The Burden of Ambiguity

I knock on the door, walk in, smile and survey the room. It’s a pediatric visit. Both parents are seated; the child, a 7-year-old boy, lies in his mother’s lap. I have already perused the chart and saw the red flags: A series of recent ER visits. A strange series of lab tests—Lyme titers, surveys for Kawasaki disease, a Monospot—all with negative results. Seemingly random imaging tests.

I begin by taking a history, which evokes only a series of non sequiturs and logical perambulations. The timeline is difficult to construct. I find myself at times unable to understand even what the chief complaint is—the current presentation (fever, an old scalp abrasion, a sore throat) or this strange notion of chronicity. It’s as if all the random minor illnesses common in childhood were part of a larger syndrome that threatens to kill their child at any possible moment.

The mother hands me a folder containing printouts from all their visits since birth. It has the breadth and haphazardness of a cold-case file. I read a few of them—benign finding by an ophthalmologist, the seemingly bemused meditations of an ER doc. As much as I want to leave the room feeling reassured the child is perfectly fine, I sit at my desk, staring at a spot on the wall, running through my rather short medical student’s repository of knowledge.

That evening, still puzzled by the case, I peruse UpToDate for more than two hours, searching terms such as “recurrent fevers” and “Bell’s palsy.” With a patient like this, you are faced with one of two possibilities: “paranoid parents” or “Am I missing something?” As medical students, we hear both of these phrases used in practice. In fact, I heard a doctor call this boy’s parents “nice people, but a bit … you know …” the day of their visit, and two days later describe the time he nearly missed a serious diagnosis in a history that seemed perfectly benign.

I keep returning to the room. I check the boy’s skin. I check his eyes. I complete the physical exam to the best of my ability. I read some more. I repeat the tests looking for new findings. I ask the parents for more history. And still, nothing. I can’t even feel confident that the findings they report at home have actually happened. It’s clear that the kid has a minor illness today, but might it be related to something larger?

The word “diagnosis” embodies this internal tension. The etymological roots dia (meaning “apart”) and gignoskein (meaning “to learn”) suggest that we can pry apart our patients’ histories and physicals to truly “know” the nature of their disease and give it a label. A label has power. (Why else create ones such as “idiopathic?”) It gives certainty even to things that seem—if not implicitly, at least by current standards—grey.

As I walk the family out of the exam room, I fumble awkwardly to give them the semblance of an answer. To “know” whether this is pattern or coincidence. To prognosticate so they know what to expect. But there is no certainty here. I am left grasping and say things I’ve heard more practiced physicians often say: “We’ll let you know when we get the lab results back.” “I’ll keep researching to see what else I can learn.” “It may be nothing at all. Let’s see how things play out.”

In private, I wonder: Would I join a chorus I have heard so many others fall back on? “They’re crazy.” “He’s probably healthy.” “I think they’re just making all of this up.” No one likes a cold-case file. We would all much rather have a label for our patients or their families.

To be honest, I don’t know which I would have chosen for this young man and his parents. I think of his case often. It remains unresolved. I find something truly unsatisfactory about that.

Dreaded diagnosis? I dread finding no diagnosis at all.

***As published in the August 2015 issue of Minnesota Medicine***

Why Putting Your Hand in Orifices Makes You A Better Doctor

“You feel them now?!?!”

She literally grabbed my hand by the wrist and pushed it up, well…

I’m not sure it’s really appropriate to say, to be honest.  Let’s just say the ‘them’ she was referring to were her ovaries.  For those who are confused, during a sensitive female exam you can press upwards from the ‘exam portion’ and downward from the abdomen and actually palpate the ovaries, especially in younger, thinner individuals.

The ‘patient’ in question was a volunteer, paid for her time, tasked with teaching first-year medical students too scared to lift a breast a sensitive female exam.  These are students who struggle listening to the heart in a buxom female patient.  Who stare at a child with an ear infection with a mixture of fear and loathing.  Who pray every medical experience they have can just feel like shadowing as they sit in the back of the room and check social media outlets on their phone.  Teaching the sensitive exam is no small task.  I’m pretty sure I downplayed my own nervousness by mumbling something about my hands having an “essential tremor.”

Yeah, I was just a big wuss.

To be honest, I’m not sure the outside world really understands this part of medical education.  They see these socially-inept nerds who ruined their college science classes – adding an element of stochasticism to what should have been smooth bell curves and asking shitty questions no one cared about to their professor for five minutes after the class let out because they were going to become an “orthopedic surgeon.” [What an asshole.]  Then they see these smooth-talking, sometimes callous, sometimes chipper, white-coated interns breezing through hospital wards, assuming they’re doctors, not really understanding how little you really know after your first four years.

Some element of the change comes from learning the sensitive exam.  For some reason, I think of a talk one of NPR’s leadership, Jason DeRose, gave at St. Olaf College many years ago.  He told us that the job of the journalist, or maybe not the job, but the essential function, of the journalist, was to enter into ‘unearned intimacy’ with the lives of the reported.  It requires learning and then disseminating knowledge about individuals in as unbiased a way as possible, trying to determine the facts both because of, and in spite of, their personal stories.

What else am I doing when I ask a patient if they’re sexually active?  [“I ask these questions to all of my patients.”]  Multiple partners, or just one?  [“Your wife sounds like a real keeper.”] Female or male? [“No, I didn’t mean to imply anything.  It’s a routine question.”] Any history of illicit drug use?  [“You wish you did because of your wife?  Funny joke, sir”].

But why should we care?  Because sometimes you diagnosis that monogamous, elderly male in my office with full-blown AIDS.  Because sometimes you find out the ‘drug-seeking’ woman in the ER is giving her boyfriend the pills because she’s homeless and without the trade he wouldn’t give her a place to stay.  Because sometimes that young woman will tell you about the time she was raped, and that’s the reason she doesn’t want you in the room during the sensitive part of the exam.

In this career, you learn to be surprised by nothing.

And sometimes you learn the best way to care is to go into the one place it hurts the most, and ask the questions and do the things no one else will.

In a much more benign way, doing the ‘sensitive stuff’ well  - i.e. making patients feel like sharing it is normal and doesn’t matter - is just good medicine.  In fact, the other day, I was in the ER.  Scrotal cyst.  Turned out to be some folliculitis, likely secondary to a new soap product he reacted poorly towards.  The small nodule had already been drained – I didn’t have to do any procedure.  Yet, some clever questioning and a more thorough exam made me decide we should test him for syphilis.  To be honest, it will probably come back negative.

But then again, maybe it won’t.

What struck me afterward was how easy it was.  How easily I could do the exam in two minutes with gloved hands.  Ask those questions.  Probe deeper about his partners and his sexual practices.  I felt like a natural.

Which brings me to my final anecdote.    This one, a counterpoint to the woman and her ovaries.  The male sensitive exam.  In the first room I entered, an elderly male volunteer sat in his hospital gown.  The exam went without a hitch.  Scrotal and penile exams are a breeze, especially for a male student like myself.  Then, in the second room, a younger male patient.  I realize I’m near the end in a long line of medical students that have examined him.  He’s tired and frankly, not paid that much.  I doubt he wants another drawn out, hesitant prostate exam.  So in front of three of my colleagues also in the room, I lube up a finger, go in, palpate, and exit in a matter of seconds.

Which would have been fine, except…

“That was amazing!  That was the fastest prostate exam I’ve ever had!  You’re like Dr. ____, a real professional.  You should be a urologist.  I barely even felt that!  Are you sure you did the whole thing?  WOOOOOWWWWW!”

And a smartass classmate smirks at me and says, in a voice loud enough that everyone in the room can hear it, “You should add that information to your dating profile, Patrick.”

The man turns ashen.  Looks to the ground.  The room is silent.  I take off my gloves and wash my hands with soap.  I mumble something as we leave the room about “having a good afternoon.”

‘Unearned intimacy?’

Perhaps.

Maybe I’d just make a better urologist than an OB/GYN.

Normal S1, S2

I wake up and head to the hospital.

 

First patient of the day - COPD, CHF, a typical slew of diagnoses.  We chat about his medications, symptoms that just won’t go away.  I ask him about smoking and drinking, the usual.  Ask where he lives, who he lives with.  His face grows somber.  “I’m alone,” he says.  “Ever since my wife died six year ago.”

 

“That must have been difficult for you,” I say.  We pause a moment.

 

I ask him about allergies to medications.

 

The next patient visit goes well until I mention his Hepatitis C.  How his recent medication has effectively cured him.  He stares at me, face reddening, eyes beginning to furrow.  “How do you know I have that?" he asks in a rage.  I tell him I read his medical chart to prepare for the visit.

 

He doesn’t want a med student perusing his medical history.  He tells me his medical problems are between him and his primary doctor.  I tell him it’s within his rights to choose who he wants as a provider, same way a female can refuse a male doctor for the sensitive female exam.  He tells me to get out.

 

I leave the room and my attending finishes the visit.

 

I get paged down to the ER.  One of my patients has just come in.  I run down the hallway and sprint down the stairs.  When I enter his room in the ER, I ask what brings him in, giving the illusion I’m not breathing hard.

 

“This,” he says, lifting up his jeans and revealing…  A scab.  Not broken open.  Not inflamed.  Uninfected.  Probably healing there for at least a week and a half.

 

So I chat with him and his wife about their recent vacation to northern Minnesota, about the new medication he has started.  No side effects.  I secretly congratulate myself on my medical student success.  I tell him not to use the ER for this in the future.  “You have my card,” I tell him.  “Just have a nurse page me and I can swing by and tell you if it’s urgent.” He laughs and we shake hands.

 

His wife grabs me as we’re leaving the room.  “You’re his favorite reason to visit the hospital,” she whispers to me.  She squeezes my arm softly.  I grab some instant disinfectant and walk outside.

 

Since I’m already in the ER, I talk to one of the docs and he gives me a new patient.  An older male with new onset chest pain.  His wife sits with him in the corner of the room.  I take a history and physical, relay pertinent findings to the attending physician.  When I return to the room, I ask an innocuous question or two: “How has your week been?” “What are you doing this weekend?”  She mentions church.  I ask which one.

 

She tells me about the church they attend every Sunday.  About their pastor.  About the afternoon two year ago when a voice spoke to her as she drove down the highway.  A voice that wasn't there.  How she panicked that she was having delusions.  That she was becoming a schizophrenic.  That the voice told her to have her husband call his sister.  The estranged one.  The one he hadn't spoken to in twenty-seven years.  To have him call because it was her birthday.

She didn’t know her husband’s sister’s birthday.

 

After an hour of pleading, she got her husband to make the call.  The husband’s sister cried on the other end of the line.  They talked for an hour and twenty minutes.  That Christmas, the whole family got together.  They took a picture, with the Christmas tree in the background.

 

Why me, she asks.  I stand there in the ER room silently, unable to articulate a reply.  Why me, she asks, when I’m ordinary?  Just an ordinary woman.

 

I tell her I don’t know, but I appreciate her entrusting her story to me.  I listen to her husband’s heart again.  Regular rate and rhythm.  Normal S1, S2.  No murmurs, rubs, or gallops.  I leave the room.

 

The rest of the afternoon, I work with my hospitalist team.  Admit a patient in atrial fibrillation, post-surgery.  Medical co-management.  He mainly talks about his girlfriend, thirty years younger.  I ask him about his book, sitting on a bedside table.  It’s a Norwegian mystery.  “Rather depressing and a bit morbid,” he remarks with a chuckle.  “Like all Norwegian fiction.”

 

At 7pm, I walk to my car in the emptying parking lot, only a star or two visible through the city’s haze.  The radio plays the same generic pop hits.  I walk through the white hallways of my apartment, open my unlabeled door, eat a frozen pizza, watch an episode of Netflix.

 

As I lay in bed about to fall asleep, I suddenly hear her words in my head.  “Why me?  An ordinary woman?”  A shudder goes through my body.  I sit up in bed.  Get a drink of water.

 

I go for a walk around the block and stare at the lights of the city, blinking vacantly.  The night is cold.  I tighten my jacket.  A couple walks by holding hands.  I return to my apartment.

 

The next morning I wake up and return to the hospital.

I Am Here

It was Thursday when an ambulance brought my aunt to the hospital. Her breast cancer had metastasized to her femur. It had shattered the bone.

The next day, a Friday, she traded stories and jokes with my parents from her bed. They learned from my uncle that she had three more months to live.

When my sister and I visited her the following morning, she was unconscious. Her breathing was heavy, uneven. An hour later, as I dropped my sister off at a play practice at school, I sobbed over my steering wheel in a corner of the parking lot. Three months... I returned to the hospital.

Within the hour, my aunt passed away.

Afterward, I could only think of the moment I stood in her room early that morning: of her labored breathing, the hum of the air-conditioning. My uncle's words: "Tina, Patrick and Kelly are here. They came to say hello." How I had stood there unable to summon the strength to simply say, "Hi, Aunt Tina, I am here."

I have never forgotten my silence.

***

Our conversations were long and energized. He would ask me about my life, my running, my education, or fuss over whether I was wearing appropriately warm clothing for the weather. In exchange, I would listen to the latest of his medical maladies at the Northfield Retirement Center, sometimes with 'colorful' descriptions of its resident doctors.

So I listened. About his pain meds and physical therapy. About how he could no longer see. About how he could no longer walk. About the back pain that would wake him up at night. About the loneliness that would consume him like a storm. Many times, we would end up laughing about our lives - the taste of the cafeteria food or the latest failures of the college football team. At other times I would try and comfort him as he sobbed; his head would heave and tears would roll, all in utter silence.

I remember one time in particular when he asked me what the year was. He let me do the math for him. "Six years... I've been here six years..." he murmured. "And all I can do is sit here and wait to die."

For once, I did not know what to say.

***

When did I decide to become a doctor? It could have been one of those cliche childhood moments we all reference in retrospect--but I doubt it. After all, I wanted to be a train conductor, courtesy of Thomas the Tank Engine. As my mom will tell you with chagrin--as mothers do--the intricacies of trains were the singular obsession of my grade-school-age life.

Then perhaps it occurred much later, when I stood with two young parents as their wheezing, three-month-old baby tested positive for RSV and was admitted to the hospital for supervision. Or when I placed my stethoscope on a scar and heard the repaired heart of a young boy with Down Syndrome. Or perhaps when a woman heard sounds on her left side for the first time following an aggressive ear surgery. She started to cry. She was thirty-two years old.

In these moments, I knew I wanted a real and palpable role in shaping the form of a patient's care.

Of course, there were the purely academic joys. Perhaps I fell in love with medicine the first time I heard something like 'replacing an eardrum with a piece from the outer ear' described with some esoteric phrase like 'cartilage tympanoplasty.' Then again, maybe it was the moment in which I was first hypnotized by the rhythmic, almost musical cant of the surgeon: "irrigation, please..." "suction..." "suture..." Or perhaps it was merely the nerdy thrill of seeing a dermatome actually mean something outside of that one neuroscience textbook, pg. 487, figure 13.5.

Yet more than anything, there are these memories which have irrevocably changed the course of my life. The day I could not find the voice to say hello to my aunt when I visited her in her hospital room. That winter afternoon when my friend Obert down at the nursing home began to cry. A summer car ride with my friend as she shared her unfulfilled plans for suicide. The next hour of that conversation remains one of the single hardest moments of my life.

Just what do you say when words are inadequate? When people expect you to solve things but you are helpless to change them?

It is not only illness, but isolation that destroys patients. Above all else, to break such silence is why I have chosen to become a doctor. Because beyond the academics and long hours and interminable paperwork, I want to offer my presence. Sometimes I still succumb to this tempting idea that after medical school, illness will somehow bow before my knowledge and grant me exquisite control over the forces of life and death. Medicine, after all, is replete with such metaphors.

But a metaphor is little encouragement for a patient.

While it is true that I may not be able to be my patients' number one confidante nor their go-to moral support system, I do want to be someone worth trusting when all else fails, even when there is not a single thing I can do to cure them. Because ultimately, that is the real side of life, and that is the real role I intend to play as a physician.

Yes, I hope to treat and I hope to cure, but neither encompasses why I fundamentally intend to become a doctor.

I want to be there when no one else is. This time I will not remain silent.