My internal medicine rotation was full of thought-provoking and memorable patient encounters. Some encounters left me heartbroken, some left me confused, and others were profoundly gratifying, but all were didactic in some way. My encounter with Ms. A provided me with a more concrete lesson than most.
Ms. A appeared too young to be in her sixties; she had a colorful scarf wrapped around her head and looked at me with an energetic and defiant stare. As the interview began, she described an episode of syncope one week ago after smoking a marijuana joint. Since then, she said, her knees kept giving out, and she wasn't feeling like herself. Her story was scattered and confusing, and her speech eccentric and inappropriately dramatic at times. She said that she felt strange whenever she turned her head to one side, so I asked her if she felt pain, nausea, or dizziness. She replied, “No, none of those things. It feels like equilibrium!” She admitted to smoking marijuana regularly and binge drinking. I performed a complete neurological exam, which was benign. A CT scan of the head showed no acute changes. Her records indicated that she had tested positive for cocaine a week ago when she presented with syncope. We put in orders for various tests and asked for a neurology consult. Over that week, Ms. A reported slow improvement of symptoms. She also frequently talked about how much money her children would make if she fell inside the hospital and filed a lawsuit. She was subsequently placed on strict bed rest.
The following week, I presented the patient to a new attending. He walked into the patient's room and asked the medical students to do a knee exam. I had to ask myself why I hadn't thought of doing one, given her chief complaint. I chose not to pursue this thought further because I wasn't thrilled about my own answer. Fortunately, the knee exam was benign. Ms. A expressed to the attending that she was having spasms of her right leg and that it shook uncontrollably when she tried to walk. I wondered quietly when her symptom had evolved from knees buckling to spasms. (She later explained to me that the symptoms had remained the same—she had only found a better way to explain them.) We watched her walk around the room with a completely normal gait. The next day, the attending asked the patient if her spasms were improving and looked concerned when she said no. He paused for long periods between questions and seemed to be in deep thought. He then asked the team to order an MRI of her brain, and I watched with skepticism and disapproval as the resident placed the order. Later that day, we received the results of the MRI, which revealed changes in the brain consistent with an acute ischemic stroke and significant narrowing of one of her carotid arteries.
I had trouble falling asleep that night, not because I had not arrived at a correct diagnosis but because I was surprised by it. Up to this point, I had been the typical inquisitive and overly concerned medical student who needed an answer to every question and a plausible explanation for every symptom. Lacking in knowledge and experience, this naive enthusiasm was the only thing we medical students could offer to any team. It was frightening to think that in a mere two months, I had possibly become jaded and complacent. I knew that I had formed biases against this patient from the beginning because of her appearance, her speech, and her history of substance use. I was also reflexively accessing memories of a previous encounter when I felt duped by a malingering patient with a history of substance use presenting with similar symptoms. I wondered what would have happened if I had thoroughly investigated every differential in my mind without this bias – whether or not I could have brought about a pertinent discussion with the team, whose patient load was particularly overwhelming that week. I thought about why the attending had considered doing an MRI, and why I did not, even when the patient continued to present with symptoms. It was possible that I put substance use on top of the differential and felt convinced, perhaps too easily, that this was the end of the road. The attending, however, was not concerned about her substance use or her inability to articulate a good history. In every encounter, his sincere concern for the patient was apparent.
In the beginning of the rotation, a fellow medical student and I talked about what we hoped to get out of the internal medicine clerkship, and I shared with him my interest in simply understanding what it means to be a good physician. He offered me an exceedingly simple but valuable piece of advice, that is, to find an attending that I want to emulate. Thankfully, I had the privilege of meeting many great doctors at this hospital, but this particular attending had a very special impact on me. He taught me through this encounter and many others that competence in a physician comes not only from experience and knowledge but also from an unbiased evaluation of a patient, and that the ability to perform an unbiased evaluation comes from compassion toward patients.
Hannah Choi
American University of Antigua
Class of 2019