Barriers

I learn so much from my patients.  I don't just learn how to conduct a medical interview, how to perform a physical exam, or how to give a case presentation.  No, I learn much more than that.

Yesterday's patient was an 80-year-old man who has been in the hospital for 6 weeks.  Medically, things have gone from bad (weakness and shortness of breath from pulmonary fibrosis complicated by heart failure) to worse (a complicated UTI with methicillin-resistant staph).  Anyone entering his room must wear a gown and gloves to avoid picking up MRSA themselves.  As I donned the protective gear, I wondered how it made him feel to know that the medical personnel feared his infection.  Lifestyle-wise, things have also gone downhill.  During his stay at the hospital, he has been informed that his home is no longer environmentally safe and that he can no longer live alone, as he has for all of his adult life.  He cannot go back to his home, which is the last place he stayed before coming to the hospital 6 weeks ago.  This was clearly upsetting to him, but he tried his best to remain stoic about the situation.  His parents and siblings died at young ages of heart attacks.  His closest relatives were a niece and nephew far out on Long Island.  He was so thin I could see all his bones.

Despite all of these hardships, he showed hardly any emotion about it all.  He clearly liked talking, as he rambled on and on after each question we asked.  He had a sense of humor.  When we asked if he ever married or had children, he said, "No, never.  I offered my hand to many ladies, but they would only give me their foot."  He looked at me and smiled.  Later, "My sister died at 60.  My brother...died at 61.  I guess I was supposed to go at 62, but thank God I'm still here."  I was somewhat surprised, but comforted, to hear this; despite his many difficulties, he was thankful to be alive.  Later, when I was conducting the physical exam, he said out of nowhere, "You're going to make a great doctor."  All I could think about was how young I must have looked to him.  I was caught off-guard.  "I hope so!" I laughed, and then, "Thank you."

By then, I had forgotten about the gown, forgotten about the gloves.  They may have been a barrier to MRSA, but they were not a barrier to connecting with my patient.

I Like My Patients (and my patients trust me)

Some of my classmates take exquisite pleasure in their ability to diagnose an unusual disease etiology on their Tuesday clinical rounds.  "I diagnosed Chlamydia psittici because I thought to ask about her pets."  Others can't wait to brag about the unusual (and often disturbing) medical sights they saw.  "We saw a guy with a necrotic...gangrenous...penis."

I'm a medical student.  Of course this stuff interests me.  Of course I would be excited if I was able to be the one who recognized the one clue that led you to an alternate (correct) diagnosis, of if I was able to see a really rare, gruesome, interesting disease process.  I admit that.  However, I think I'm different from many of my (more vocal) classmates.  For me, the most interesting and rewarding parts of my Tuesday physical exam hospital rounds are my interactions with the patients.

One of medicine's really big pulls, for me, is the patient interaction.  Science is great, but it's even better when it's science and a unique person with a unique personality and a unique history.  It's not just the disease process, it's how the disease affects the individual's life.  An ulcer is an ulcer, but how does the patient experience it?  Deal with it?  Require help for it?  I've always known that patient interaction was a crucial part of the doctoring process, but I was never really sure how good I'd be at it.  I don't want to make any premature judgments, and I certainly don't want to brag, but I think I've found out the answer:

I like my patients, and my patients trust me.  This has been evident multiple times over the course of our physical exam course, when my patients tend to look to me for a smile or understanding even when my partner is doing the interview or exam, but it's been especially evident over the last two weeks.  Two weeks ago, our patient was a young woman with cellulitis complicated by a deep vein thrombosis.  She was in good spirits despite being in the hospital with an immovably swollen, painful, itchy leg.  We performed a full physical exam, as always, to get practice at it.  She asked a few questions along the way, curious about what we were doing.  "We're listening for the size of your liver," I explained, or, "We're comparing the circulation in your legs."  She reminded me of myself, simply curious and interested in the process.

Last week, our patient was a middle-aged woman with every chronic disease in the book -- what we like to call a "typical Bronx patient."  Asthma, diabetes, emphysema, and some sort of upper respiratory infection that had landed her in the hospital for a few days, but she was friendly and cooperative.  In taking a thorough history, my partner asked about her social history, which included drinking habits.  "Ohhh...I drink a lot, we'll just say that."  How much, my partner wanted to know.  "We'll just leave it at that," she chuckled.

But this is a crucial part of the medical history, so I stepped in.  I knew that patients often feel uncomfortable talking about how much they drink or smoke.  I also knew that it can be hard to quantify sometimes, even if the patient isn't uncomfortable.  I tried to help out.  "How many days do you think you drink?  Almost every day?  A few days a week?"  That was all it took.

She looked at me with a smile in her eyes.  "Oh, pretty much most days, almost every day."

"What do you drink?"  Sometimes it's easier to quantify when directly asked about the type of drinks.

"I love my Coors Light.  I get me those big cans -- not the little ones, but the big 24-ounce ones."  She gestured to show me the size of the can.  "Yeah, the big ones.  I like to have 'em nice and cold."

"How many do you usually drink?" I pressed.

"Oh, maybe 3.  Sometimes 2, sometimes 4.  Depends how I'm feelin'."

Usually when you ask about lifestyle habits, like smoking or drinking, you get a vague answer.  Usually patients don't like to go into detail.  They don't lie, but they don't really want to get into the whole story.  I don't think it's because patients aren't trustworthy, or because they're unwilling to tell the truth.  I think it's because we sometimes simply don't ask the right questions.  All it took was a little understanding and creativity to get an answer that was much more full of details and trust than I needed or expected.

I like that.  I like being able to connect with my patients, knowing that I'm able to excel at the part of medicine that pulled me into it in the first place.  When we were done with the interview and exam, and we were about to leave the room, our patient asked us about our status in school.  She was wondering how far along we were, and how much longer we had.  I explained that we were in our second year, and that the first two years were mostly classroom learning whereas the third and fourth years will be spent in the hospital doing rotations, and that patients like her are our teachers.  She loved that.  She laughed and smiled, and thanked us.  Thanked us?  For poking and prodding her when she was already sick in the hospital?  Yes, thanked us.  Need more proof that we connected?  She remembered my name.  "Take it easy, Michelle!"  I did.  The rest of the day, I was elated.

Patient Interaction

The first time, I was nervous.  I desperately hoped that my partner, whom I had happened not to have met during our entire first year and a half at medical school, would be excited and ready to do the physical exam, because I sure wasn’t – I was nervous.  We found our patient.  After introducing ourselves to her, I looked at my partner and suggested, somewhat proud of myself for thinking to do it this way, “Should I start with the history, then?”  I would obtain the medical history, and then he would perform the physical exam.  My plan was perfect.

Unfortunately, my plan was not perfect, and he was just as nervous as I was.  “Well, I could do the history, and then maybe you could do the exam…?”  He asked it as a question, but I already knew my plan had failed miserably.

Come on, Michelle, I thought.  You’re in the Air Force.  You can’t wimp out with something as small as this.  You’ve just got to get through it; it will be fine.  I didn’t want to be difficult, and I didn’t want leave my partner hanging on our very first day together.  I acquiesced.  It felt strange to be examining another human being who probably had no idea how little experience we’d had, but I had expected that.  I was nervous, but I got through it.

The second time, I was less nervous.  I was the one obtaining the medical history that time.  I felt completely comfortable talking to my patient, finding out so many details about something so personal as her own body while also establishing a trustful relationship, an easy rapport.  My partner and I talked through the exam, helping out one another.  Of course it didn’t feel natural, but at least it didn’t feel as scary as the first time.

The third time, I was excited.  By then, I was more familiar with the exam, more trusting of my partner, and more confident in my skills.  An hour before, however, I learned that my partner was sick and would not be able to come that week.  My certainty deflated instantly.  Would I be required to do the entire history and exam on my own?  I felt comfortable interacting with a patient alone, but I certainly did not feel ready to perform the physical exam alone.

The third time, then, I was incredibly nervous, but I was determined to do my best.  To say it was easy would be an egregious misstatement.  The patient was not at all talkative, answering most of my questions, even the open-ended ones, in single words or phrases.  His accent and quiet voice made it even more difficult for me to understand and interact with him.  When I had exhausted my mental stockpile of questions, I moved on to the exam with a new rush of nerves.  He knew that I was a student, but at the same time, I did not wish to appear inept.  I tried my hardest to appear as though I had done this sort of thing many times before.  Since he was a chronic liver failure patient, he had seen his share of medical students.  As I performed the exam, he told me about a time he did not feel comfortable with the student.  It did not seem to him that the student knew the right exam procedures.  I paused.  Was he hinting that he didn’t trust me?  I looked him in the eyes.  He went on, “But you – you’re all right.”  Not wanting to violate his trust, I asked his permission before I proceeded with the rest of the exam, to which he replied, “Of course.”

I’ve only participated in the physical examination of three patients, but I’ve learned so much already.  I’ve realized that it is natural and even expected to be nervous for these powerful new experiences.  I’ve also realized that as nervous as I may become, I can do it.  I can establish relationships with patients, and I can work through my own apprehensions to learn the most important skills we’ve been taught in medical school thus far.  Some exams will be more difficult than others, but that’s why I chose medicine.  I wanted to interact with people – people whose disease processes, medical histories, temperaments, and ultimately lives are all different.   I’ve been nervous, but I’ve also been privileged.  I can’t wait to continue to experience the miracle of interaction throughout the rest of my career.

Feet

First admitted patient.
We talked about her asthma, listened to her wheezing lungs.  They were musical, singing a chord every breath she took.  She told us that she had diabetes as well.  Wishing to be thorough - and hoping to practice as much of the physical exam as we could in our allotted time with her - we attempted the neurological exam.  Attempted, because we didn't have all the necessary instruments.  We did, however, have a tuning fork.  Proprioception was fine in her fingers, but what about her toes?  I moved to the foot of the bed, asking her if I could remove her hospital-issued socks.  Underneath, her feet were dry and cracked.  Her toenails were fragile.  Proprioception was not fine; she couldn't feel the fine vibrations of the tuning fork.  She didn't seem concerned.  She'd probably never had a tuning fork pressed to her toes before.  I helped her put her socks back on and thanked her for helping us learn.

First ER patient.
She came to the hospital, on the busiest day of the year, because of the pain in her ankle.  She and her home-health aide braved the crowded department with the beds triple-stacked and protruding into the already crowded walkways, because she herself could not walk with the pain.  We touched and maneuvered her ankle.  "Ohh!" she cried in pain.  We moved her knee.  "Ohh!"  We manipulated her hip.  "Ohh!" again.  What was the problem?  The ankle, the knee, the hip?  Which one had caused the others' pain?  But her feet were fine.  I tried to find her dorsalis pedis pulse, assuming it would take several tries since I can never seem to find it even on my own feet.  First try, and there it was, bounding and strong.  Her warm feet were more lively, it seemed, than my own.

Second ER patient
She was in the West section, the one where those with the most serious problems are taken.  My preceptor, wanting to make sure I saw interesting cases in my afternoon at the ER, asked another of the attendings if she had anything cool.  "I've got a woman with a cold foot."  We found her and said hello, but she was only minimally conscious and did not even acknowledge us.  Still, a good teaching moment.  We felt her right foot; it was, indeed, cold.  And her ankle.  And her calf - but not her knee.  Left side was not what I would call warm, but it wasn't as cold as the right.  Left was pink; right was white.  No pulses on the right leg, but the femoral pulse was strong.  Was it a DVT?  Something else?  Doppler had been scheduled, but they were unsure if they would admit her or not; they might just send her back to the nursing home.  Before we walked away, I looked again at her feet.  Most of the digits were hammertoes.  I tried to imagine her as a young woman, wearing nothing but high heels every day.  In my mind, she was happy, beautiful, fashionable, not minimally conscious in an ER bed with a cold foot.  I walked away and wondered what would happen to her.

Second admitted patient
What didn't she have?  We talked about her asthma, her quadruple bypass, her liver cirrhosis, her kidney failure, her ascites, her edema, her shortness of breath.  Despite all of these problems, she looked at least twenty years younger than her real age, even though she had already told us about her six great-grandchildren.  She had a moment of sadness when telling us of her frequent hospitalizations, and of how scared she felt when she suddenly couldn't breathe, or when her nose suddenly spilled clots of blood.  I tried to comfort her despite having only minimal experience in this sort of thing.  She cheered up, then commented about how hard it was getting old.  I laughed, and she smiled.  "She's laughin' at me, but it's true!  It's hard gettin' old!" she laughed back.  We began the exam, hearing her labored breathing and the shifting dullness of the abdomen.  She told us she had diabetes, so out came the old tuning fork again.  Off came the socks again.  She looked down and commented on her feet.  "I got no one to take care of my feet.  Can't cut my nails."  It was too hard for her to bend down that far to do it.  "I look at them, and they look like claws to me!" she pronounced with a grin.  I smiled back.  I never knew you could learn so much from feet.

Enthusiasm on the Job

"Everything's cool when you're a first-year medical student," said Dr. Katz as he accompanied me to visit the orthopedist 3 floors above the internal medicine office. Last week, Dr. Katz and I saw a patient who was having terrible pain in her foot because she had to step quickly to the side to avoid running into her dog. For real. Because he thought it would be an interesting learning experience for me, Dr. Katz suggested I go with her to the orthopedist (in the same building) to see them do the x-rays and casting (if necessary). Well, I went with the patient, but unfortunately, I had to leave for the day before she had even gotten an x-ray. Today I went to the office early so that Dr. Katz and I could go up and see the x-rays -- my first experience of continuity of care, I suppose. Indeed, the patient had broken her fifth metatarsal in a place that doesn't receive much blood flow, so she needed a leg cast that will be on for 4-6 weeks. The orthopedist and Dr. Katz were both eager to explain how those types of breaks normally happen, what the different types of treatments are for different types of foot fractures, etc. So now, according to them, I'm an expert on foot fractures.

Those two weren't the only eager doctors today, either. A few weeks ago, Dr. Weisholtz wanted me to feel a large thyroid. Today, just after Dr. Katz had observed me interview 2 different patients, Dr. Kocher came into the common area and asked, "Where's the medical student? I want to show her something." I waved and followed him into his patient's room. She had chronic lymphedema (swelling) in her left arm, which was easy to see when comparing the arms. But there was something else that Dr. Kocher was even more excited about. He asked the patient to show me her palms. Then he asked me, "What is different about her palms compared to mine? Or yours?" I looked at my own hands and then the patient's, and I could see that hers were quite yellow. I said as much to Dr. Kocher, and he said, "Yes, exactly. But look at her eyes. They're nice and white, so you know it's not jaundice. Want to know what it is? It's carotenemia!" The woman explained that she had been drinking carrot juice -- LOTS of carrot juice. All of the beta carotene had colored her skin yellow.

Yes, Dr. Katz is right -- everything's cool when you're a first-year medical student.

Thyroid

Here is a reason why I love ICM. Before I give the reason, let me explain that ICM stands for Introduction to Clinical Medicine, a 6-month-long course in which each of us is paired with a physician preceptor/mentor. Throughout the next 6 months, we will spend almost every Monday afternoon with our preceptors, learning how to interview patients by actually interviewing them. I've been fortunate enough to be paired with Dr. Katz, an internal medicine physician in a small practice in Englewood, NJ. (Yes, I drive to New Jersey every Monday.) He, along with the other physicians in the office, is friendly, energetic, and interested in making Monday afternoons a great learning experience for me. Plus, he is a graduate of Einstein, so he's always eager to chat about classes, instructors, housing, the Bronx...

So here is why I love ICM. This afternoon, between the first and second patient appointments, Dr. Katz and I were in the central common area, where he was jotting down a few notes from the previous patient as well as explaining to me what the patient's different medicines were for. One of the other doctors waltzed over, looked down at me and asked, "You wanna feel a really big thyroid?" I raised my eyebrows, shrugged, smiled and said, "Sure!" Less than a minute later, I was walking into the exam room, where sure enough, there was a woman suffering from hyperthyroidism; she will soon have surgery to remove it. She had no objections to me using her as a learning experience (although I have a sneaky suspicion that most patients don't realize I'm only 2 months into medical school -- the white coat is tricky like that), so I was able to gently press on her throat, feeling around the edges of the butterfly-shaped organ.

After I thanked her, I left, and the rest of the afternoon was "normal": I interviewed a patient with a painkiller addiction, helped dress a diabetic patient's leg sores, listened to a heart murmur, and studied chest X-rays. I'm learning so much every Monday, not the least of which is the fact that I picked the right career. All the studying and reading and classwork may often be tedious, but the Monday experiences are a good reminder of what I'm really here to do. I love science, and I'll learn what I need to learn to practice great medicine. But in the end, medicine is about people, and that's that.