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Crow’s Feet


Monday
“Before you leave today,” said my surprisingly tall, bearded resident, “you should introduce yourself to the patients on our service so that they will know who you are tomorrow morning when you pre-round.” I didn’t yet know what pre-rounding was, but I presumed it was similar to pre-boarding an aircraft, a practice reserved for people (medical students) who require extra time to perform routine tasks. “After you introduce yourself, pick one patient to follow. You will be writing notes on that patient every morning and presenting on rounds.”

It didn’t take long to meet our patients, many of whom exhibited little interest in exchanging pleasantries. There was an elderly man suffering from late-stage Parkinson’s dementia. There was a patient with schizophrenia experiencing a COPD (chronic obstructive pulmonary disease) exacerbation. Then, there was Mrs. G, who was admitted for immune thrombocytopenia. She was a retired teacher who spent her time volunteering at her church and caring for family members. She smiled warmly when I introduced myself as, “Joshua the Medical Student” and announced that she would take good care of me during her stay. She asked me what year of school I was in and whether I had decided on a specialty. In turn, I asked about what brought her to the hospital and if there were any concerns I could communicate to the real doctors. She was kind, appreciative and outwardly healthy; a rarity in any hospital. She was my first patient.

Tuesday
When I woke up Mrs. G the next morning at an impolite hour, she was just as friendly as she had been the previous afternoon. “Good morning, Joshua.” At this point she was the only person in the hospital who actually knew my name. Her smile wrinkled her cheeks and the corners of her eyes in all of the ways that Botox, fillers, and face-lifts seek to reverse.

“My platelet count is up today. I can feel it,” she told me as I was preparing to leave the room and start working on my note.

“I hope you are right. We should have the results in about an hour. I will see you again soon, Mrs. G.”

When the results came back, they confirmed what our patient already knew. Her platelet count had risen high enough that she could be discharged from the hospital. “Med student!” my resident beckoned, rekindling my hope for anonymity, “Go tell Mrs. G about her platelets. Enjoy giving your first piece of good news—it’s not going to happen often!”

“How did you know your platelets were up?” I asked Ms. G, curious if there was a physical exam finding that could have tipped me off.

“Praying and believing, Joshua.”

We talked about her discharge as I wrote down a few questions to bring back to the resident and intern. We wished each other well. She told me I was going to make a good doctor and I told her she lifted everyone’s spirits on the floor.

An hour later, in the middle of Grand Rounds I saw my resident and intern simultaneously look down at their pagers and begin the purposeful strut of the white coat warrior. They didn’t look at me, but I followed nonetheless with long, fast strides and sturdy eyebrows splashed with concern for the patient, anger at the disease and resolve. Like many genuine clinical skills, the walk can’t be taught via textbook, PowerPoint or YouTube.

Observe. Imitate. Repeat.

When we arrived at her room, Mrs. G looked scared by all the serious faces. She smiled half-heartedly and unevenly when instructed to, and failed to keep her arms raised with her eyes closed. The wrinkles on one side of her face were absent. The number of people in the room increased exponentially. The stroke team converged, pointed, murmured, and peppered the nurses and doctors with questions. “When…? When exactly!? How sure are you?” I took out my shiny new clipboard, flipped over a sheet of paper and started scribbling furiously, hoping that enough details could somehow halt the momentum of her illness. I blended in with the wall, standing still as the white-coated herd rolled her out of the room.

Wednesday
Mrs. G was transferred to a nearby tertiary-care hospital better equipped to evaluate and treat her stroke. From that point on we had no information and no way to access her medical record. There was no way to know if she was alive, severely disabled or had experienced only a TIA that could resolve by the morning. The next day I asked my resident if he had heard anything about our patient. “No,” he told me, “but call the hospital and see if you can find out what happened. Tell them you are a resident.”

For the first time, I neglected a direct order from the tall, bearded one who would be writing my clinical evaluation. I pondered excuses ready to deploy should he ask me for an update. “They can’t provide protected health information over the phone,” or “The intern figured out I was a med student and promised to smother me in my sleep if I ever wasted her time again.”

Friday
The first week steamrolled my spirits sufficiently to make me question the veracity of the TV doctor shows that led me to medicine. We had to restrain our Parkinson’s patient so he would stop pulling out his nasogastric tube. The man with schizophrenia yelled at me in the hallway calling me “retarded” when the doctors refused to give him opioids. I wanted to tell him that we don’t use the “R-word” anymore, but it seemed beside the point. When I left the hospital at the end of my first week on the wards, I still hadn’t called. I felt ashamed at my solipsism; that Mrs. G’s condition was a tragedy for me. I didn’t want to face the possibility that my first patient, the first person in the hospital to remember my name, might never be the same.

On my walk home, the bearded one sent the text message I had been dreading for the past three days, “Any news on Mrs. G?” I froze, tried to type, and then turned around. For the first time, I imitated the walk, unburdened by comparison with the real doctors sharing a corridor. 30 minutes later I was at our nearby referral hospital asking for directions to Mrs. G’s room. “Prayer and believing,” I told myself as I squinted at the confusing, color-coded signs.

I found her room, put on my white coat, knocked gently and stepped inside. Mrs. G looked at me, sat up in her bed and gently remarked, “Hello, Joshua. What a wonderful surprise.” Then, she smiled her big, crinkly smile.

Reflection
Nearly a year has passed since I met Mrs. G, my first patient, who I had the privilege to encounter several more times as part of a longitudinal clinical clerkship. Her recovery and our relationship helped buoy me through some of the most challenging months of medical school. Since then, I have been struck by how many patients relish their role as educators for medical students. When a student asks permission to learn from a patient, the roles of caregiver and care-recipient become reciprocal. We trainees have an opportunity to develop true partnerships with our patients, which, as Mrs. G taught me, can sustain student and teacher alike.

Joshua Stein Joshua Stein (2 Posts)

Contributing Writer

Columbia University College of Physicians and Surgeons


Joshua Stein is currently a Class of 2018 medical student at Columbia University in the city of New York. He graduated from Washington University in St. Louis with a bachelor's degree in neuroscience and subsequently earned a Master of Science in Teaching at Pace University. Prior to enrolling in medical school, he taught science for two years in the New York City public school system.