The Week After discharge

Jason Denoncourt

There’s always a patient that lingers, discharged from the hospital but not from my ruminating mind. It’s almost always a young person. Cancer ending a life far too short. Substances demanding a ransom, kidnapping a life of potential. 

She arrived confused and then obtunded, with deranged electrolytes, hallucinations, tremors, and agitation, all consistent with severe alcohol withdrawal. She was intubated and sent up to the ICU, where machines breathed for her and barbiturates minimized her symptoms. Once she was extubated and transferred to general medicine, my team continued routine care, including thiamine, nutritional support, and daily labs. Slowly, over several days, she began to resemble what I imagined she might look like outside the hospital.

She was thin and malnourished with streaks of green-dyed hair, and she confabulated stories to fill in gaps that alcohol had burned into her memory. Although she medically improved each day, the story of how she ended up here slowly emerged. Just months earlier, she had been stable, even in early remission for several weeks at a time. I couldn’t understand how she deteriorated so quickly.

I had the time the residents and attending physicians lacked. Medical students occupy this rare space. We are knowledgeable enough to interview and counsel patients but not overwhelmed by heavy patient loads or administrative tasks. I slowed down. I sat with her. I listened. I gave attention that often feels extinct in healthcare today. Each day, I spent an hour with her, not examining her and not documenting. I was just there, ready to listen when she was ready to share. Each day, she smiled when I asked how she was doing. For days, it was that kind of smile meant to keep people from asking more. Trust takes time. After about a week, she began to share her story.

She started drinking in middle school. Though she was adopted into a large family, she could not escape the effects of her early experiences. She had fought hard. She had ten years of remission. Ten years of waking up clear-headed, remembering yesterday, and building something stable. Then she met a man who made her feel supported and loved. Though from what I heard, this twisted version of love looked more like isolation and abuse. She started drinking again, at first just socially, just at night, and just to be close to him. I asked her gently if she felt safe with him. She cried. I asked if he abused her. More tears. When I asked if he hit her, she nodded, rationalizing the abuse and blaming the alcohol.

I wanted to report it and intervene. I shared what she told me with my resident and attending, and each spoke with her to assess safety and offer resources. But she was an adult, not a minor and not elderly, and the law provides few protections for adults who do not meet criteria for mandated reporting.

Prior to discharge, she shared her minimal social support beyond her parents and partner. Despite our efforts and those of the addiction medicine team, she refused rehab. She shared her traumatic experience in the past with Section 35, a law that enables the involuntary commitment of a person to a treatment facility for a substance use disorder. She was deeply afraid of having her rights stripped away yet again. She was eventually discharged from the hospital one afternoon. She had no phone, no primary care physician, no one to follow up with her or notice if she began spiraling again.

What troubles me most is that she needed longitudinal support greater than anything we could offer in the hospital. The day she was discharged, she was still under our care. A nurse checked her vital signs every four hours. The team rounded on her each morning. Her electrolytes were monitored, medications reconciled, and withdrawal symptoms managed. But the moment she walked out, she entered a void. No one was assigned to call her in three days. No one would notice if she missed the follow-up appointment she didn’t have. She needed someone who would be there the next week, and the week after that, and on the day she felt ready to seek help again. She needed primary care.

But primary care in our area is sparse. It's troubling that nearly one in four Americans live in designated primary care shortage areas, especially given primary care is the one component of healthcare where increased supply leads to better population health and more equitable outcomes. This crisis is poised to worsen as the number of primary care physicians continues to decline, and fewer medical students choose the field. 

It is difficult to measure the impact of primary care. It’s quiet, unglamorous work. It’s showing up, knowing patients over time, and noticing the subtle changes that matter. I imagine a different version of this patient’s story. In that version, she has a primary care physician who has known her for years. Someone who understands her history and the significance of ten years of sobriety. Someone who asks about her new boyfriend. Someone who screens for intimate partner violence. Someone who catches the spiral before it becomes a freefall. Someone who calls when she misses an appointment.

But that version of care rarely generates revenue. You cannot bill for remembering a patient’s story and providing emotional support. There is no code for preventing a crisis that never happens. Instead, we have emergency rooms replacing relationships and hospitalizations replacing continuity. 

I don’t know what happened to her. I never will. She walked out, returning to the same conditions that brought her into crisis without any meaningful follow-up. Maybe she is doing better now. Maybe she found treatment. Maybe she left him. Maybe she somehow found a primary care physician who had space for one more patient.

I carry her story with me. We are very good at saving lives in hospitals, but we are failing to sustain them outside.

Jason Denoncourt is an M4 at UMass Chan Medical School who is interested in family medicine and community health.