Very Sick and Nearly Dead

When caring for patients on an inpatient basis — that is, patients who are admitted to the hospital as opposed to seeing patients in clinic — there are many moments when you must have crucial conversations. For the most part, medical students are shielded from needing to carry out these conversations. As a medical student, I may have asked patients on admission about their code status. However, I never wrote orders based on my conversations. And if a patient stated that they did not want to be resuscitated in the event that their heart stopped or they could not breathe on their own, I always told the intern or resident so that they could confirm and document the conversation. I think it’s appropriate to allow students to begin asking these types of questions; I also think it’s appropriate (and legal) to have residents/interns confirm and do their own asking when a medical student initiates discussion of these topics.

There are other conversations that, unfortunately, become more familiar as one gets accustomed to inpatient medicine. The conversation with patients and families regarding goals of care is probably as heavy as it gets. At times, this conversation spans days. When taking care of patients who are all-of-a-sudden critically ill, it is often extremely difficult for this conversation to take place and families often need to be walked through the reality of the situation and the grim prognosis. Even with patients who are chronically ill, these conversations may take time.

One of the key pieces of information during these conversations is the severity of the condition and the prognosis. In my short experience I have found that patients and families react differently. Some will cling to your every word, writing down the way you say things and even making sure to write down your name. Others listen with a blank stare; they make you wonder if the are even listening. It is both the honor and the burden of the physician to accurately and effectively convey this information.

Unforunately, it isn’t always a burden we carry well. Too often, I hear doctors (myself included) described the state of a patient as “very sick.” I don’t know if there is a good answer to why we, as a profession, do this. Perhaps it is easier to say someone is “very sick” rather than that they “are dying.” Perhaps some of us view death as the doctor’s ultimate defeat — something that we sometimes refuse to admit. Perhaps we have our own personal issues with death and dying (consciously or sub-consciously) and treating a dying patient forces us to confront, or at least acknowledge these issues (consciously or sub-consciously). Regardless of the “why,” I think we ought to do a better job of communicating to families and patients.

I remember calling a patient’s daughter. I remember telling her that her father was “very sick.” As she tried to grapple with the words I were telling her, she asked me, “Is he dying?” As I sat holding the telphone handset to my ear I finally answered, “Yes, he is dying. I cannot say when. I cannot tell you if it is days or weeks right now. But he is dying. He is getting weaker everyday.” Five days later, after I had left the service, I learned that my patient had passed. And in finding out about his death, I found solace in the fact that I had done what I could to prepare the family.

As difficult as it is to hear that your loved one is dying, I think we owe it to our patients and their families to be prepared for whatever comes next — at least what we think is most likely according to our education and experience. Some patients and their families understand what “very sick” means. Others don’t. The words we use, though, are not important. What is important — what is crucial — is that we communicate effectively with our patients and their families.


Guess Mom Was Worried About Pathophys

Yesterday I had my Pathophysiology final exam. The policy is that as long as you pass the final with a 65%, then you pass the course. If you don’t get below 65% on the final, then they will average all the scores, with the final weighing 40% of your grade and the average must be above 65%

The test was 120 questions and we were given 5 hours. It started at 9:00 AM and we were given 60 questions and 2.5 hours to complete it. We had to come back at 1:00 PM for the second.

After the test my brain was a wreck. I couldn’t think and it was hard for me to get studying for the next exam (Pharmacology). Well the posted the scores later that night and I passed it.

Today I messaged mom on Yahoo:

Me: so i passed the hardest class in 2nd year
Mom: thank GOd

Yeah.. So I guess she was worried about it.


How’re You Doing Today?

Me: How’re you doing today?
Patient: Oh, can’t complain.
Me: That’s good.
Patient: No one listens to me!
Me: Oh… well that’s not good.

I love patients with a sense of humor. Well, I hope my patient was just joking…


Sometimes Patients Just Won’t Give You The Answers

Some time ago I saw a patient that came into the clinic with a complaint of cough and congestion that had lasted for longer than the patient was comfortable with. I’ll call this patient, Gloria. Before seeing the patient, I spoke with the attending1 regarding Gloria.

He asked me for my thoughts regarding the differential2, but I didn’t really have a good answer. My first thought was that the symptoms were due to an infection. However, I was already told that this was not the most likely etiology for her symptoms for a couple of reasons: 1) symptoms started about a month ago, 2) blood pressure, temperature, respiratory rate were all within normal range 3) the chest x-ray came back normal, and 4) Gloria’s file showed that she had come in annually around the same time of the year with similar complaints.

At this point, the attending told me that the most likely cause of the symptoms was allergies. And, looking into Gloria’s file I saw that she had a history of allergic rhinitis3. Mentally, I chastised myself for not thinking of allergies. The attending, though, just moved on and ignored my ignorance.

The good thing about being a lowly 2nd year medical student attending clinic is the low expectations — expectations that you probably won’t even be held to. The doctors know that you are still just going through your basic sciences and know that your clinical knowledge/skills still have a ton of room for improvement.

I went to the waiting room, called Gloria inside, and walked her to the exam room. She explained that she had been congested for a month and also had a cough. Her symptoms had a seasonal pattern, occurring around the same time each year. They had also worsened in the days leading up to her clinic visit. This had coincided with the increased winds.

I proceeded to ask for specific symptoms. I asked Gloria about her eyes. I asked if she had any pain. I asked if there was a change in vision. I asked if she had any problems with her eyes. Each time I asked she said, “no.” And so I moved on to other organ systems.

When I finished the interview I listen to Gloria’s lungs. The lung fields were clear with normal breath sounds. Feeling pretty sure it was allergies (and not something more serious like a pneumonia), I left the patient in the exam room and waited for my attending so that we could discuss Gloria’s case.

After reporting my findings to the doctor, he asked if I had done a HEENT exam4. Sheepishly, I told him I hadn’t. Another thing had slipped my mind. He then asked if the patient had any problems with dry, itchy, red, and/or watery eyes since those are common with allergies.

I hadn’t thought about asking specifically, but I told him that I had asked the patient about eye problems in general, and more specifically, about pain and visual acuity changes. She told me she had no complaints about her eye.

Well a few minutes later when the attending pulled Gloria in to see her for himself, he asked her if she had experienced and itching or redness in her eyes. Her eyes lit up. “Why, yes,” she exclaimed.

And I, standing in the corner, shook my head — mentally. Physically, I just kind of looked straight ahead.

Sometimes patients just won’t give you the answers.

  1. An attending physician is a doctor who as completed his or her residency. See here for more details. []
  2. I like to compare a differential diagnosis to a lineup of suspects that may be causing the patient’s complaint(s). Click here for Wikipedia entry. []
  3. Medline Plus: Allergic rhinitis is a collection of symptoms, mostly in the nose and eyes, which occur when you breathe in something you are allergic to, such as dust, dander, or pollen. []
  4. Head, eyes, ears, nose & throat exam []

You Always Learn Something New With Patients

One time I called a patient in from the waiting room, introduced myself as a medical student, and told the patient I would be taking him to see his doctor.

The patient nodded but then let out with this statement:

I refuse to go with you. I usually have some pretty girl take me.

So there’s that… At least I found out that I don’t look like a pretty girl…


Conversations: How Much To Walk Away?

I asked my cousin (and if you’ve been following this blog you’ll know that my cousin is also a classmate of mine) this question, “If someone were to pay you to leave medical school, and you could never come back, how much money would it have to be?”

She thought for a while, and, instead of answering me with a straight answer, she asked me how much it would take for me to walk away.

I quickly replied, “$100 million.”

I’m not sure if she laughed or chuckled. My memory is a bit hazy on that part. But she said she’d probably do it for a “little less.” But upon pressing her about what “a little less” meant, I think she said $50 million. She did say, however, that she’d probably always wonder “What if?’ about staying in medical school.

Ideally someone would offer me $100 million to take and I could stay in medical school too. But if the condition was that I walk away and never return to med school… Well, I don’t think I’d have any qualms about that.

Does that make me any less of a medical student? Does it reflect poorly on me?

I wonder because I asked another classmate the same question. Her reply was a lighting-fast, “You couldn’t pay me to leave. You’d have to kick me out.”

Her answer left me speechless. Well kind of… I did manage to say, “Oh… that’s cool.”


Conversations: Feeling Unprepared

I recently had a conversation with my cousin (who also happens to be my classmate). The conversation was sandwiched between a couple hours of studying about ischemic heart disease, vascular disease, valvular disease, and congenital heart diseases. We were preparing for a Pathology lab where we were scheduled to do some “team-based learning.” (These team-based sessions involve working in groups of five to figure out a diagnosis based on a small clinical vignettes. Once the diagnosis is obtained we usually have to figure out the mechanisms leading to the condition.)

The conversation took place right after I showed her a sample test that applicants to the San Francisco Police Department can download at the department website. The first few sections were really simple and we skimmed through right through it. It felt easy. (At least the first sections felt easy. There was at least one section towards the end that looked pretty tricky.)

I’m not sure who first verbalized it, but we noted how it had been a long time since we had walked into an exam feeling fully confident in what we knew and of what the outcome would be. So far in medical school it hasn’t mattered how much I have spent preparing for an exam. I have never walked into a test site feeling like I know everything as well as I should. Maybe that one student that keeps scoring between 98-100% knows how that feels, but I sure don’t. And that is a very frustrating thing.