here is, within physicians, a special breed who have honed the uncanny ability to simply…feel what is wrong with a patient, and pursue this observation appropriately. This is the breed of Joseph Bell, a man perhaps most famously known for being the real-life inspiration behind Sir Arthur Conan Doyle’s character Sherlock Holmes.
A story will likely illustrate this better than simply expressing the concept, so…here goes.
Early in my clinical rotations, I was told to see a young lady in her early 30s who had come into the emergency room with a chief complaint of “chest pain”. Her electrocardiograms were completely unremarkable, her labs were fine, and as I questioned her at length trying to figure out what was going on, I only became more and more confused, as it didn’t seem to me like there was anything wrong with the patient…but surely, something must be?
I went to the attending physician and told them everything that I had gleaned, and the decision was made to simply admit her to the hospital for further workup in case things were really wrong; if they weren’t, well, whatever, the admitting team could make that call and decide whether or not she could go home.
Fair enough, I thought, and let it be. Throughout the weeks, I saw patients very similar to this case, and their dispositions were much the same, until one physician irrevocably changed my worldview.
It was a kindred case. Young woman in her late 20s who came in for “chest pain”. Workup in the ED was negative, and as I went through my standard set of evaluative questions, I again came up dry.
I told my attending physician the story, and he cocked his head and simply said “Hmm.” He then gestured for us to go see the patient together, and the first thing he did was kneel at this woman’s side and ask in the gentlest of voices, “Hey, I just wanted to check–is everything alright at home?”
The floodgates broke.
The patient’s husband had been laid off and out of work for nearly 9 months. They had recently had their home foreclosed on. Their car had nearly been repossessed multiple times. They had three young children to feed and buy school supplies for, with minimal income. This woman had been working odd night shifts to help bring in money. They had already bounced around a few shelters and soup kitchens with their children whilst trying to make ends meet.
For the next several minutes, this woman went on, telling her story. She was fearful, anxious, nervous about what would happen to her husband, her sons and daughter. She was worried sick for her husband, who had become depressed about not being able to support his family, ashamed that he had to stand in line at the soup kitchen when before he could afford whatever groceries his growing boys wanted.
She began to have anxiety attacks a month ago, always manifesting as mild chest discomfort. These attacks always occurred when the bills were due, and today had been no exception, but they had received yet another letter saying their car was going to be repossessed, and this time with her anxiety came an episode of chest discomfort so severe she became frightened and came into the emergency room.
That’s what this was. It wasn’t a heart attack or arrhythmia or something physiologic. It was psychiatric in origin. This woman just needed someone to listen and offer guidance, not 324mg of aspirin or a dab of nitroglycerin.
How did he know? What did he see that led him to ask this pivotal question?
My god. How could I have not noticed before. Her eyes, faintly bloodshot from prior crying now brimming again with tears. The constantly downward gaze they held. Her face with the permanent creases of tearful expressions. Those slumped shoulders signaling lack of confidence. The hunched back you would expect to see on a grandmother of 85. The wringing motion her hands kept doing. The curled position of her very body as she sat up in the hospital bed, practically begging for someone to reach out and comfort her.
Fuck. How did this miss my eyes the first time around? Why didn’t I notice and ask that question myself? What were my eyes doing, looking at this woman in pain yet not really seeing?
I was thunderstruck.
As we gave the woman resources to find a therapist and financial assistance, and eventually discharged her home to be with her family, I kept looking at the physician, wondering how he’d come to be the man he was, and how I could be like him.
At the end of the shift, I simply asked him: “How?”
He of course knew exactly what I was talking about. “It comes with experience. Don’t worry, you’ll get there. But you have to keep trying.”
I worked with this man 2 more times during the course of my month. This was not an isolated incident; it was a consistent pattern. And so it is, with this type of physician, that they display a level of remarkable insight simply not found in others. I have thankfully had the honor of working with more than one of this type, and it is my hope that one day I might be able to join their number; at the very least, I will die trying.
Jae Won Joh 31/12/2012