infants and toddlers are much more likely to trust me during the exam after they realize I’m a safe person from watching me interact with the adults. This time the conversation was somber. For the physical exam piece, I always start with the fun part with toddlers: jumping and clapping. Getting them out of the chair and moving not only is fun, but also lets me see the majority of what I need to see for the development, musculoskeletal and neurological exam. We balance on one leg, then the other, jump, toe-walk and more. In this case, I found my usual cheer faltering.
“It’s OK,” the grandmother said. “We brought him back to you because I was in the room when you delivered him. His mom thought the world of you, and we knew you’d be the best doctor for him.”
I continued my exam, then made referrals for physical therapy and pediatric psychiatry. He had been through such trauma and was just starting to talk again. He had newly developed a few self-harmful tics and repetitive movements, which seemed to be fading away now that he was settling into his new home.
What I actually wanted to do was hold him and hug him. I wanted to tell him that his mother loved everything about him, and that she did everything in her power to make sure he was safe. But I also told myself that the real reason he is still my patient is that the family wants that continuity bond to grow. Over time, I will hug him and tell him that his mother adored him, that I knew her, and that she was smart, wonderful, fun and witty.
One of the best parts of family medicine is not just continuity of care throughout someone’s life, but intergenerational care. It is both wonderful and challenging to take care of entire families, including grandparents and grandchildren. Longitudinal trust, support and care, especially with patients who are struggling, can really impact health and interactions with the health care system. Many of my office-based addiction treatment patients have a distrust of the health care system. Fortunately my OBAT practice, based out of Manet Community Health Centers, is a space that many patients find welcoming and attentive.
There is a definite need for practices that offer OBAT and similar services. The age-adjusted rate of drug overdose deaths in the United States increased by more than 4% between 2018 and 2019, from 20.7 per 100,000 to 21.6 per 100,000. The COVID-19 pandemic has seen these numbers continue to rise: In 2020, there were more than 7,000 overdose deaths per month. Before 2020, U.S. monthly overdose deaths had never been higher than 6,300.
Despite the clear need for more substance misuse care, many physicians still do not feel comfortable providing care to patients with substance use disorders. I still get asked why I provide OBAT. The question always surprises me. As someone who is deeply passionate about my full-scope family medicine practice, I have never felt inclined to exclude any group of patients from my practice.
One key component of OBAT care in my practice is the couplet care model, in which the mother continues her primary care while we add in the child’s visits to be at the same time. This makes for easy scheduling for the parents, and they already have existing rapport. We develop a plan of safe care during pregnancy and continue to refer to it later. Couplet care gives me many more visits where I get to see both mother and child and help them get the right support. I hope it saves the children judgment and provides them with positive interactions with the health care system.
There is also strong evidence starting from birth that shows focusing on the mother-baby connection benefits both the mom and the baby’s health and well-being.
Indeed, I would not have known about this mom’s relapse had she not been an existing patient who was coming in with her toddler.
Although the support we tried to provide wasn’t enough to get this patient back into care, it was what gave the grandparents the assurance that we were the right place for them to continue to bring their grandson. I am thankful to the grandparents that they are allowing me further continuity. I am excited to see him grow.
MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is the associate program director of the Family Medicine Residency at Boston University Medical Center. She is also Women’s Health Director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.