I was spending the day in the Emergency Department of a community hospital. Though it was a small department with just one doctor and two nurses, it got so busy at one point in the day that the doctor gave me the opportunity to get involved actively, rather than just shadow her. Though I had just finished my first-year of medical school at the time, she had me speaking with and examining patients on my own and reporting back to her with a plan for us to treat them together.
Things were going smoothly; most of the patients I saw presented with either non-urgent aches or minor trauma, along with the occasional laceration or scraped knee. One of the patients I was assigned, however, presented me with a unique challenge. The patient, whom I’ll call Mrs. M to keep her identity confidential, was a woman in her early 70’s. She had a history of gastrointestinal issues, including Crohn’s disease as well as chronic gallstones that led to her gallbladder being removed a few years earlier. She was also relatively overweight and was awaiting joint replacement surgery to fix the limited mobility caused by the arthritis in her knees. Glancing at the patient’s file before going to see her, I saw that the triage nurse had only written “abdo pain” as the reason for Mrs. M’s visit.
Throughout the encounter, Mrs. M was visibly anxious and for some reason kept apologizing repeatedly, saying she felt like she was wasting our time because she has problems nobody could fix. Doing my best to assure her that I was happy to see her and wanted to understand what was going on with her, I proceeded to get a history of her presenting illness. I learned that she woke up early that morning with pain all over her belly. She has also been experiencing diarrhea 3-4 times a day for the past few days, but she said that wasn’t unusual for her because of her Crohn’s. She hadn’t eaten anything unusual and was taking all her prescribed medications properly. After a few hours at home with her refusing to leave the bed, her husband insisted on bringing her to the ER. I proceeded with the physical exam, carefully remembering all the steps of the different clinical exams I was taught in school. She appeared achy when I examined her abdomen, but otherwise I found nothing abnormal. She had no fever, which made peritonitis less likely I thought, and her other vital signs seemed normal for her age. Despite this, as a junior medical student there is at the back of your mind a constant reminder of your limited knowledge and experience. For all I knew, there could be something serious and deadly going on with this woman and I was missing it—a scary thought.
The clinical component of medical education is, at least in the very early stages, based on “schemas” and “checklists” that students are taught to go through in a very didactic manner. These include the proper way of taking a history of presenting illness, the different physical and clinical exams a doctor is expected to master, and ways to diagnose common presentations of simple diseases based on signs and symptoms. Going through these in first year, I found that I began learning and practicing things very methodically, which is good except for the fact that it can make a patient encounter seem unnaturally structured and robotic. Being proficient in clinical analysis while still maintaining a naturally conversational persona with patients takes lots of experience and is a difficult thing to master.
Back to Mrs. M., I had decided that it is best at this point to consult the attending physician and have her examine this patient, since I was puzzled as to what the source of her pain could be. I said this to her and turned to leave the room, but just as I grabbed the doorknob I heard sobbing behind me. I turned around to see Mrs. M crying into her scarf. Shocked and trying to think of the most “doctor-ish” way to respond, I quickly ran through in my head all the clinical skills checklists I had memorized for my exams. Not a single one of them prepared me for this, and the fear of not knowing what to do for this poor woman almost had me running out the door. I could have easily stepped out into the hall, called for the doctor, and stood back allowing her to take care of everything. My concern for Mrs. M, however, kept me in that room a while longer. I walked back and sat on the chair in front of her. I quietly sat there for a couple of minutes, sheepishly offering her tissues as she wept loudly. As she quieted down a bit I tried asking her what was wrong. Through her sobs I soon learned why she was so on edge that day, and it was a tragic story to hear.
Exactly one year ago, she and her husband were called into this very same Emergency Department to identify the victim of a fatal car accident. Mrs. M, it turns out, was in the horrible position of having to identify her grandson’s body just a few feet down the hall from where she was sitting right now. Was her abdominal pain related to the intense emotional stress she was going through? After a few minutes of holding her hand and attempting to comfort her by saying how sorry I was for her loss, Mrs. M seemed more at ease so I stood up to leave. To my surprise, she reached out to grab my arm just then, and quietly said “Thank you, Doctor,” with what looked like a smile on her tear-filled face. Still trying to process the tragic story I had just heard, I didn’t have time to repeat my usual spiel of how I’m just a med student, and that I will be reviewing everything I do with the real doctor. I made my way out of the room and ran to find that real doctor for guidance.
I learned that Mrs. M is a patient the ER doctor sees regularly, and that the belly aches and pains she always presents with are likely a mix of her Crohn’s acting up and a psychosomatic expression of her grief for her grandson. She had also been battling depression for the past year.
Most people choose a career in medicine because they want to help others. As a young medical student, there is, in reality, very little actual medical care that I am able to provide on my own at this early stage of my training. The beauty of medicine is that, beneath the surface of the doctor-patient relationship, there lies an even stronger human-human relationship. Amidst learning about drugs and diseases, it’s easy to forget that there is significant therapeutic value to just being there for another human being and listening to their tribulations. One of the privileges of being a doctor is that it facilitates these encounters, and that should not be taken for granted. I will forever remember Mrs. M for showing me how severe the physical manifestations of emotional pain can be.