I had been building a therapeutic relationship with a patient over her last three visits. We bonded over being newly married, our mutual excitement about married life and the varying definitions of cleanliness partners could have in a relationship. During this visit, she had been experiencing abdominal discomfort and nausea. A simple test revealed she was pregnant. 

The patient looked stunned and began to cry softly. She had previously told me that she and her husband were struggling financially and were not planning to become pregnant for several years. We had discussed contraception at her last visit and she was considering several options.  She explained that she had been thinking seriously about contraception and was frustrated that she had not moved forward with an intrauterine device (IUD) prior to becoming pregnant. 

As a trainee, I am constantly working on the therapeutic relationship which begins with trust.  I learn every day the impact that the small things that I do have on my patients.

Through our previous interactions I had a sense that what she needed after receiving this news was time to process.  We initially sat in silence and I held her hand. I then stated that I was here to listen and help support her. I was not there to judge her and would give her all the information to make whatever choice was right for her.  At that moment I felt as though our therapeutic relationship, which initially started with a bond over shared lived experiences, had developed into a trusting patient/physician relationship.

She felt comfortable telling me that she wanted to terminate the pregnancy and would like an IUD placed after the procedure. I included the address for Planned Parenthood in her after-visit summary along with a note to my checkout staff to assist in scheduling the IUD placement appointment.

She later told me that when she went to check out, the clerk was adamant that she schedule a follow-up appointment for the IUD placement. This was an uncomfortable question for her and she felt pressured into explaining the need for an initial appointment at Planned Parenthood.  She felt embarrassed and upset.

I have reflected on this many times since it occurred. She trusted that I understood the sensitivity of the matter.  In my effort to be helpful and efficient, I feel damage was done to our relationship because of the way the checkout process unfolded.  I have thought about various ways in which I could have made this experience easier on her, including asking her to contact the clinic when she felt she was ready for contraception or adjusting my communication to my checkout staff to include a note about the  sensitive nature of this visit. Fortunately, the patient did come back for follow-up so we have a chance to continue to build our therapeutic relationship.

We all strive to do our best for the patients that we serve. As a trainee, I am constantly working on the therapeutic relationship which begins with trust.  I learn every day the impact that the small things that I do have on my patients. I am humbled in this endeavor and hope that the hard lessons are few.

Adetoye is a third-year resident in Family Medicine at Michigan Medicine, the University of Michigan Health System.