Walking from an exam room to the nurse's station in the small outpatient clinic where I worked as a second-year medical student, I paused by a window to gaze out at the winter sunset. After a moment, I looked down to scan the notebook where I kept my schedule and notes for my last patient of the day.
4:15, Ms. Smith, 26, lump on groin--the bare bones of a story waiting to be filled in.
Feeling tired and looking forward to dinner, I sighed dramatically, dropped into a chair in front of a computer console and called up Ms. Smith's electronic health record.
Like most medical records, it was divided into tabs that reflected the parts of a medical history--"Past Surgical History," "Medications," "Allergies," etc.
I clicked on the tab labeled "Problem List." Up popped a staggering collection of diagnoses, from diabetes, hypertension and high cholesterol to kidney failure and dialysis.
Yikes! I thought. This isn't going to be easy.
In the eighteen months since I'd started medical school, I'd seen quite a few patients with multiple chronic conditions. For the most part when dealing with these very ill patients, I'd sheltered behind an inward sense of separateness, captured in an unspoken mantra: These people aren't like me. If I couldn't maintain this "professional distance," I feared, I'd be overwhelmed by a tsunami of grief, pain and desperation.
But Ms. Smith was different. She was like me. She was about my age. I'd need a new mantra.
"Ms. Smith is ready to see you," the medical assistant announced cheerfully.
I walked towards the exam room, half expecting to see a gray-faced, emaciated woman hunched over in a wheelchair, and half trying not to picture anything.
Inside the room, instead of the pitiful creature I'd imagined, I found two utterly normal-looking young women sitting placidly in adjacent chairs near the desk.
"Hi, I'm Matt. I'm a medical student who's working with Dr. Taylor. May I ask which of you is Ms. Smith?"
The woman sitting nearest the desk looked up. "That would be me," she said in a deep, husky voice.
Looking more closely, I saw that her face seemed swollen in comparison with her thin frame, probably as a result of long-term steroid use. Elaborate, colorful tattoos graced her right forearm.
I extended my hand. "Good to meet you. Who's with you today?" The other woman smiled.
"Sharron's my girlfriend," said Ms. Smith. "She can hear whatever I have to say to you. She's heard it all a million times before anyway."
"Thanks for letting me know," I said, sitting down at the desk.
How could Ms. Smith possibly be the patient on the computer screen? Surely there had been some coding error; she looked like she could be my classmate, not someone with enough illnesses to fill an entire page of my notebook.
These thoughts kept snaking through my head as I dutifully asked the right questions about the bump she'd felt in her groin a few days back: "Can you point to where you noticed it?" "Has it ever gone away?" "Is it ever painful?"
All the while, I really wanted to ask, "How are you sitting here talking to me when your record tells me that you're so ill? Do you ever think about what people like me take for granted?"
As Ms. Smith ticked off the many and varied diagnoses she'd accumulated, my sense of dread and helplessness mounted. I began to feel acutely aware of my own mortality, and how tenuous my status was as a "healthy person." How easily could I--could anyone--travel from health to sickness? How would I survive if I had to contend with so many serious conditions?
"How do you cope with the stress of your illnesses?" I asked.
Ms. Smith glanced at Sharron, who--clearly well-acquainted with the tedium of accompanying her girlfriend to doctor's appointments--was reading a book she'd brought in her handbag.
"She's all I got," Ms. Smith said. "My family's out of the picture. There's no one else."
Her words left me dumbfounded.
Somewhere amid the puzzle of her many diagnoses, I'd expected to discover a piece connecting the digital patient, so incredibly ill, with the healthy-looking young woman sitting before me. I'd assumed that this piece probably took the form of an extensive support system and a loving family. Now I wondered if I had any of the right pieces.
I felt like starting the interview over, to search for a key phrase or clue that would explain the gaping chasm between my theoretical expectations and my real-life observations. I refused to believe that a single relationship could sustain someone who was facing such a mountain of hardship.
After completing a preliminary physical exam, I excused myself and returned with Dr. Taylor.
Examining Ms. Smith's left groin, he asked her more about the mass and any related symptoms.
"I had an ovarian cyst removed a year ago," she told him. "I'm afraid that this bump means that it's come back...Or maybe it's cancer."
Finally, Dr. Taylor delivered a verdict.
"Most masses are not cancerous, and I suspect this isn't related to the cyst you had before. Let me know if it gets bigger or causes any pain, and we can reevaluate it. I don't see any reason to worry now."
Ms. Smith seemed satisfied with this, and the visit came to an end.
How incongruous, I reflected, that we could tell a woman with so many severe illnesses that she didn't need to worry about something related to her health. This may have been one of her few clinic visits that ended in relief rather than dread. Still pondering this, I returned to the computer screen to pore over Ms. Smith's medical record.
Suddenly, I pinpointed the crucial missing puzzle piece.
Ms. Smith's medical record, I realized--in fact, every patient's medical record--needed another tab, one that would act as a counterpoint to the Problem List. I would label this tab "Hidden Strengths." In Ms. Smith's case, it would include terms like "hope" and "incredible resolve." It might also include her powerful, loving relationship with her partner, or the momentary lift of a well-timed joke.
I wished I'd asked Ms. Smith more about what kept her going--the forces that buttressed her against a torrent of bad news. Because of my schedule, it was unlikely that we would meet again. I wish I could have spent more time adding to this new section of Ms. Smith's medical record--the one that explained her resolve and cheerfulness, and that made me like her so much.
About the author:
Matthew Hirschtritt is a third-year medical student in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Outside of medical school, he enjoys road biking, hiking and exploring Cleveland's art scene. He would like to thank Drs. Martin Kohn and Jan Bautista for their mentorship and editorial assistance with this story.