"Lame?"

(Disclaimer- while this blog is a real account of some of the things I went through- any patient descriptions have been changed out of respect for privacy - i e the patient described here does NOT resemble any patient I have come across- there was, however "a" patient deemed "lame" by an intern)

At the start of my new rotation, my resident sat down with me to explain expectations, how I could succeed, how he could help me. He told me I would be on "call" with him and that during each call, it was my job to "work up" one patient. I would then "present" the patient to him.

"When I was a medical student, I thought my presentations were pretty good... but when I got my evaluations, they weren't as good as I thought..." he explained that he would save me from a similar fate by working with me. The thought of "presenting a patient" had always made me a little bit nervous. Practice, practice, practice... I was told. Practice in front of your friends, in front of a mirror... A great presentation was key to honoring a rotation. The way presentations were described they sounded like they required something on the level of power point. Patient presentations always used to make me nervous, but they shouldn't have.

A patient presenation is basically a way of telling people how the patient came to be at the hospital, relevent symptoms, medical history, physical exam findings, and any x-rays or lab results. If a patient comes to the hospital with a heart attack, your presentation should convince those listening that this is why your patient came to the hospital. Presentations are really not something to be feared, they're just a way of communicating, a way of weaving together a story.

So, if you have a brown haired, brown eyed patient with three pet golden retrievers, and a recent history of coughing, and you know he came to the hospital with pneumonia, you're going to want to highlight things in his presentation and history that are relevant to this diagnosis. Telling the attending that this is a brown haired brown eyed patient with three golden retrievers who ate clam chowder last week might not be relevant, whereas a history of smoking, a cough productive of green sputum, and chest pain worsened by deep inspiration might be.

But, as my resident told me it should take me hours to work up my patient, and that he had spent all night on his patient presentations during medical school, I actually started to wonder. What did "working up" a patient really mean? Was there something I was missing? It didn't generally take me hours to interview and examine a patient, and it had certainly never taken me all night to work on a presentation. The resident was wasting his time with me, he didn't know that I was a Student In Trouble, a student pegged by the deans office, a student in danger of failing out of school. I wasn't an honors candidate, I was barely hanging on.

My first patient, on the infectious disease service, had multiple medical problems and she had been admitted with chest pain. She'd already been admitted to the service, and the resident presumably knew the reason why, but it was now my job to interview the patient, perform a physical, and decide why she had come, what her diagnosis was, and how to treat her. The first thing that struck me was how thin the patient was, beyond thin, emaciated. She was there for chest pain, but it was obvious he had something much worse going on, something greater than just her chest. Her head looked too big for her body, like a distorted lollipop. Her skin hung like an outfit that was two sizes too big.

The patient was from the Ukraine and didn't speak English so I got a translator. "So what brought you to the hospital today?" I asked. The translator, who sat next to me, looking toward the patient, repeated what I'd said in Russian. The patient replied and the translator spoke to me in English.

"Can't you see? It's obvious." I wasn't sure what to say. The patient spoke in Russian, throwing up her hands as she did. The translator explained that he had been interviewed by several people and didn't understand why I now was asking the same questions. I smiled, explaining again that I was the medical student, but that if she did not wish to speak to me, it was her choice. She threw up her hands again, and the translator relayed the fact that she didn't care, what did it matter.

I wasn't sure what to do, I knew the patient did not want to see me, even if she would not admit this outright. And, although she refused to answer most of my questions, it appeared that she did not have very much time left on this earth. I knew it couldn't be pleasant answering the same questions from person after person, and I didn't want to subject her to any unnecessary trouble. I wanted to drop her, and ask for a new patient, but I knew from the student handbook that students were not allowed to refuse to see a patient for any reason.

I asked my intern for advice, and he assured me that I could use some of the data he had gathered during his history taking. "She's sort of a lame patient, sorry you have to work her up." I wasn't sure what to say to this. There were apparently "lame" patients and "not lame" patients. What made this patient lame? The fact that she was difficult? Were her medical problems not interesting? Was it that she was Russian speaking? I wasn't sure how to respond, so I smiled and said, "It's ok, she seems nice."

"Nice." The intern looked at me. Now I really wasn't sure what to say. While she hadn't been "nice" by any stretch, but I thought that feeling really horrible physically might excuse one from societal expectations of politeness. I did a search for the patient's medical record and started to read about her history.

The patient had terminal cancer, and now, according the intern's assessment, she had pneumonia on top of this. It did seem that he had created some problems during past visits- she'd refused to speak to residents and attendings, she'd refused treatment, she'd been belligerent I worked hard to see how his more recent history and physical exam findings had lead to this diagnosis. She'd had a cough productive of green sputum, chest pain worse on inspiration, and her chest x ray showed an area of "focal consolidation" meaning that part of one of the lung fields was completely whited out. The patient would need to stay in the hospital while she got antibiotics. Then, she would be released back to her nursing home.

I wasn't sure what was worse- the fact that my time in the hospital was to be spent badgering a patient I felt should be left in peace as much as possible, or that my time in the hospital was spent in the company of someone who deemed this patient "lame." The resident didn't seem to share the intern's sentiment, and seemed to have a genuine feeling of empathy for the patient, but most of my time, I learned, would be spent with the intern. And if the intern had the world divided into "lame" and "not lame" I was pretty sure I fit into the "lame" category. But, I tried, I smiled, I was nice, I offered to help out.

So, I sunk into another sort of routine. I woke up, plodded to Starbucks for some caffeine, and then plodded to the hospital where I would briefly examine my patient and then present my findings to the intern and resident before meeting for attending rounds. Then we would all go to noon conference where I would swallow pizza and diet soda. When my day ended, I plodded back home to where I would watch television while waiting to fall asleep.