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Academic Medicine:
doi: 10.1097/ACM.0b013e31815c6921
Other Features: Teaching and Learning Moments

Where Were You When I Needed You?

Fisher, Joslyn W. MD, MPH

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Dr. Fisher is assistant professor of Medicine and Medical Ethics, Baylor College of Medicine, Ben Taub General Hospital, Section of General Medicine, Houston, Texas.

Six years ago, I promised my colleague that I would take “good care of” his patient, Ms. Carmel, a 72-year-old woman with multiple medical problems. Subsequently, Ms. Carmel and I have been through a lot together. She visits regularly to monitor her diabetes and hypertension. I followed her closely when she broke her wrist, was hospitalized for pneumonia, and most recently when she developed severe tricuspid regurgitation and it was unclear if she would survive that hospitalization (now six months ago). I shed tears with her when Daniel, her eldest child, was sent to Iraq as a pilot and shared her joy when he returned home safely. I felt like I knew her grandson Bobby, whom Ms. Carmel had been raising since his own mother died.

On one particular clinic visit with Ms. Carmel, I was worried about her increasing shortness of breath and fatigue. I knew she needed close follow-up; however, my upcoming morning primary care clinic dates were full so I invited her to come for follow-up during my domestic violence clinic on another afternoon. I was startled when she asked, “Where were you when I needed you?” I did not understand her question and felt an anxious pit in my stomach. Disconcerted, I looked at Ms. Carmel for an explanation.

She began slowly and quietly, then the story poured out. “My husband was a monster. We were married for 15 years. He beat me severely numerous times. No one really knew about it—except my parents. My mother said I would be disowned if I divorced him. I had five children but only wanted two. I love them all but my husband forbade the use any form of contraception. I pleaded with several gynecologists to do a hysterectomy and finally with the help of a doctor friend from work found one that would. I finally left my husband after he abandoned our youngest daughter at a grocery store. I did not know anything about resources for ‘domestic violence.’ All I knew at the time was that I was not going to endanger my children ever again.”

Ms. Carmel told me that her husband’s violence had affected her both physically and emotionally. She attributed some of her aches and ailments to his physical abuse. She became tearful when discussing some of the permanently disrupted family dynamics. I had always felt that Ms. Carmel, shrunken by an osteoporotic, kyphotic spine, smiling with her slight hemiparetic grin, was a survivor with incredible strength. I never knew how true that really was! A few visits later, Ms. Carmel told me, “Just listening helped—I have never told that story to anyone.”

Although she found some peace in talking with me, I realize humbly that her revelation likely had a greater impact on me than on her. I see domestic violence survivors weekly yet nearly missed this important story. Her words echo in my mind—“where were you when I needed you?” (I had in my clinic notes “Hysterectomy—for benign reasons”—little had I known!). I think about this when I educate medical students, residents, and my colleagues about domestic violence. “Screening” for domestic violence may be controversial, but listening and being available for your patients is not. Many of my patients in the domestic violence clinic have indicated that information provided by the referring health care professional is what has ultimately contributed to their greater safety and improved health. While Ms. Carmel’s revelation was somewhat fortuitous, I suspect that our established relationship allowed her to feel more comfortable in introducing the issue. I have learned a lot about the science of medicine through caring for Ms. Carmel and her many ailments—however, her story most poignantly clarified my understanding of the importance of practicing and teaching the art of medicine.

Joslyn W. Fisher, MD, MPH

Dr. Fisher is assistant professor of Medicine and Medical Ethics, Baylor College of Medicine, Ben Taub General Hospital, Section of General Medicine, Houston, Texas.

© 2008 Association of American Medical Colleges

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