Objective vs Subjective

By Jessica Dominguez, MS4
All patient names and identifying information has been changed to uphold privacy.

© Tomas Castelazo, http://www.tomascastelazo.com / Wikimedia Commons

“Another border jumper,” I heard them say.

When I go into a new patient’s room, I see them on their bed, dressed in their gown, either alone or with loved ones at their bedside. And in my mind I wonder, 
          ‘How did they end up here?
          Who are they outside of this hospital?
          What do they do for a living?
          Do they want us to contact someone for them?
          How do they feel about being here?’

I remember waking up in a hospital room three years ago. Before then, I was just on my way to the gym when suddenly a pickup truck ran into my car. The next thing I remember was waking up alone in a dark hospital room. Five days later, I became aware that I had been in a motor vehicle accident. I suffered various injuries. Among those – fractured left ulnar bone, 2 subarachnoid hemorrhages, and a ligamentous injury of my neck. Though I was thankful to have had my family’s support during this time, I felt frustrated, upset that in a matter of seconds I had lost a sense of my independence. During this time period, I had many doctors appointments. I often wondered if the doctors I saw cared about who I was. I was only three months away from starting my first year of medical school when this happened.  I found that when I would tell them, they would open up to me, and explain my conditions and treatment with further detail. I keep my experiences as a patient in the back of my mind as I interact with my patients. 

I was working in trauma surgery when the call came in – “We have another border jumper. Jumped 30ft down from the wall.” I had heard of these traumas being common at our hospital. As an immigrant myself, I felt a special connection to this patient. As she was brought into the trauma bay, we quickly assessed her. She had suffered severe open bilateral calcaneal fractures. Through her silent tears, I could sense her fear. In our shared language of Spanish, I took the time to talk to her when things in the bay settled down. “Hola señora, cómo está? De dónde es?” She’s a young woman in her 30’s who fell from, not jumped, the border wall. She shared with me that she wanted to come to the U.S. with the hopes of working and earning money so that she may pay for the medical treatment her son needed back at home. She said she had never imagined something like this happening to her. We consulted the ortho team, who said that there was too much damage and that she would possibly need a below-the-knee amputation of her left leg. My heart felt for her. 

She was then transferred to the floor where two members from Border Patrol sat outside her room. When I had time, I would go visit her and briefly talk with her. She was tearful that she could not communicate with her loved ones back home. Her mother and son must be worried about her. ‘Til this day, I still think of her and wonder if she ever got in touch with them, if she ended up getting the amputation, if she is safe or back at home with her loved ones. 

As a third year medical student, I like to take the time to get to know my patients. I want to learn more about them, not just the medical aspect of them, but also about their life outside the hospital, about what is important to them, and how they feel. As providers, we are taking care of patients during some of their most difficult and critical times of their lives, when they are at their most vulnerable. During these times, I feel it is important for us to show that we also care about who they are as humans and appreciate who they are beyond their medical condition. 

~

Jessica Dominguez is a 4th year medical student in PRIME pursuing Emergency Medicine and a Masters in Public Health. She’s passionate about community health and mentorship, and enjoys spending time with her family.

My First Patient Who Died

 

Photo by Pixabay on Pexels.com

by Milli Desai

All patient names and identifying information has been changed to uphold privacy.

I was third in line to perform chest compressions. Emergency Room bed 6 was filled with the synchronized chaos of a cardiac code. My heart was pounding out of my chest but this was hardly the loudest thing in the room – things were moving around all over the place as everyone seemed to know what they were doing, except me.

Now, I was about to be second in line. Someone asked me if I remembered how to do chest compressions and I mumbled “yes”, trying to quickly replay the steps in my head and hoping that my arms were strong enough to sustain chest compressions…it had been a while since I worked out.

And then, nothing. The time of death was declared, and the commotion in the room turned into calmness. There was nothing more to do, and the medical team started to wrap up and walk away. All we knew was that John Doe was likely in his 60s, had a cardiac pacemaker, and was brought to the emergency department in an ambulance from the facility where he was living after being found unresponsive.

I thought I would have a personal relationship with my first patient who died. It was exactly the opposite. Though the medical team had done everything we could, it was difficult for me to walk away from that room without knowing more. So, I tried to learn more about John Doe. I tried to learn his real name, his age, his medical history, and what led to his death. I wished I could learn about his hopes and dreams, hear his stories and life lessons, and talk to his family members. I wanted to know the circumstances in which he lived. I wondered what his last conversations were, and if he felt ready for death.

There is a sacred bond in knowing these things, in having our patients open up to us and teach us about the mysteries of the human condition. This is the kind of bond I assumed I would have with my first patient who died.

My attempts to learn more about John Doe were not successful, and I realized I would not be able to have this sacred bond with all my patients. But I owed it to my future patients to try. I made a commitment to try to ask each patient I encountered a question about their life, anything that would help them feel heard and would teach me something. This experience made the moments I can share with my patients a privilege.

It was still a sacred moment to observe John Doe’s death – despite not knowing anything about him. In the Healer’s Art elective course I had taken as a first year medical student, I wrote a letter to my future first patient who would die. This exercise helped me think about what I might want to ask someone as they faced death. And later in my medical school career when I observed John Doe’s death, I found clarity in knowing that someone had thought of asking him these questions about his life, even if he was not there to hear them.

 

Milli Desai, MHS is a medical student at UC San Diego. You can follow her on twitter @millidesai.

A Physician-Patient Connection

By Nicole Basler, MS3

Photo by Pixabay on Pexels.com

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

“Sometimes, we don’t have a clear explanation. Most miscarriages are due to some kind of chromosomal abnormality.”

I heard the sounds of sniffling as the patient grabbed a nearby tissue and blew her nose.

The physician continued softly, “There isn’t anything you could have done differently.”

She paused, as the patient bit her lip and cast her eyes downwards, visibly lost in her own thoughts.

Several moments of silence passed as the patient deliberated her next few words.

The silence was deafening, as it was a quiet afternoon in clinic, and while the exam room itself was rather small, even I sensed the air of heaviness and melancholy.

I looked at the two women in the room. The patient was seated on the exam table, staring at the rays of sunlight spilling through the window on the opposite wall.

The physician herself was several months pregnant, her bulging belly visible underneath the white coat she was wearing. She stood next to the exam table, close to the seated patient.

I slowly shifted my weight from one foot to the other from the corner of the room, trying not to disturb the interaction before me.

The patient finally said, “It took me a while to come to terms with it. But I realized that my body was telling me I wasn’t ready. If my body wants me to wait, then I guess I’ll wait.”

The physician placed her palm over the patient’s hand and gripped it tightly. The physician’s other hand instinctively came to rest on the side of her own belly.

Both women locked eyes as they held hands.

One mourning the loss of a baby, the other a few months away from giving birth to new life.

One radiating pain and sadness as she attempted to find peace in her situation, the other consoling her with an outpouring of compassion and empathy.

The interaction lasted a few powerful seconds, but I felt a deep energy between them.

An emotional connection that transcended the physician-patient relationship. Two unique outcomes during their shared journeys to motherhood.

~~

Nicole Basler is a 3rd year medical student pursuing family medicine with an interest in health communication. She likes playing the piano and trying new foods in her spare time.

The Business of Healthcare

Photo by Pixabay on Pexels.com

By Olumuyiwa P Akinrimisi, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

I found myself rushing again to the surgical floor. Upon entering the ambulatory surgery unit, I glanced at the monitor and saw my attending surgeon’s name listed for two laparoscopic hernia repairs this morning. “Easy peasy,” I said. Immediately, I logged onto the electronic medical record system. After reading up on the patients’ histories and data, I had a good understanding of their health statuses. However, reading numbers and words is never enough to get a clear picture of a patient’s story, so I found the first patient’s bed and introduced myself. “Hello, my name is Olu, and I am the third-year medical student working with you today.” We spoke for a bit about what the patient did for a living and how the hernia was discovered. This suggested possible causes and gave me a good sense of the patient as a whole. Once I finished with the patient, I went to the workroom and cracked open Surgical Recall to prepare for the questions I was soon to be “tested” on in the operating room.

Upon entering the OR, I saw the patient lying on the operating table completely covered in sterile blue cloth with only the lower left quadrant of the abdomen exposed with skin markings. The nurse said, “Timeout!” At this point, they listed the patient’s name, diagnosis, surgical site, chronic diseases and other things on the pre-surgery checklist. Minutes later, the attending surgeon exclaimed, “Scalpel!” He pierced the skin at an angle, creating a perfect opening to insert the surgical instrument. I stood there and watched attentively every move the surgeons made and I was ready to assist in any way I could.

In the middle of surgery, the surgeon said, “Well, they have another hernia on the right side.” Then the attending surgeon asked me, “Olu, what should we do? Operate on the two hernias now, or schedule a separate operation to repair the right hernia?” This is when putting on my management hat was necessary. I thought to myself, the obvious answer was to schedule a separate surgery, because we did not get the patient’s consent to operate on the right-sided hernia. That is exactly what I told the attending surgeon, and he said, “Yes, currently that is my only legal option.” However, is that option cost-effective? We must consider the cost of the surgical consultation, physician visit, surgical equipment, and surgical team labor. It doesn’t make financial sense to reintroduce these costs when we can save at least $7,750 if we operated on both hernias at that moment. In addition, we could also reduce the burden on the patient by avoiding scheduling additional doctor visits and a second operation. On the other hand, doing unplanned surgery can introduce a host of legal issues. For instance, there is always the risk of surgical error, which is more likely when additional sites are being operated on. Overall, it is crucial that, as physicians, we do what is best for our patient and, as businesspeople, we strive to sustain our health care system. At the end of the day, health care is about serving the patient, hence every business decision we make as health care professionals must be in the best interest of our consumers.

The inner workings of the health care system are what medical schools don’t teach. When I applied to medical school, I knew I wanted to have a role beyond that of a physician. Management caught my eye once I started my third-year rotations. My experience during the hernia repair expanded my mind on how critical the operations behind hospitals are in promoting effective and efficient care. Also, how that transcends into health care costs and how health care settings are eating up so much of the federal budget, partly because their methods of practice aren’t efficient. I then became curious about what I could do to provide efficient and effective care to communities that need it the most. In addition, how could I help combat these excessive health care expenditures so that the federal budget can be used more resourcefully?

Therefore, I applied to Johns Hopkins Carey School of Business to pursue a degree in health care management. I chose Carey because the curriculum focuses on business in medicine and the influences health care institutions have on the community. My experience so far has taught me that there is so much value when a physician is not only an expert on operating or creating a good differential diagnosis but also able to understand the mechanics of medicine. It is very necessary that physicians develop skills in business and leadership, especially with new payment models such as value-based payment schedules being introduced. Commonly, physicians are paid based on the services that they provide; however, this new payment schedule takes into account certain quality metrics. Are the physicians actually doing their jobs? Are they managing their chronic diabetes patients properly?

I took a particular interest in the physician payment schedules after learning about them in my health care management courses. Provider payment method is a part of the business in medicine that physicians should actively learn and advocate for. There are many other sectors in the business of medicine, such as operations, accounting, safety, and community outreach, that physicians should be engaged in.

Throughout the first semester of my program, I have taken in the knowledge that will be applicable upon my return to medicine. I can say that I am comfortable advocating for change in a hospital setting and creating alternate options to solve operational issues. I can use the knowledge I have acquired, such as human physiology, patient autonomy, health care laws, and health care services improvement strategies, to develop new strategies that allow care to be more efficient and effective so that we are using health care dollars wisely.

Looking back at the hernia repair, a business-minded physician would take initiative to propose a new approach in surgery consultation. What can we do as a health care facility to cut costs and save resources in case this were to happen again? What are some of the legal implications? How can we create a better experience for the patient? Asking questions like these is how physician leaders can stimulate change to push health care in the right direction.

Olu Akinrimisi is an MS4 pursuing internal medicine with an interest in healthcare management and public health. You can follow him via twitter at @drakinrimisi

Portrait of a Woman

By Pallavi Basu, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

“Ready for your first admission?” 

Scott, my senior resident, interrupts the monotony of fervent typing in the workroom. Like all unassuming long call days, a torrent of admissions will inevitably follow; my team steels itself in preparation. But it is my second day as a medicine sub-intern, and the novelty of having my “own” patients is still exciting. In indecipherable shorthand, I note the history Scott recites: “Mid-forties, HIV-positive, male-to-female transgender veteran, recently treated for chlamydia, presenting with fever and flank pain.” He looks up. “Interesting patient – great for a medical student.” 

What renders her interesting? Perhaps he refers to her broad differential diagnosis, a reprieve from the cirrhosis and heart failure exacerbations predominating our service. Maybe he means the challenge of interacting sensitively with a transgender patient – a member of a historically vulnerable patient population – a task for which medical schools often ill prepare students. 

Walking to the ED, I recall a late afternoon stroll years ago with my grandmother in India. She’d paused to seek blessings from an eloquent, ornately dressed woman seated proudly amongst her belongings beneath a bodhi tree. My ten-year-old self had stared, fascinated; who was this lady my grandmother treated so reverently? I learned later she was part of the hijra, a three thousand year-old community of transgender women perceived to be in communion with goddesses in the Hindu Ramayana. Yet these “goddesses,” who centuries ago graced royal councils and blessed newborns, became criminalized during colonial rule simply for their identity. How did they see themselves amidst such branding? 

I knock on the sliding glass door. Louise – her preferred name – looks up suspiciously, her hands moving restlessly around threadbare blankets. The smell of stale smoke, unruly blonde wig positioned slightly askew, and shiny tear tracks paint a picture of misery. I pull over a chair and introduce myself, apologizing for her obvious distress and rubbing her shoulder. She appears taken aback by the simple gestures and haltingly answers my questions. As I take a sexual history, her hopelessness becomes especially prominent. 

“Do I have chlamydia again?” Her eyes water once again. Without meeting my gaze, she flatly informs me, “no one wants to touch me anyway.” 

I sense her anguish and don’t immediately know how to respond – I gently place my hand over hers as her painful narrative continues. Louise is not only living in a shelter after a recent assault by a partner, but she has also been attempting to obtain a consult for gender reassignment surgery for months without success. Her physical and emotional trauma are incomprehensible to me – when did this woman last feel safe, or feel seen? 

As I enter the remaining admission orders, a nurse approaches. “Is her room assignment right?” I check the record of her hospital wing and bed assignment – the hospital’s policy does not permit co-ed rooms. Yet, given the “M” next to “sex” listed on her medical chart, the system had placed her with three male patients. The attending and senior are elsewhere; do I step in? Trusting I am not overreaching, I thank the nurse and with his help, modify the assignment. We poke our heads back into Louise’s room and notify her a female or private room will be ready shortly. For the first time since meeting, Louise smiles: a hesitant, delicate motion that transforms her face entirely. 

While the IV antibiotics run, we secure an outpatient urology surgical consult next month and repeat STI labs given her concerns. Over the next couple days, Louise’s pyelonephritis improves and with it, her mood. At each encounter, my attending or I perform a brief physical exam – not so much to check for costovertebral angle tenderness but rather to tangibly remind her that our touch, at least, carries no conditionality. 

On rounds one morning, I relay that her cultures grew a resistant strain of E. Coli, to which she unexpectedly starts laughing. Taking in our confusion, she explains that the bacterium’s name reminds her of her pastor’s vibrant exclamations in Swahili, whom she proceeds to imitate with dramatic gesticulation. It is such a shift from our previously subdued exchanges that, despite our best professional effort, no one maintains a straight face. 

For a moment, we all revel in the brief moments of levity the hospital so rarely offers. “She seems much better,” my attending observes as we exit the room. Yet nothing about her physical appearance obviously changed – her illness, after all, was a symphony of microorganisms and immune responses beyond our visual scope. 

I think again of the hijra woman I’d met in India, who despite her societal “fall from grace,” retained an elegant and resilient spirit, validated by other strong women like my grandmother and indeed a “goddess” in her own right. Perhaps Louise, too, had finally found the space and care she needed to recuperate – to recover her sense of self: a combination of faith, fashion, and obscure R&B music beyond even a medical student’s capacity for study. 

It is a simple act our team performs before her discharge: retrieving a comb and some nail polish, which we leave with her nurse. We knew a friend from the shelter would pick her up and that Louise was self-conscious about her disheveled appearance. But seeing her afterward, “relentlessly red” nails and all, makes the gesture totally worthwhile. 

The aura of hopelessness hasn’t dissipated entirely. But she sits straighter, her eyes meet mine, and she engages with our team by asking questions or soliciting advice. For however briefly she was in our care, she was seen. For a few fleeting moments, Louise had a safe haven which, through a series of small acts on our part, gave her the freedom to “long, as does every human being, to be at home wherever [she] found [her]self.” Maybe in a moment of need Louise might remember our short-lived connection and feel her inner goddess reveal herself, fiercely and unabashedly.

Pallavi Basu is a fourth year medical student at UC San Diego School of Medicine. Her essay “Portrait of a Woman”  received an honorable mention in the 2019 Hope Babette Tang Humanism in Healthcare Essay Contest.

More than Meets The Eye: Learning to Incorporate Humanism into Fourth Year

By Joel Klas, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

One of the most impactful insights I received into understanding patients came before medical school as I volunteered for a hospice program.  During the training, our leader often pointed out that patients, especially hospice patients, do not see themselves as we see them in the hospital.  When we as physicians and medical students meet a patient, they are often gowned, tired-looking, weak, sick, and often alone. In this setting, especially with our medical system’s strong focus on pathology, it is very easy to view patients solely as their disease and their data points.

Love, by Aleksandr Milov

Take Mr. Rodriguez, an 80 year-old gentleman with a 50-year smoking history and stage four cancer who was refusing treatment and had presented with severe dyspnea due to a spontaneous pneumothorax secondary either to his severe emphysema or cancer.  You may be able to picture this patient already, and the image you have probably fits. You might also be thinking about his poor prognosis, need for hospice, and have an accurate mental picture of his cachectic appearance, chest tubes, oxygen requirement, and grimace from his pain.

When I asked Mr. Rodriguez to tell me about himself, he did not mention any of these things.  These were realities to him but did not represent his self-view. “I am a former CFO of a biotech company. I shot a 10 handicap nearly every day until this stupid cancer happened.  I put myself through college after my wife left while I took care of my 2 year-old daughter which was highly unusual at that time, and now my daughter has a wonderful family with two kids and runs her own business.”

Another patient I met, Mr. Smith, was four years into having progressive idiopathic pulmonary fibrosis and was being readmitted into the hospital for hospital acquired pneumonia.   Mr. Smith’s pulmonary fibrosis had reduced him to skin and bones and was making him live a vicious anxiety positive feedback loop. Already anxious from becoming dyspneic, Mr. Smith would start breathing faster with any type of conversation, thus making his dyspnea worse and increasing his anxiety level.  As such, he refused all conversations with physicians or nursing and he tried to calm himself by watching reruns of Andy Griffith and I love Lucy. Mr. Smith also refused all medication to calm his anxiety and dyspnea, accepting only oxygen as he did not believe in those “pain killing medications that kill you.”  Mr. Smith presented an emotionally complex case for our medical providers, as we could offer no treatment to halt the progression of his disease and every provider knew that hospice presented the best hope to meet Mr. Smith’s wish to return home. However, any attempts of discussing hospice only exacerbated his anxiety and dyspnea symptoms making conversation impossible.

          Mr. Smith did have the wonderful gift of a truly loving son John who was his full time caregiver.  When we met, John’s fatigue and sorrow were palpable. Deep dark circles surrounded his eyes. Dry wall dust and powdered cement covered his shorts and socks. It didn’t take long to realize how uncomfortable John was in the hospital environment surrounded by scrubs, dressed up physicians, and beeping machines.  I had never met such a physically strong male made so uneasy by a setting where I felt comfortable. He often kept his eyes down, always spoke in a passive manner, and spoke softly. John had very little medical understanding, but he understood we could not improve his father’s condition and that it would only continue to worsen.

          We had set up a care team meeting with John to discuss his father’s condition.  As we reiterated the realities of his father’s disease and our recommendation of hospice, John broke into tears.  When he stopped crying, he looked at the floor and said, “I want you to understand who my father was. He was the best, independent man I ever knew.  He built his own house where his wife later died. He took care of her the whole time. He was a mason and taught me everything I know. He took me in when things weren’t going too hot for me……paused to catch his voice….. His arms were like this (holding his hands 6 inches apart) until he was diagnosed with this disease 4 years ago. He was throwing down his own 50 pound concrete blocks and mudding even though he was in his 70s.  As he has gotten weaker, he has always found ways to stay independent. I just hate seeing him like this.” At this moment, I realized I had no idea of who Mr. Smith was, what he represented, or the life he had lived. I had only known this small sliver of his existence decimated by disease, and I realized then that there is just so much more to people than their diseases.

As I reflected on these experiences and others that I had as a third and fourth year medical student, I realized that to treat my patients holistically, I must improve how I learn about them and speak to them.  With the majority of my training focusing on pathology, I recognized that learning these humanistic skills was my personal responsibility. So I began observing my residents and attending physicians to see who maintained a holistic and humanistic focus with patients during their busy days and how they did this.  Watching them, I learned several lessons.

1. The first thing I learned was to sit down. Almost all meaningful personal conversations that I had as a fourth year occurred when I sat instead of standing up. It was amazing how a conversation dynamic changed with sitting.

2. Second, incorporating reflective statements during difficult conversations made sure patients felt listened to and ensured that I truly understood what they wanted to communicate.  Reflective Statements are when the interviewer rephrases or paraphrases the patient’s comments and emotions. When Mr. Rodriguez would start some of our morning conversations bitter and angry, I found reflective phrases such as “It sounds like you are very frustrated that this has not healed as expected, and your goal is to return home as fast as possible” allowed us to name his emotion and address the deeper meaning. Sometimes my statements were incorrect, but it gave patients the space to clarify what they were actually feeling.

3. Third, I placed more emphasis on the social aspect of the H&P by asking large open ended questions like “Could you tell me a little about yourself? What are the most important things in your life? What are the difficult parts?” to provide the patient a small window where they could tell me about significant history not included in my pre-formed checklist. I then learned to incorporate important parts of the social history into my patient’s one liner to provide my team with more depth during patient presentations on rounds. For example, I would start Mr. Rodriguez’s history as “This is an 84 year old male with history of stage 4 lung cancer who is a retired CFO and single father who presents with a spontaneous pneumothorax…”.

Lastly, I try to remember that the small sliver of time where I am caring for them is only that, a sliver, and if I gave my patients the space, many would give me the privilege of understanding their fuller picture.

Joel Klas is a fourth year medical student at UC San Diego School of Medicine. He is one of 19 students nominated by his peers to the Gold Humanism Honor Society’s class of 2019.  

Labor of Love

By Cecilia Bonaduce-Leggett, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

It took several years for my path in medicine to become clear. I knew that I wanted to pursue a path with lots of patient interaction. I explored colorectal surgery, pediatrics, and internal medicine but, ultimately, I found that I felt most connected to my patients when I rotated on obstetrics and gynecology (OBGYN).

Women empowering women. “Temple” by Laura Berger

As an OBGYN, performing surgery and practicing medicine are part of your job. But, when you get down to the core of it, your job as an OBGYN provider is to wholeheartedly and unequivocally value women. Value their bodies. Their choices. Their dignity. Their wellbeing.

In a world where women and girls have been chronically undervalued for centuries, it is a profound privilege to pursue a path where the prioritization of women is at the forefront.

Medicine is not an easy career path and at times I find myself fatigued not just physically but also, at times, intellectually and emotionally. In those moments, I call upon memories, little moments in medicine, that inspire me. There is one moment in particular that is unique to OBGYN that always reinvigorates me. That moment happens with each delivery that I participate in and it is a moment that I would like to share with you through the Gold Humanism Honor Society Blog.

From the medical issues at play to the people in the room, every delivery, like every family, is unique. In my experience, it is often the case that patients will ask several family members present, a whole team, during the delivery, ready to meet baby and to cheer mom on as she pushes.

After potentially hours of pushing, of pain and of anticipation, a new life enters the world. Though incredible, that moment is not the magic moment I’m referring to.  

When the baby is crowning, everyone’s focus is on helping mom push through those final moments. When mom looks up she sees the faces of her most trusted family members looking down at her. Once a baby is born he or she is often taken to a nearby crib to be examined by “the baby team” made up of either pediatricians or newborn nurses depending on the situation. And then, something happens.

The family often unconsciously shifts from bedside to crib-side. Some moms, maybe even many moms, may want the family to go with baby, the first of many selfless acts as a parent. From the family members’ and fathers’ perspectives, I understand the inclination, the curiosity and the desire to see this brand new person up close, and to walk away from the hospital bed and towards the crib. For me, the best part of the delivery is getting to stay with mom.

She is exhausted. Bleeding. Nervous. Baby has been moved away be examined, it is their first ever moments apart. The faces that had surrounded her seconds earlier, vanish.  

Choosing to stay with mom, our cheer team now downsized to the two of us, inspires a very powerful feeling. To me, it is the ultimate way to value women and their bodies. In that moment, I feel truly honored to have the privilege to stay and care for brand new mothers in one of their most vulnerable moments.

This is my story in medicine. Have you considered sharing yours? Please email ucsdstoriesinmed@gmail.com

Cecilia Leggett is a fourth year medical student at UC San Diego School of Medicine. She is one of 19 students nominated by her peers to the Gold Humanism Honor Society’s class of 2019.  

Resilience and Hope through Human Connection

By David Carlson, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

Force of Will, by Matt Stewart 

21 year old female, T-cell lymphoma, on multiple chemotherapy agents, now presenting with new neurologic problems – slowed speech, shaking in both hands, and right leg shaking that could be suppressed. This is the kind of tragic picture that can affect even people who have studied medicine for years and witnessed many incredible and horrible cases.

For a birthday that people often celebrate by going out on the town for the first time, this young woman spent receiving chemotherapy.  In addition to her slowed speech, her mood had been affected too – she was struggling to deal with this information, and her family was too.

I decided to do something I rarely do – my new haircut (thanks Dominic!) exposed my craniotomy scar, so I showed it to them and pulled up the MRI on my phone. “My heart goes out to you, I was diagnosed with a brain tumor almost two years ago and went through a full year of chemo cycles. I know it’s not fun.”

I hoped they would just appreciate the gesture, but her dad immediately said, “that’s so inspirational right there” and I saw his eyes light up. “Thank you for telling us that, Doctor Dave.” I could feel goosebumps underneath my white coat. There’s no amount of medical training that can account for the human element of healthcare – forging a connection with someone through shared understanding of the deeper aspects of how our physical ailments affect us.

He asked me more and I told them – it was brutal, I went through 5 days of chemotherapy every month, and now I’m done with that and back in school. I lost vision in the left side of both eyes, had to relearn to drive, and retake my driver’s test. Just last week, I had passed my driver’s test!

Excitedly, her dad asked me “Can you show that picture to Jay? Take a look at this – he had cancer too, and now he’s right back in med school.” She saw the picture, and in her soft, trembling voice, said “wow, that’s big.”

As the visit went on, the dad felt comfortable asking me more questions. He wanted to look at the MRI of her head, hear more about the pathways that were being affected and about how the treatments were supposed to work.

That same visit, she uttered “well, maybe I can get better.” That moment of hope and optimism stuck with me:  Research has shown that optimism, resilience, and social engagement are all associated with improved outcomes in people facing serious illnesses. This is something we’ve long believed – proliferated through anecdotes and folk tales – but we have only recently begun to quantify this connection scientifically.

… … . … . . .. . . . . . … … Cell No. 11, by Angela Canada-Hopkins from her Cancer Cell Art series

 

Despite this increasing knowledge, it is harmful and difficult to talk about cancer patients needing to find the will to survive. Surviving cancer is a far more brutal task than that. Your body is being harmed by your own cells, and the only ways to appropriately treat most cancers are through surgery, chemotherapy and radiation – all designed to remove or kill specific cell lines, but none completely efficient at this task. You lose some of your “good” cells, and the body responds as it would to any other major assault: with fatigue, nausea, hair loss, weight changes, and other losses specific to the type of treatment.

So there’s the physical stress and pain, the derailment of the “onward trajectory” of life that we all assume we’ll maintain, and the additional aspect of dealing with loss:

• Loss of cash due to treatment costs
• Loss of productive time – months to years of suffering, treatment, and follow-up
• The loss (initially) of a sense of hope and well-being, which are battling the multi-headed giant of fear, sadness, uncertainty, anxiety, and having to rely on others (possibly parents), which raises myriad issues we thought we’d outgrown.

Over the next days, I continued to round on my group of patients but found myself spending a bit more of my “down time” with this young woman and her parents (one of whom was always present).

I spoke with her and reflected on the wisdom I had gained from battling cancer myself. 

I talked about being amazed by the people who came around to offer support – many whom I hadn’t seen in years or had only met briefly, students I had taught or tutored before medical school who recalled the impact I had on them, high school friends who thanked me for small gestures of kindness during those tender years over a decade ago, and friends of friends who knew someone else fighting this fight and wanted to share goodwill and support.

I shared how it reminded me of the importance of people and human connection. So often we get caught up chasing goals and tasks, and forget to cherish those rare moments in time when we share part of our finite life-span enjoying the company of others who are also grateful to spend some time with us. I don’t know for sure, but I can’t imagine on my deathbed remembering chance encounters with celebrities, but instead the timeless joy of connecting with friends and family.

We will all die with items in our to-do list and bucket lists, but I don’t believe that’s what matters most. I remember a time before learning mine was a lower-grade brain tumor (and thus gave me a much better prognosis) when I thought about life and was most grateful for good times spent with family and friends. And luckily I have a second chance at life, with that new level of awareness, a still-long projected life span, and the understanding it could all end tomorrow.

After discussing many options with Jay and her family, we went ahead with a treatment plan and she went home, to follow up in two weeks to gauge her response. She was still quite tired and tremulous, but had a slightly more optimistic outlook.

Unfortunately, I rotated off of that service before the follow-up appointment and didn’t get to follow up with them. But I’ll never forget those moments of hope and connection with this horrifically grief-stricken young woman and her family.

I’ll remember those mornings and afternoons in a cold hospital room when, as the med student – not the resident or attending physician – I became the person who could offer an extraordinarily important type of therapeutic treatment that no or few others in our 3.3-million-person county could offer. And where a struggling young woman, ten years my junior, and who had tragically lost most of the physical gifts we take for granted, gave me the greatest gifts of all – the chance to connect and bond with another person, the chance to process my thoughts and learn from a patient for whom I was providing medical care, and the feeling that I was maturing from a medical student trainee into a doctor and a healer.

I will always cherish those times when, in a busy and sterile hospital environment, a group of humans gathered together to help each other deal with the challenges of this gift called life. Thank you, Jay.

David Carlson is a fourth year medical student at UC San Diego School of Medicine. He is one of 19 students nominated by his peers to the Gold Humanism Honor Society’s class of 2019.  

 

Thank You is an Understatement

By Ian Simpson-Shelton, MS4

Dear Dean Kelly,

Dean Carolyn Kelly, MD

I sat in your office unsure of my future. You were patient, calm, and collected while I sat there crying thinking about a new career path. However, you never let that dwindling flame die. You gave me a new sense of hope and encouraged me to continue chasing my dreams.

I am forever grateful for the opportunity you gave me and the day I heard your voice telling me I was accepted into medical school is still one of the happiest days of my life. That excitement only heightened when you told me one of your close colleagues had offered me a position in PRIME-HeQ. When reflecting on that moment, I still get emotional because I was on the verge of having another opportunity swept away from me. First, it was my mom. Then, it was my baseball scholarship. Then, my favorite aunt. Soon, I thought it was going to be medicine. Yet, something I understood was that from each process I grew and I think you knew I would grow from that point.

Dean Lindia Willies-Jacobo, MD

When I arrived on campus, you and Dr. Willies-Jacobo – another one of your colleagues that is going to depart UCSD – were the mother figures I needed at a time of uncertainty. We never spent an extraordinary amount of time with one another, but the two of you always spoke to me with a smile on your face. That’s all I needed to feel welcome in a very unfamiliar place. And, as I grew as a medical student, I truly came to understand how superhuman the two of you were.

You both taught classes, saw patients, sat in on several meetings, ensured medical students had everything you needed within reason, and most importantly kept your door open for everyone. I will never meet two women so influential to my life outside of the women in my family. I have to admit something though. I have stolen from you both. I stole your charisma, your calm demeanors, your willingness to lend an open ear even when time is scarce, and most importantly your desire to see the next generation of medical students succeed.

Ian Simpson-Shelton, soon-to-be MD

I am writing this because I want you both to know that I am forever grateful for your work at UCSD. I am thankful to have been students of such powerful, influential, intelligent, and compassionate individuals. If we as a student body can be as half as great as you two were, I guarantee we will be successful change leading physicians. It has been a privilege being one of your medical students and I wish you only the best moving forward.

Ian Simpson-Shelton is a fourth year medical student at UC San Diego School of Medicine. He is one of 19 students nominated by his peers to the Gold Humanism Honor Society’s class of 2019.  

 

When We Dream of Patients

Visionary art by Gilbert Williams, https://www.facebook.com/gilbertwilliamsgallery/

By Shanon Astley, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

I met Mr. M after his second code blue. My team was on-call and surgery had been consulted. He was obtunded, intubated and bleeding internally following a myocardial biopsy. He was also young. His 5 o’clock shadow overlay jaundiced skin and his abdomen swelled with his and transfused stranger’s blood. Medical staff surrounded him, keeping him alive with tubes and lines while chatter of how to save him filled the room.

He would code a third time before coming to the OR. I stood at his table, scrubbed in, with suction in hand. By then, his face and limbs had been covered and all that was exposed was his hard and swollen abdomen – made orange by the PU surgical film. The incision was made and eight liters of blood erupted. As a medical student your overwhelming hope is that you are never in the way, and your best hope is that you are useful. I found middle ground between the two by scooping warm blood clots out of the field.

He had a liver laceration, which by no small feat, the surgeons were able to repair. With his liver and bowels abused too much in one day, it was decided he would be packed and closed later that week. The OR cleared out, Mr.M went to the ICU and with that, the pulsing electricity in the room fizzled out and time slowed. My resident asked for help spotting the blood splatters that the surgical gowns failed to protect against. Then I left to join the second case my team was on, and the day continued like any other.

It was hovering close 8pm, when we went to check on all our post-op patients. In a dimmed ICU room, a trauma-surg attending evaluated Mr.M. His pupils were fixed, dilated and devoid of pupillary reflex. A tap of a glove finger showed his missing corneal reflex. I listened to the attending and resident discuss the significance of these findings while my thumb nervously flicked back and forth over his right index finger. He felt cool to the touch, despite being buried under blankets.

That night I had a dream about him. Not how I had known him, jaundiced and unconscious with a belly full of blood – but in the way I wish I had. Moving around his hospital room laughing – he was having a conversation I couldn’t hear, with a family I never met. He gestured wildly as if telling a story, his face bright with life. I had overheard he had an ex-wife and daughter somewhere in the hospital, maybe that is who was in the room with him. Would they ever see him like this again?

I woke unsettled, thinking about Mr.M and what would happen. I carried those questions with me on rounds. When we arrived at his bedside, my resident told me his brainstem functions were present today – it was likely the anesthesia limiting his response. There’s not really a word for how I felt – relief, but something else. It was like standing at the door of a plane about to sky-dive with no parachute and then finding out you didn’t have to.  Nothing prepares you for when you almost lose a patient – and for the feelings that build up but then become inappropriate to let out. What do you do with them?

I struggled with those emotions. This was the best possible outcome, but still I couldn’t shake the weight of the moment. I felt its heaviness like a second set of scrubs – with me in every surgery and patient interaction, pressing down just enough to remind me it was still there.

Later in the week he returned to the OR and my team closed his abdomen. We signed off on his care shortly after. A few days later when we were no longer following him, I learned that as they weaned his sedative his extremities moved in response to pain stimulation. This would be the beginning of a very long journey of recovery for him, but it seemed like he was moving in the right direction.

Even though Mr.M was no longer in our care, I couldn’t stop my thoughts from returning to the dream I had. I don’t know the person he is when he is awake. I don’t know who his ex-wife and daughter are. And I don’t know what it is like to lose a patient. I do know that when I thought I had, my mind yearned for the opportunity to know the kind of person Mr.M was.

I can’t say how many times I had let my mind wander while retracting during surgery, or how many patient interactions I may have cut short so I could make sure to finish my notes. I don’t know if I missed out on opportunities to learn who my patients are as people. What I did learn from my patient, despite us never speaking, was a reminder of something I came into medical school innately knowing, but somehow lost during my third year rotations. The art of medicine isn’t puzzling through chief complaints, or knowing the most current guidelines or first line treatments. It’s in the small moments, when you learn your patient has a dog, or is a high school history teacher who traveled the world, or loves murder mystery novels, or has had trauma you can’t begin to imagine. It’s in sharing peer-reviewed publications with them because you know they have an inquisitive mind, in grabbing their hand and squeezing it to let them know you’re there, and in respecting how vulnerable they are.

When I dreamed of my patient, it wasn’t about the medical interventions necessary to save him – it was to understand who he was before his illness defined him.

 

Shanon Astley is a fourth year medical student at UC San Diego School of Medicine. She is one of 19 students nominated by her peers to the Gold Humanism Honor Society’s class of 2019.