Seeing the full picture of a patient

A palliative care physician finds benefit in asking for photos of patients.

As a palliative care physician, Elizabeth C. Gundersen, MD, often meets patients when they don't have much time left. But she has found a way to rapidly build stronger connections with their family members—asking them for photos of the patient.

Photos are a quick and effective way to understand patients as individuals, especially given how easily they are stored and shared today. “When I was in my medical training, we actually didn't have smartphones. . . . That's opened up a new avenue for us to really get a glimpse of patients' lives that we were never able to do before,” said Dr. Gundersen, director of the hospice and palliative medicine fellowship at the Florida Atlantic University Charles E. Schmidt College of Medicine in Boca Raton. Earlier this year, Dr. Gundersen wrote about the power of seeing patients' pictures for, a Johns Hopkins-based website dedicated to moving medicine “closer to Osler.”

Dr Gundersen
Dr. Gundersen

In asking a family to describe their mother, for example, the conversation may naturally flow to looking at photos from before she was sick, revealing a more complete picture beyond the ill person in the hospital bed, she said. ACP Hospitalist recently spoke with Dr. Gundersen about the effects of this simple request.

Q: What led you to start asking to see your patients' photos?

A: The idea really came from patients and families themselves. I think we've all had the experience where we've walked into a patient's room and seen part of the wall plastered with photos. I've seen that in the ICU next to the bedside of an intubated patient. When I see that, I'm often just really struck by the difference between the patient in the bed and the photos on the wall. I think if anybody walked in at that moment, they would see me looking back and forth from the wall to the patient to the wall to the patient, kind of coming to mental grips with the fact that this was the same person. When that has happened, it's been a reminder to me about how easy it is to just look at the person in the bed and think, “Oh, this frail patient or this dying patient, this is all they ever were.” It seemed like a natural progression, when you don't have a bunch of photos on the wall, to ask patients or families to see those photos, as a reminder to me and sort of a reassurance to the patient and family that we're looking at the whole person. . . . I'm certainly not the only one who does this. I've heard from a lot of folks that have started doing this, and I've gotten a lot of really great feedback about it.

Q: How do patients' families react?

A: It's an interesting reaction. I would describe it as hopeful, and I think that they might be hoping for different things. I think sometimes, when they show me a picture, they're hoping that we can restore their loved one to how they were in that picture. I think other times, they're just hoping that I'll be able to see their loved one the way they see their loved one. It can be kind of a joyful thing almost, where the family is showing their loved one at birthday parties or playing with their grandkids. Sometimes it can turn into a really solemn occasion also because you can see the family start scrolling through the photos, and you can almost see this realization sink in that “Gosh, my husband, he's not able to do these things anymore.” We kind of have to shift our thinking and shift our goals of care.

Q: Which people should be asked?

A: I haven't had any bad experiences with asking for photos. From a practical standpoint, I think it's helpful when you see that somebody has a smartphone, so that lets you know that they're comfortable with this technology and do probably have photos on there. Other than that, though, when you're looking at what kinds of situations you might ask in, it could be patients who can't speak for themselves—they could have dementia, they could be delirious, they could be intubated in the ICU. . . . So these photos speak for them. And then certainly, if the patient is close to the end of life or if you're making decisions around treatment options when you're having goals-of-care conversations, I think that's helpful also. But even further upstream when you have patients with chronic illnesses or serious illness, like our patients with [congestive heart failure] or our patients with [chronic obstructive pulmonary disease] who come into the hospital repeatedly. They are probably struggling with their illness at that point and how it's impacted their lives, so I think asking for photos in that case too is a way to recognize that and validate that.

Q: Should hospitalists consider doing this?

A: Absolutely. I'm a former hospitalist, and I think one of the challenges that hospitalists face is the fact that we're taking care of patients sometimes in a very brief window of time. Obviously, we have some patients who come back for subsequent hospitalizations, but oftentimes we are taking care of patients that are at a crisis point—maybe they're even at end of life. So I've always found it fulfilling to form really intense relationships with these patients and families really quickly. That can be challenging for a hospitalist because we're trying to build that bond and that trust and that relationship so quickly, in a matter of days. So I think that asking for photos can be really powerful in terms of facilitating that and letting them know, “We care about you. We want to know who you are.”

Q: How does seeing photos affect clinicians?

A: It's important for the patients and families to feel validated, but I think this also validates us as clinicians. We hear so much these days about burnout and declining satisfaction with our work, and I think a lot of that centers around the fact that sometimes we feel like we have more of a relationship with the electronic medical record than with the patient. So I think asking for these photos and having conversations around that can be really fulfilling and nurturing as a clinician, especially when we're taking care of patients at the end of life.