As third-year medical students, we embark upon the adventure of clinical rotations for the first time. We stay up several hours perusing years of medical records in preparation for the foreign patients of the next day. We learn the various intricacies of their lives prior to ever knowing what they even look like. We delve into past medical histories, family histories and other private histories that may otherwise be hidden from the world. We take notes, we prepare, we get overly stressed out about the pre-clinic huddle where we are expected to review the scheduled patients and provide a plan of action for each.
This was when I came across Patient 15.
One day a week, I work at a mobile health clinic. Most of these patients have complex personal histories – uninsured, unemployed, psychiatric conditions, domestic violence victims, recent immigrants. You name it; we have probably seen it. The night before my second Tuesday ever at the clinic, I buried myself in medical records, case after case, taking five pages of notes front and back with microscopic handwriting so as to ensure I had enough information to present to the attending and resident. I was exhausted.
Patient 15 would have to wait until morning.
4 AM: wake up. Plan: finish reviewing Patient 15, make breakfast, do some morning stretches before a long day of clinic, reread all the patient notes, search UpToDate for anything that I may be unsure of before 8 AM pre-clinic huddle.
Patient 15 was a fit 38-year-old female with a past medical history of dilated cardiomyopathy who presented for follow-up on her most recent echocardiogram results. Flipping through the past notes, prior echos, family histories, I was captivated. A previous echo revealed an ejection fraction of about 50% — her heart was already revealing its impending fragility. The most recent echo, just five months later, revealed an ejection fraction of 20% — her heart was failing!
My mind began to race with questions regarding symptomatic presentation, management, anticipatory guidance, and all the things we might discuss with this last patient of the day. Trying to gather more information, I delved deeper. What might have caused this woman’s heart to fail at such a young age? Then I saw it: “family history significant for mother with heart failure and heart transplant.” It was hereditary.
We went through the day seeing patient after patient, writing notes, presenting to the attending. We repeated this cycle for each of the 14 patients ahead of Patient 15, for whom I was anxiously awaiting to see how our conversation would go. With each pause in the day, my thoughts were consumed by this patient – did she know how significantly her heart failure had progressed? Was I going to be the one to have to give her the bad news? Does she know what her options are at this point for management? Does she want to try any of those options? How is she coping with all of this?
I worried for her, and I worried about my own inadequacy in having this difficult conversation; I worried about how she would respond and what needs would be expressed.
The time finally came. During my 10-minute lunch break, I spent time researching medical management for heart failure – ACE inhibitor/ARB, furosemide, beta-blockers, spironolactone, automated internal cardiac defibrillator, and, finally, transplant. I knew the steps. I knew for her level of compromised ejection fraction what would be indicated at this time. I was feeling just slightly more prepared.
Then came Patient 15.
Patient 15 was an athletic, well-appearing woman in no acute distress, alert and oriented x3, mood and affect were appropriate at that time – all this to mean, she appeared normal. I would never have thought twice about this woman’s condition if I had seen her in a non-clinical setting.
I started my interview by introducing myself and my role, stating that everything we speak about today will be shared with the doctor and that the doctor will be in shortly. I asked, “So what brings you in today?” I was quickly relieved to find out that she already knew the recent results of her decompensating heart failure. I would not be faced with breaking the bad news to her. I proceeded to disregard all my preparation for this patient, but then the second wave of my psychological turmoil began – what now? How would a medical student have a role in a patient who needs continuous monitoring by cardiology and a transplant team? Maybe she was not even coming in for anything related to her heart condition.
Accepting my own limitations, I fell back onto my first- and second-year training: be patient-centered. What was she here for? As it turned out, for much more than I could have anticipated.
Her mind had gone foggy. Her breaths had run short. She could no longer walk into her daughter’s room without forgetting her initial motivation for doing so. She could no longer complete the tasks demanded by her career. She could no longer complete her 2-hour morning runs as she once had. She had grown increasingly frustrated with herself and with life.
My job at that time was not to “fix” her; I am not capable of that. I could, however, provide personalized and empathetic care to address what it was she needed from us at that time – someone to speak to and to try to make sense of the new reality she was now living. We did just that. We spoke about her experience in traversing the multifaceted healthcare system. We dug deeper. We spoke about how her family was coping with the news of her failing heart. We spoke about how she was coping with it. We spoke about the philosophical values she holds and the struggles she has had in her day-to-day life as she becomes overwhelmingly aware of her compromised status.
This conversation reminded me why I decided to pursue a career in medicine: the beauty of one being there for another; the compassion shared between patient and provider; the empathetic demand required of persons in such a position; the opportunity to offer a caring thought, a comforting smile, a supportive hand to a vulnerable stranger.
The medications, the disease pathologies, the management of medical conditions are all important to being a good physician; of that there is no doubt. What makes a great doctor, however, is the ability to connect with another human being. We are placed in such privileged positions where strangers come to us and confide in us in their most defenseless states. Asa result, care is so much more than disease and treatment. It is about the person sitting in front of you. It is about being attentive and really grasping their story. What brings them in today? A listening ear, emotional support, guidance through a complicated medical system: it is our job to be there, to be present. Remember the honor we will have in being titled, doctor.
Keeping this honor in mind, I try to do a few things in every patient visit.
1. Be engaged: the conversation may be the only time I can intervene.
2. Be conscientious of the patient experience: I might be the one positive interaction they have all day.
3. Be aware of the hardships that may be plaguing the individuals I am meeting: this visit may be costing them more than I could ever know.
4. Be patient with those I strive to help: change is hard when the rest of their world seems out of control.
5. And finally, be grateful: the patient chose me.
The visit with Patient 15 could have been quick – follow up with cardiology, follow up with the transplant team, order routine labs for a wellness visit. Instead, it became about mental health counseling. It became about a social work referral for more hands-on assistance navigating the overly complex health care system. It became about the challenges faced every day by the uninsured with significant medical conditions. It is what she wanted, what she needed. Holding back my own tears, empathizing with this woman’s experience, I was immeasurably grateful she entrusted me, a nervous medical student, with such untold and intimate details of her life.
To me, Patient 15 became about the profoundness of a visit so easily attained by simply listening.