"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.

The Final Straw

I plugged along for one week at [] hospital. I came into the hospital early in the morning to round on my patients, but there was always something missing when I reported to my resident, a kind and patient third year named William. Actually, there was always a lot missing. I usually hadn't talked to the nurse about overnight events, I usually hadn't looked up the vital signs, I may have looked at the Electronic Medical Record, but I often hadn't looked in the Paper Chart.

As an aside, electronic medical records promise to solve the problems and confusion arising from scattered notes written in illegible handwriting. The hospital was trying to upgrade to a completely electronic system, but, while some of the electronically written notes were easy to read, the changes were creating even more chaos. There were two computer systems- one was older, and the hospital was trying to phase it out. Unfortunately, the new computer system wasn't as user friendly so those used to the old system shied away. And then some people didn't use either, preferring to leave scrawls in the old fashioned "paper chart."

So, when I came in each morning, I was supposed to look up the vitals, carefully recorded by the nurses overnight at 4 hour intervals, in the newer of the two computer systems. Then, I was supposed to check for notes. While in a hospital, a patient may be followed by a particular service, in this case Medicine. But, while there, any number of consults may be called. The patient suddenly develops numbness and tingling? Call Neurology. Questions about a new antibiotic regimen? Call Infectious Diseases. The patient has chest pain? Call Cardiology. Funny vaginal discharge? Call Obstetrics and Gynecology. Broken bones? Orthopedics. So, during the day, any number of clinicians may have visited each patient. And, each department tended to leave notes in different places. Neurology invariably left notes in the new computer system. Obstetrics and Gynecology used both computer systems, so any notes discussing the possible etiologies of vaginal discharge could be found in either. Of course, there were individuals from every consult service who preferred the Paper Chart, leaving an actual tangible note there.

The nurses basically serve as the eyes and ears of the service. Teams of medical students, attendings, and residents constantly switch. A particular resident, for instance, may be on one of the Internal Medicine services for a few weeks and then switch to another service, vacation, or outpatient clinic. Medical students only stayed five weeks in any particular place. And, the attending physicians seemed to rotate as well. A single patient staying in the hospital for any length of time would see a great number of medical students and doctors passing through. Teams of nurses, however, tend to remain on the same floor. Not only that, during their shifts, they actually stay on their assigned floors. Doctors and medical students might be running around to clinics, the operating room, rounds, teaching sessions, or any number of activities, but the nurses are actually present, on the floors, at all times. So every morning, nurses can provide information on how a patient has done overnight. Did the patient spike a fever? Sleep well?

It was generally the job of the medical student to gather and consolidate data in the morning. But with my sudden pathological forgetfullness, this became a nearly impossible task. William took me aside, saying, "Are you confused about what you're supposed to do in the mornings?" I nodded. "I already told you this, you go to the PAPER chart, you go to the COMPUTER, you talk to the NURSES, you talk to the PATIENT, you gather ALL THAT DATA, and then you report to me..." He stopped, looking at me, and then wondered aloud about whether there was something wrong with me. William generally had a look of kind understanding. He was the sort lauded on good bedside manner, the type patients could trust, and the type not to be annoyed without good reason.

"I think I could be a good doctor one day..." I tried to explain that I wasn't usually this forgetful, that this wasn't me, that I didn't know what was wrong, but that I was sure if it was fixed, that eventually, I could function as a doctor. But the mounting tears prevented me from speaking.

"Did you have trouble during first and second year?" asked the resident. The look of kind understanding reappeared on his face. I didn't answer- a tear rolled down my cheek and another threatened to join it. The fact that I had done well during the first two years, that my board scores were excellent, almost made things worse. The resident likely took my silence as agreement. Our conversation ended with him pausing and saying "I don't think you can function in a hospital." He spoke carefully, as though delivering bad news to a patient. He paused, looking at me with a mixture of sympathy, confusion, and annoyance.

The fact that William was mild mannered and didn't routinely abuse those around him made our conversation even worse. I couldn't complain to my classmates over drinks about yet another injustice incurred at the hospital. I couldn't dismiss this or laugh about it later.

I knew he was right. I left the hospital that night and didn't return for nearly a year.

(The above post describes past events, right now I'm in school and doing fine)