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.

Aleksandr Milov
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.  

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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
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
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.

dave hairI 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.

cancer cell no 11 angela canada-hopkin
… … . … . . .. . . . . . … … 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.  

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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

Gilbert Williams
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.  

At Second Sight

By Meera Reghunathan, MS4

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

Le Sommeil - Dali
Le Sommeil (Sleep) by Salvador Dali, 1939. Dali described this painting as “The act of sleeping was a monster sustained on the crutches of reality”

The first time I came face-to-face with a pedophile was nothing like I expected. At first sight, the gentleman was in jail uniform, a demented old man with disheveled hair and beady eyes. He leaned on his walker as he hobbled in, putting his bagged breakfast aside so he could comfortably sit. Through steel grey vertical bars, he looked up at me. As soon as I met his aged, sunken eyes, a shiver ran down my back. I saw him see me and recoiled, resisting the urge to run out of the room. The words from his victims’ statements flashed in front of my eyes. I felt an indescribable disgust, my stomach boiling thinking of this man’s wrongdoings.

I saw a predator. I saw a monster.

What I saw built a lens by which I perceived the rest of the encounter. Thoughts flashed through my head, thoughts that felt righteous in the moment.

“Why are we wasting our time with this guy? He deserves whatever he gets.”

“Mental illness? This guy is sick and twisted, and is making a choice.”

“Why does he deserve our compassion, when he doesn’t give compassion to his victims?”

“He donates to charities to cure cancer for kids? Does he realize how twisted that is?”

The interviewing psychologist continued to amaze me, an ocean of calm, methodically interviewing the pedophile before us. Before I knew it, the interview was over and I, the observer, was still caught in a storm of negative emotions towards the patient.

A sense of unrest lingered with me. Later that week in a morning meeting, an attending psychiatrist asked if I had any interesting cases to discuss. This was the first patient to come to mind, something about him still unresolved in my mind. The ensuing discussion was profound.

“You exhibited negative countertransference”.

I learned that the emotions I felt towards the patient have a label in psychiatry, although the concept applies across many fields: countertransference. This patient exerted an influence on my conscious and unconscious feelings, and without proper recognition and resolution of these feelings, optimal health care could not ensue. Before this man had even opened his mouth, I had formed an impression of who he was and what I expected him to say. My walls were up before he said hello.

“Aggressors were often the victims”

How easy to forget the vicious cycle that feeds the darkest parts of our society—poverty, abuse, and crime. A child’s sense of “right and wrong” is crafted by the social and physical experiences he or she attains throughout childhood. My attending elaborates, “this doesn’t make it okay to be a pedophile, but…”. But you can’t help but have your heart ache for someone when you see the flash of the helpless kid they used to be, the kid whose norm was abuse.  

“Pedophilia is a mental illness.”

Like most mental illness, pedophilia is not a choice. It represents a complicated intersection of genes, environment, and neurology. In fact, the despise that much of American society holds towards pedophilia contributes to the counterproductive ways that criminal justice and mental health systems address this mental disease.

“Mental illness is defined by our societal and cultural norms”

It was not easy to zoom out of my societal and cultural norms and see the diversity of experiences that exist in this world. My attending reminded me that there are entire societies where pedophilic behavior is considered a norm. This was not offered to justify such behaviors, but to imply something much bigger – that judgment does not play a role in compassion. It is not our burden to determine right and wrong, but it is our privilege to show humanity without discrimination.  

Reflecting on these lessons, I realized that my journey towards compassionate care has a long way to go. It was stunning to introspect and realize I had a mentality of “giving to those who deserve it”. I enforced an expectation that the recipient of my time and skills be “worthy”.

But compassion has no place for judgment. Humanism isn’t something we get to pick and choose and give to “deserving” people. I want to see the best in people and aid them in their darkest times. We are neither the judge nor the jury, we are the givers, and that is a beautiful thing.

Henry David Thoreau may not have been referring to medicine when he said “It’s not what you look at that matters, but what you see”, but I can think of no field in which this mindset is more important. I have the honor and privilege of being in a healthcare profession, where my duty will be to improve the lives of those I care for. I must learn to see with compassionate eyes and know that I am looking at a human who deserves excellence, empathy, and respect.

So, please allow me to start over again.

The first time I came face-to-face with a pedophile was nothing like I expected. At second sight, the gentleman was in jail uniform, an elderly man suffering from dementia, with disheveled hair and sad eyes. He was an aggressor and a victim. He was a man plagued by his own demons. He was a man who suffered from mental illness. He was a human.

____

Meera Reghunathan is a fourth year medical student at UC San Diego School of Medicine. She is one of the two winners of the 2018 Gold Humanism Honor Society essay contest. 

Not Another Cirrhotic

by Evaline Cheng, MS4.

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

“It’s not what you look at that matters, but what you see.” – Henry David Thoreau

Statue
Statue of man. Source: Addiction Hope

I stood frozen, staring at the man on the hospital bed. This was my first night on call during my medicine rotation at the VA, and I was in the emergency department to evaluate and admit a new patient. “Another cirrhotic,” I was told. On my way down, I carefully recited the stigmata of cirrhosis in my head: jaundice, ascites, asterixis, among other physical manifestations. We had learned about cirrhosis in our pre-clinical years, and I knew what those words meant. Yet none of that had fully prepared me for this encounter.  

His face was yellow and gaunt, both temples and eyes sunken in. “Mr. V,” I said as I snapped back from my initial shock. He grunted.  

“Mr. V,” I called out again, louder. His eyes rolled back into his head as he mumbled in reply. Did he even know where he was?  

His feet hung off the bed. His limbs were cachectic while his belly protruded as if he were hiding a basketball under his jacket. I introduced myself and explained what was happening. As I attempted to take a history, he occasionally answered with bursts of phrases before his gaze and attention trailed away. In the physical exam, I held his arms up and watched as his hands rhythmically jerked back and forth. He seemed to have decompensated cirrhosis with signs of hepatic encephalopathy, which indicated severe liver failure.  

From the pieces of my history and his chart, Mr. V was a 31-year-old veteran with alcoholic cirrhosis, surprisingly young for his state. He also had a history of drug abuse and had been taking methadone daily. I was not surprised to learn that he had been in the emergency department before. As a former EMT, I realized that the emergency department had an unfortunate reputation as a revolving door for patients who lacked resources. The alcoholics, cirrhotics, and drug users were expected tenants among those rooms. Yet when I left the hospital that night, I could not shake the image of Mr. V lying on the hospital bed, his body visibly deranged with disease. How did someone so young end up with severe cirrhosis? I was frustrated that he had continued to return to the hospital in the same, declining state. What else would this admission accomplish? There was no cure for his cirrhosis, and he was not eligible for a liver transplant. He would be labeled as “another cirrhotic.”  

Over the next days, I watched as Mr. V responded to our treatments and slowly improved. We removed 6 liters of bright, yellow fluid from his abdomen with a paracentesis. By day two, he was conversing clearly and asking me for more string cheese. His anxiety, tremors, and sweating from opioid withdrawal began to subside after I tracked down his methadone clinic and confirmed his dose. He even liked the taste of lactulose, which was helping to clear his hepatic encephalopathy. While I was optimistic about his improvement, I was reminded that this was the same cycle as his prior admissions for cirrhosis.  

By next week, Mr. V was nearly recovered and it was almost time for his discharge. When I bumped into him in the hallway, he stood taller now, one hand carrying the bag of urine draining from his catheter. He seemed cheerful as he said, “I’m going out to the rec deck for a smoke.” “Would you mind if I joined you?” I asked.  

We sat face-to-face on the outdoor patio as I reviewed his progress and updated Mr. V on the plan for upcoming discharge. Then, I paused, wondering if my next question would be too personal. “May I ask… how did you get to this point?” To my surprise, Mr. V began: He had graduated early from high school and enlisted in the Marines, where his drinking began and escalated. After multiple deployments, he relied on alcohol and drugs to self-medicate for PTSD, and his addiction continued into civilian life. He was divorced with 2 young sons, including a 9-year old with autism. He was a Christian, and he had started going to methadone clinic daily. I marveled at his insight as he said, “I know that I don’t have long to live. I regret my choices, and my biggest regret is knowing that my sons won’t have a father.”  

I held back tears as I walked away. Mr. V had been the stereotype of “another cirrhotic” with his cycle of admissions and substance use. Yet, I did not consider how his personal struggles had led to this point— that trauma from his service and years of inner turmoil cumulated in his condition. Could there have been more opportunities to intervene before he deteriorated? I was frustrated that his decline had not been prevented. At the same time, I cried for the loss that his sons would experience and for the magnitude of his regret.  

In asking Mr. V about himself, I was trying to reconcile my shock at seeing a young man, not much older than I was, with severe disease. In the process, I learned that he was motivated by his role as a father. We laughed at stories he shared about his boys, even though he did not see them often anymore. For his family’s sake, Mr. V wanted his end-of-life to be peaceful, and later that day, I helped him start an advanced directive to clarify those wishes. By setting my judgements aside and listening to Mr. V’s story, I began to see him as another human being instead of “another cirrhotic.”  

On his day of discharge, I saw Mr. V in the hallway again, his thin frame towering over a walker. He saw me and smiled, “I guess I’m out of here now.” I complimented his tie, mismatched and slightly too long. This was not his first hospital admission, and the odds were that it would not be his last. But as I watched him push the walker along, I hoped that he would make it.

 

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Evaline Cheng is a fourth year medical student at UC San Diego School of Medicine. She is one of the two winners of the 2018 Gold Humanism Honor Society essay contest.