A medical student learns to listen with her hands

Simone Phillips, MS4

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

_{The author pictured in clinic. Patient image used with permission.}

In my first quarter of medical school, we learned the pulmonary exam.  We were told to watch the patient’s breathing, feel for any asymmetries, use our hands to gauge resonance, and listen to all lung fields with our stethoscopes. It didn’t seem too difficult. Our instructor demonstrated the exam on one of my classmates and we were set loose with a checklist to practice on one another.

I repeated the steps of the exam, Observation, Palpation, Percussion, and Auscultation as I tapped up and down the back of the person in front of me. Each time I practiced on one of my medical school peers, I sped through the steps with the goal to make it to the end without missing anything. The most important thing seemed to be to complete every step on our clinical checklist; I often was too rushed to pause and listen for breath sounds.

It wasn’t until I spent two months learning osteopathic manual medicine (OMM) that I realized the value of my own sense of touch to diagnose and treat patients. As part of my fourth-year elective in integrative medicine, I was paired with a DO a couple of days a week who provided hands-on treatment to patients. Many of the patients had neck and low-back pain, but there were also patients with inflammatory bowel disease, anxiety, and cancer.

One of my first days in clinic we had a patient, I’ll call Kathy, with a genetic lung condition who had received a lung transplant. Likely as a result of taking immunosuppressant drugs for the transplant, she had developed metastatic melanoma. Dr. Chen instructed me to place my hands at Kathy’s feet. After checking for range of motion in the ankles, knees and hips, I was instructed to place my hands on her feet. For the next twenty minutes I sat with my hands draped gently around her ankles. I observed the dry, pale quality of the skin in her lower legs and feet, and the partially healed wound on her left shin.

Initially, the pulses in her feet were dim and her lower legs felt so light they could be hollow. I noticed how my own breathing slowed as I allowed myself to perceive subtle changes in Kathy’s tissue. After some time, I felt the bloodflow return to Kathy’s feet. The edema that had stretched her delicate skin also began to recede as though there had been a dam in her body that was broken, allowing interstitial fluid, lymph and blood to flow evenly. As the treatment progressed, I noticed Kathy’s breathing change so that it encompassed not just her lungs and chest but her whole body.

Outside of clinic, I followed Dr. Chen to the hospital where we saw patients who had just undergone surgery or were suffering from pain associated with cancer. Our university hospital specializes in surgeries for acoustic neuromas, a rare kind of benign tumor that grows on the cranial nerves which facilitate balance and hearing. Most days in the hospital we saw patients in the neuro critical care unit who had just undergone surgery to remove this kind of tumor, often from their inner ear or base of their skull. 

One patient, a middle-aged man who had flown in from Reno to have surgery to remove an acoustic neuroma, was experiencing especially acute pain when we came to his room. He explained that he had a headache and double vision. When we looked at his neck, his vertebrae clung together without much room for motion, likely the result of a series of car accidents he had experienced in his twenties. On top of that, the swelling from his recent surgery seemed to pool at the top of his clavicle with nowhere to go. Dr. Chen placed her hands on his head and instructed me to palpate the intersection between his first rib and the first thoracic vertebrae. Without excessive pressure, I steadied my fingers and followed the first rib towards the spine. With one hand, I gently drew the spine towards me, and with the other, I lifted and extended the rib. As I made these subtle and targeted movements, I felt the structures shift and the flow of lymph and blood return to his neck. It was as though opening the constriction between his first rib and spine, broke the floodgates and once again allowed fluid to flow normally. After twenty minutes of similar movements, there was a visible decrease in the edema at the patients neck and collar bone; he also had considerably less pain and his double vision was gone. There are few drugs that could so rapidly relieve so many differing symptoms; osteopathic manual medicine offers an approach that can treat the sources of pain and discomfort through skillful touch.

Prior to my OMM rotation, I had little appreciation for the role of the physician’s hands in diagnosing and treating patients. I had learned in my allopathic medical training that the physical exam was a convention that may soon be supplemented by increasingly accessible bedside imagining techniques. While I memorized the steps of the major exams, I did not learn how to take in variations in texture, temperature or density from the tissues that I palpated. It was not until I spent time working with a DO highly trained in osteopathic manual medicine that I began to learn to listen with my hands.

Previously published on KevinMD  https://www.kevinmd.com/blog/2021/03/a-medical-student-learns-to-listen-with-her-hands.html 

Listen Deeply

Note: This reflection contains descriptions of anti-Black violence, police brutality, and suicidality. Additionally, I wish to remain anonymous. Should you read this and put the pieces together, I ask kindly that you leave the pieces here. 

In 2014 I found myself at the lowest of lows. Unexpected personal loss, isolation in my college environment, and nearly a decade of battling a mental health disorder left me unable to cope with life’s stressors. I sat in my car sobbing and aching more than ever when I got a call from an unknown number. Answering my phone through tears, I can remember the feeling when the person on the other line introduced himself as a member of law enforcement. The feeling? A moment of hope, protection, maybe even relief. He said he wanted to do a welfare check on me because a concerned person in my circle reported that my texts hinted at suicidal ideation. Divulging my location to him, he said he would be there soon. I recall waiting in my car, without a single thought about my safety in light of the approaching police vehicles. He introduced himself to me respectfully, then listened patiently to my comments. I broke down, telling him everything. The expression of genuine concern on his face was unmistakable. I knew he was there to protect me, and he even expressed hope that I would find strength to heal. He consulted with his partner, and they decided to take me to the nearest emergency room for a psychiatric evaluation. I asked if they would leave me alone, but he said no. As I left my car, I remember him reminding me to hide my Garmin GPS device from view. “Those get stolen a lot around here,” he said. Only the finest attention to detail and dignity came from that officer. I recall being more afraid of what awaited me at the emergency department than what it was like to get a ride in the back of a police car. Never once did my safety at the hands of those officers cross my mind.

The rest of the night flashed by in a blur. I sobbed, embarrassed that I had to wait in a hospital gown in the crowded hallways near other patients, some handcuffed to the gurneys. I felt naked, more ashamed than I could imagine. I was so emotionally distressed that I accidentally vomited on myself. I doubted I could ever become a doctor. This experience shaped me so deeply, and I am now grateful that it happened. Eventually, I regained my confidence to pursue medicine. I landed myself a job as a scribe in an emergency department. I was now on the “other side,” and seeing patients with suicidal ideation became a once-or-twice-a-shift reality for me. Writing down their stories became my job. I did my best to record their stories, even though I could not tell them I had once been in their shoes.

I showed up early to my 0600 shift one morning. The overnight doctor was nowhere to be seen. It was just me with a few nurses and several patients. I began prepping my workstation, and I peered up to Room 15. Inside, I saw a Black gentleman serenely sitting on the edge of his bed, peering back at me. We locked eyes for a moment, then exchanged bright smiles. I had a feeling he would be our patient, and it turned out he was. I looked to see why he was there. The tracker read:

“Patient had police called on him because his neighbors thought he was doing drugs. Possible use of PCP.”

I remember reading this and feeling frustrated and concerned that someone had called the police on this man, just because they “thought” he had been “doing drugs.” I knew we would be seeing him soon and hoped that we could clarify what happened to ensure that he had all his needs met. Realizing I still had 15 minutes before my shift started, I went to the break room to make a cup of coffee. As I was in the break room, I heard someone singing. I dolled up my coffee and came out, searching for the beautiful voice, and realized it was the same man I had just exchanged glances with. I hadn’t heard anyone sing in an ER before.

Suddenly, four or five police officers charged through the ambulance bay entrance. They must have been some of the same officers who brought the man in. I looked on, terrified, as they ran toward Room 15. From my vantage point, I could see the look of surprise terror that fell across the patient’s face as his melody was abruptly interrupted by the armed police officers closing in on him. He jumped in fright. It was hard for me to see what was going on; the view was nearly blocked by so many police cornering the man in a small room. Through the cracks of uniformed bodies, I could see the patient, still sitting on his bed, and I could hear his voice as he continued to sing. Then, without prompting, one of the police officers grabbed the patient, at which point the patient sang louder but did not resist. The others joined in, and I could see the patient’s body tense up as his arms were pulled behind his back, his legs pinned to the bed, and his long hair yanked down by the officers. He continued to sing, and the officers began shouting at him. They screamed “You’re resisting, stop resisting!” The patient continued to sing deeply, his very existence perceived as a threat.

The sound of a taser is loud. It has a piercing, cracking noise when it is discharged. I watched as the officers shot their weapon into the patient’s chest. His voice ceased, and he began jerking as his body absorbed the voltage. I watched in horror as the patient collapsed to the ground and appeared to lose consciousness. This all happened over the course of approximately one and a half minutes. The physician finally  showed up just in time to see his patient writhing on the floor, then stop moving altogether. We rushed into the room, and the physician began demanding that the officers explain why they had used such excessive force on a man who was simply singing. The doctor ordered a stat EKG, explaining to me that the shock of a taser can cause cardiac arrest. The patient had not entered cardiac arrest, but he still would need to be admitted for observation. With no answer from the police, the physician exited the room, asking who had involved the police. As the morning shift began rolling in and the night shift began leaving, no one was able to pin-point who had called the police. No one wanted to take accountability for nearly ending a life.

I remember the absurdity of writing up the patient’s note. “Patient had police called on him by neighbors because he was suspected to be using recreational substances, possibly PCP. Patient began singing while in ED, police were called, and patient continued to sing… and then was tasered?” Or maybe, “Unknown member of the ED staff called police on patient for singing, and patient would not stop singing, so was tasered?” No matter which way I tried to write it, the racism I documented made no logical sense. Not one thing the patient did deserved this outcome. I told my physician exactly what I had seen, and finally we found and discussed the case with the night shift physician who was also the Medical Director for the ED. The Medical Director assured me repeatedly that he would look into this incident and figure out who made the phone call. I trusted that this egregious act of anti-Black violence would be handled swiftly and appropriately.

I still recall watching as the physician removed the two prongs buried in the patient’s chest and abdomen. I documented the foreign body removal procedure note, hoping that some form of justice would be served. Just as quickly as the patient had been brought to the ED, he was whisked away unconscious to the floor for observation.

I wish I knew what happened to this patient, but I don’t. I wish I had followed up with the Medical Director in detail, but I didn’t. To this day, I have no idea if any form of justice was served for this man, and I regret that I did not take more direct responsibility. Though I wished to maintain the utmost confidentiality for this patient’s case, I now realize that there were options I could have pursued to get more involved with reporting the mistreatment I witnessed. Though I was expected to be the silent scribe, I now realize that I should have voiced my concerns until these concerns were acted upon.

When we see acts of violence toward our patients, especially anti-Black violence, we must normalize taking direct, personal responsibility. We cannot assume that our higher-ups will take care of it for us. We must play an individual, active role in deconstructing anti-Black racism from our field. I sincerely hope that my Medical Director addressed this case with the urgency it necessitated, but because I stopped at hope, I was complicit in anti-Black racism.

I worked in that emergency department for another year, and I saw the same police officers extend the highest degree of patience and tolerance to people who did things much more threatening than singing. I saw the same officers get bitten, punched, kicked, spit on, and cursed at by white patients, yet never once did I see another taser deployed. I think back to the officer who stopped and talked to me, the feeling of protection I got from his presence, and I now realize the disparate double-reality which characterizes the interactions of racism, mental health, law enforcement, and medicine.

I urge you to remember this story moving forward, and to never delay your direct action when you witness anti-Black racism, no matter where you encounter it. We must uplift and honor Black voices. We must hear what they call for. We must listen deeply. We must let them sing.

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.