Brrring!
The landline in my call room trills, jolting me awake. I have a consult. I’m a third-year medical student on my internal-medicine rotation. This is my second overnight call and second week of clerkship.
“Hi, Keith!” the caffeinated resident chirps. “I have a consult for you!”
The patient is Ms. Carrera: a young woman with a history of diabetes, renal disease and a recent heart attack. She’s here because her legs hurt. Cardiology and nephrology have no explanation, so they called internal medicine—and by extension, me. My shoulders slump.
Actual doctors already saw this patient, I think. What can a third-year medical student possibly contribute?
The resident notices my pause.
“Sorry, I know this is a bad consult for you,” she sighs. “Just try your best!”
I take a deep breath, bracing myself with the sharp smell of disinfectant that clings to my scrubs.
The resident expects me to think of a treatment plan, but so far, most of my plans have been slightly off. Last week, I learned that a patient who was retaining urine didn’t need a medication I’d suggested; they needed a catheter. Another patient with a cough didn’t need the antibiotics I’d ordered; they needed a chest X-ray. I know that mistakes are necessary for learning, but I feel like I’m failing to care for patients if my plans miss the mark.
Meanwhile, a fourth-year student on my team seems to be an expert in patient care. He can see through someone’s hazy symptoms and target the right tests. He can line up potential medications to treat an illness, then knock each one down until the best option remains. Once, I saw him return a textbook about electrolytes to our supervising physician.
“This was so good!” he gushed, and the doctor agreed emphatically, praising his commitment to patients. I gazed in wonder, thinking, Maybe if I had more medical knowledge, I too could care for patients well.
I enter Ms. Carrera’s dark room and peer at a snoring mound of blankets.
“Hello,” I say timidly. No response. I try again, a bit louder. She startles awake with a shout. After giving us both a moment to recover, I introduce myself.
When I say that I’m a medical student, her eyes narrow.
“I don’t mean to be rude,” she says, stifling a yawn. “But what’re you hoping to get out of this discussion? I’ve already repeated myself so many times. Isn’t everything in my chart?”
“I was hoping to, um, clarify the timeline of your illness,” I stammer. When in doubt, a preceptor once told me, start with the onset of illness.
She sighs. “I’ll talk for five minutes only. Everything has gone downhill since my heart attack last week….”
My questions soon peter out. I try to listen to her answers, but my mind is scrambling to recall everything I know about heart attacks. I bite the inside of my cheek—the clock is ticking.
I’ve never felt pressure like this. Before clerkship, I didn’t stress about memorizing every detail of diseases. Preceptors often asserted that knowing minutia won’t make me a good doctor. So instead of reading textbooks, I devoured Pachinko, Braiding Sweetgrass and dozens of other books, continuing the literary adventures I’d loved since childhood.
As clerkship approached, I wondered if I should be cramming my brain with medical knowledge instead. I signed up for a flashcard website that claimed to help clerks “stand out on rotations.” I subscribed to a podcast on how to approach common presentations. I flipped through hundreds of pages of notes that older students passed down like heirlooms.
And yet, all I can offer Ms. Carrera is silence. I start retracing our conversation. Suddenly, I recall her comment about her life spiraling since her recent heart attack. This story sounds familiar.
“Can you tell me more about your heart attack?” I ask. “That must have been terrifying.” I can only imagine how her life changed instantly. Any perceived control over her health must have vanished.
The wrinkles in her forehead unfurl slightly.
“Yes,” she sighs. “It was awful.” Her aging mother, whom she used to care for, must now care for her. She’s also become more dependent on her friends, and she worries about burdening them. None of this was in her chart.
Her words pull on ideas in my mind, drawing them into place like an arrow poised on a bowstring.
“How else did it affect you?” I ask.
“Well…” she gazes at the wall behind me. “It made me think about death, which is totally wrong for my age.” There, a target. I let my words fly.
“You’re very young,” I agree. “It seems like your heart attack divided your life into before and after.”
She sits up, suddenly alert. “Yes, that’s it!”
A few weeks ago, I read Between Two Kingdoms: A Memoir of a Life Interrupted by Suleika Jaouad. Its hundreds of pages guided me through a journey that I’d never seen on a flashcard: an experience of suffering and recovering from cancer that mirrors Ms. Carrera’s story.
Conversation flows as Ms. Carrera and I explore the undercurrents of fear and uncertainty in her life. Five minutes pass, then ten, then more. Afterwards, she thanks me for listening and drifts back to sleep.
Our conversation swirls in my mind as I consider what to tell the resident. The medical treatments that Ms. Carrera needs probably won’t relieve her emotional concerns.
I meet with the resident and stammer through a summary. But my thoughts straighten when I arrive at the treatment plan. “Honestly, I don’t know what to do for Ms. Carrera’s leg pain,” I confess. “But I think we should offer spiritual care. The therapists on the team can help Ms. Carrera process her experience with illness.”
The resident stops typing and looks at me.
“That’s a good idea,” she says slowly. “I didn’t even think of that. Great work! For her pain, we should…”
As she continues, a memory drifts to my mind’s surface. I recall my grade-four teacher drawing a triangle on a piece of paper. Her marker squeaked as she wrote the connections that people make when reading a story: text to text, text to self and text to world. I was half listening to her, half daydreaming about Percy Jackson, a series about teenagers who are descended from Greek gods. I loved the books, and I often fantasized about inheriting a deity’s powers. Apollo—the god of healing, music and archery—was my favorite. But I knew I could never be like his children: They stitch wounds, strum lyres and shoot arrows effortlessly.
Back in my call room, I picture Apollo’s children speaking to patients, aiming their words carefully to strike the right chord. These demigods probably love reading cardiology textbooks, and if I’d studied like them, perhaps I could’ve decoded Ms. Carrera’s symptoms. But a large portion of my medical knowledge will come from experience. Meanwhile, I should remind myself that medicine encompasses more than just fixing a disease. I still helped Ms. Carrera by exploring the impact of illness on her life, listening to her story and connecting it to books I’ve read. Although I didn’t cure her, I did care for her.
The following Tuesday. Another week, another overnight shift. I’m reading Dracula in my call room, trying to tune out the blare of ambulance sirens. A landline sits nearby, threatening to ring. I’m ready: I might not be able to solve a patient’s medical problems yet, but I can help untangle their knotted emotions.
The phone trills, and I pick it up immediately. I have a consult.
10 thoughts on “Medicine by the Books”
Echoing beautiful. Wish I could have done the same for my daughter.
This piece really struck me, both for the compassion you learned and for what it brought up about my own experiences. I have refractory myasthenia gravis and have been hospitalized with exacerbations a dozen times since the beginning of 2023. Many have been very difficult; as a young white woman repeatedly admitted, I was misdiagnosed more than once with somatic symptom disorder, functional neurological symptom disorder, and even accused of “faking.”
The impact MG has had on my life has been enormous: my career as a family medicine PA is on hold, my husband (also a PA) stopped working to care for me, I rely on a walker, and the emotional and mental toll has been heavy.
Across all those hospitalizations, not a single person (except the chaplain, whom I requested) asked how my diagnosis has affected me, changed my life, or divided it into a “before” and “after” (as it distinctly has). Your piece made me think about how differently those hospitalizations would have gone if I’d been invited to reflect, or if I’d felt heard and understood and cared for in a way only compassionate inquiries like that can do.
So thank you. I hope all current and future providers can be reminded of how impactful simple, humane questions can be for a patient and their well-being.
This is such a wonderful example of what patient centered care means. I would expect that her physical pain eased once you addressed her psychic pain, especially since no medical cause had been identified. I once had an orthopedic surgeon say “ if you listen to the patient, they often tell you what is wrong…” Thank you for your insight and kindness.
This is beautiful. You’re going to be a great doctor, a rare doctor who truly listens.
I am going to recommend the medical students I teach read this article. Thanks.
Great job with your patient. Mr. Wong; your assistance to her was both timely and very human. As for those feelings of not knowing enough, join the club: I practiced for 40 years and was always concerned that no matter how much I read to keep up, it might not be enough for the patients I’d be seeing. But the truth is, the more crucial part of our craft is listening to the patient and being present, and in spite of your worry, you were actually able to focus in on a key concern articulated by the patient and explore that with her. Doing that is very important, and it’s a skill which frankly not everyone works on like they would a procedural skill, yet it may often be a critical part of the diagnostic process. So kudos to you for doing the hard part in that moment, and remember: you can always get a consult if you need further help with either the diagnosis or the further management of your patient, because Medicine is largely a team sport. The Latin root of the English word “colleague” literally means “to bind together”…which is what our system is designed to do when it is working properly. You are not alone in this work, and that thought should be of comfort.
Oftentimes listening is more important than speaking. Our patients want to be heard and not thought of as a disease. I always made a point of sitting, either in a chair or on the bedside, rather than standing when speaking with patients. Sitting takes no longer than standing while speaking or listening. It does, however, give the impression of a less rushed encounter.
This is a silent yet firm reminder of all rounded life investment for a healthcare professional for his/her patients. It includes medical knowledge and skills. It also entails spiritual, psychosocial, and financial solutions that can easily be assumed yet massively impact outcomes. Keith, thanks for the story. Keep on this path and you’ll remain of great help to society.
Beautiful.
Listening to your patient, helping her feel heard and acknowledged, is powerful medicine. Especially for women with heart disease which is often dismissed or discounted. Your books gave you the sensitivity that those flash cards could not. Bravo to you!