Failure !!

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Failure

Keiran K. Tuck, MBBS

Neurology August 9, 2016 vol. 87 no. 6 639-640

 failed only one exam in medical school. In my second year of medical school, I was given the name and bed number of a patient and told to report back about her medical condition. As the elevator bore me up to the fifth floor of a dark hospital built before the advent of the x-ray machine, I reviewed the blanks of the medical census I needed to fill in: _____ is a ____ year old _____ with a medical history of ____ who presents with ____. At the same time, my stomach stirred with fear of the 3 forbidding senior clinicians who in 30 minutes would be the arbiters of my ability to interact with a real patient.

I walked into a 4-bed hospital room and called out through the curtains to the corner where my patient was supposed to be. A soft groan cued me to enter. Pulling back the curtain, I briefly thought the gray, gaunt figure wrapped in green sheets was a corpse until I noticed her eyes slowly inspecting me. I dutifully introduced myself and sat down to commence my patient history protocol. Her monosyllabic responses were perfect for data collection and my stomach slowed. However, my cataloging of data hit a glitch when I asked the simple closed-ended screening question, “Do you have depression?”

There was no response, so I jumped ahead. “How long have you had depression? Do you take any medications? Have you ever attempted suicide?” Again, silence.

I looked up from my notes to see if she had heard me. Tears ran down her face and my stomach churned in a new direction. Her suffering dissolved my checklist; I didn't know what to do. Timidly, I asked her if she was OK. After what seemed like an eon of silence, she began talking. At first, she spoke slowly then became more animated as her story unfolded. She talked about her fears, her regrets, and her family. I nodded quietly and asked a few follow-up questions. I smiled when she talked about things that made her happy and frowned when she spoke of things that pained her. I learned that she had been born on a sheep farm. She thought she was dying, although no one had told her that. She felt that her smoking had led her to this place and away from her children and that guilt ate at her.

I wish I had been more human and ended our conversation with a hand on her shoulder or even a handshake. Instead, I said something about the time and got up to leave. Fortunately, this amazing lady had one last thing to say. I will always remember the way the dark circles under her eyes made her look almost desperate as she looked up at me and said, “Thank you, you're the best doctor I've met since I've been here.”

I floated down to the first floor, certain that I must have aced the test after such an endorsement. I didn't worry that my note pad was empty after the line “depression?” and that I wasn't exactly sure what I was going to say. My stomach was calm as I sat down in front of the 3 preceptors. Soon, however, the subtle nods of approval that greeted the introduction to my patient's story became cocked eyebrows and sideways glances as I delved into her depression and life story. A sudden “What about her lung disease?” arrested my narrative.

“Oh yes, she has bronchitis—”

“Is it chronic?”

“She's had it for a long time.”

“Does she meet the criteria for chronic bronchitis?”

“I, I don't know.”

“Do you know the criteria for chronic bronchitis?”

“Yes.”

“Did you ask about them?”

“No.”

“Why not?”

“I didn't have time. We talked about her depression.”

I think they tried to help me by quizzing me on every possible detail about her lung disease, perhaps hoping they could give me some kind of credit. The clearer it became that I couldn't answer their questions, the more frustrated they became. With stony faces, they pulled their chairs back from the table and quietly conferred among themselves about whether the patient was depressed and what to do with me. They decided to go talk to the patient themselves and left my stomach and me alone. Many minutes later they silently returned to the table. One of them smiled coolly and said, “We talked to the patient, and you're right, she is depressed. However, you failed to address her most serious and concerning medical issue, which was her chronic bronchitis. Thank you, you'll find out your grade next week.” I left the room with my head hung low.

Luckily, the few of us who failed were given a second chance, which I passed by exhaustively cataloging the bowel movements and surgeries of an inflamed colon. However, I felt wronged. How could it be that having such a profound connection with a patient was a failure?

When applying to medical school, I had no idea what I was getting myself into. I had no friends or family in medicine. I just knew I was bored in my laboratory job and I wanted to make the world a better place. I wanted to help people. I was thrilled to start the journey. Yet throughout medical school, I became increasingly cynical and distrustful of medicine. In my third year of school, I told my parents that they should avoid doctors at all costs because they were no better than the cold, shallow scientists I had worked with in my previous job at a biotech company.

Scattered throughout the initial years of my medical career I found the occasional oasis of humanity. A young girl with mononeuritis multiplex due to cryoglobulinemia thanked me for taking the time to talk to her and her boyfriend about the effects of cyclophosphamide on her fertility. A middle-aged woman who was aphasic after a large intracerebral hemorrhage pulled me over and spoke her first words … “I love you.” A Greek family struggling with what to do with their hemiplegic and aphasic patriarch thanked me for mediating. These events all felt special to me, but seemed to be ignored by the physicians around me. Here were people who needed help. Here were opportunities to make the world a better place, but few seemed interested. “Consult social work,” “That's PT's problem,” and “There's nothing we can do,” were common refrains. Discussions about whether a stroke was due to obstruction of the recurrent artery of Huebner or a lenticulostriate artery were interesting but to me were less important than how the patient was going to eat without the use of an arm. I felt out of place in medicine. I felt angry. I felt I'd made a mistake. Without great enthusiasm, I started a neurology residency with the goals of doing my work, getting paid, and going home.

Thankfully, my residency program decided that I should spend some time with physicians who felt it was their job to put humanity on par with science. I spent a month with our inpatient palliative care team and my perspective on the doctor–patient relationship changed profoundly. I learned there was more to death than cessation of heart and brain function and that death is often about those left behind. But more important, I learned about suffering. I learned that tremor is not always the problem. The problem may be the patient's inability to tie flies and cast a rod. I learned that a spouse's lack of time to live his or her own life may be more important than the burden of amyloid in a patient's brain. I learned that a DNR decision is not an acute problem, rather one that should be discussed years in advance of being implemented. Most important, I learned that I am not alone in feeling that the cold science of medicine needs to be tempered by the warmth of humanity.

Today, I have a much better opinion of medicine. I don't see my fellow physicians as cold, lab coat–wearing scientists. I see them as good people who have been taught to fill in blanks rather than listen, but who are changing themselves because their passion is to improve patient care. I have encouraged my parents to complete an advanced directive and find physicians they are comfortable talking to. Furthermore, I am heartened that the principles of palliative care are being recognized in the medical literature, especially in the field of neurology.1,2 Finally, I realize that the patient who triggered this journey was more than depressed. She was suffering. However, she did not suffer from lack of a cure. She was suffering because her physicians thought there was nothing they could do. Because of her, I realize that I can always help my patients even if I do not have a cure or treatment for the breakdown of their body.

I am glad I failed.