Going into my medicine rotation, I had already had my family medicine, psychiatry, and neurology rotations. I was initially very grateful for my schedule; I was able to start my year with some of the more “relaxed” rotations, as they were often referred to, so that I could ease my way into the difficulties of medicine and surgery. Family medicine I liked but could not quite see myself enjoying as a career because the work became rote after only two or three weeks, the acuity was low, and I could not bring myself to care as deeply for a patient that I knew I would likely never see again. Psychiatry I similarly liked but could not see myself doing long term, as I’m unsure whether I have the coping and compartmentalizing skills to separate my patients’ problems and disorders from my own life. I did enjoy my time on the stroke team on Neurology, as it was my very first inpatient experience, and I got to run around the different floors and departments of the hospital chasing strokes and taking patients to radiology, comforting them along the way. However, the consult work ended abruptly at neurologic problems; not for us was the management of “simpler” issues: that was to be left to the primary teams after we signed off. Whereas most people told me they were nervous or apprehensive to start Internal Medicine, I had heard tell of how complete the care of a patient was on this rotation, and I could not wait to start.
When my Medicine rotation finally began, I was less than enthused. There was so much going on, so many moving pieces to a patient’s care, and so many different services we could call upon to help us: not just consult services, but speech and language pathology, physical and occupational therapy, chaplain services, even visiting dogs. However, the more I got used to the inpatient environment, the more I fell in love with it. I began to feel at home, and felt a freedom I had not felt before. I was a friendly person, but never considered myself particularly sociable or talkative – until I started seeing patients on my own during Medicine. Though I introduced myself as a student, to these patients, I was their doctor. Sure, I didn’t place orders, I knew only the gist of how to manage their condition, and I didn’t even get the final say in what was or wasn’t done for their care. What I did do, however, was spend time with them, and in my mind, this was the most important thing both for the care of the patient and for my own peace of mind. I realized – I can be there for them. I can give them my time, and make them feel more at home, and alleviate some of their inevitable trepidations about spending time in a hospital. Where I had lamented my psychiatry rotation because I was placed at a glorified day program for substance use disorders, I suddenly came to realize how well I had honed my skills in therapeutic conversation. Suddenly, I was both their medical advisor as well as their personal confidant, here to listen to their concerns, here to relay their wishes, and here to advocate for them. Two specific instances of my therapeutic alliance with patients stick deeply in my mind.
The first patient I truly connected with did not speak English, and in fact did not speak any language easily called upon via phone interpreter services. Every morning, as we rounded on her, we would preempt a call for an Indonesian phone interpreter, and meanwhile, run her vitals, labs, and plan while painfully waiting for an interpreter to finally connect with us. This, of course, led to difficulties with getting to know her on any meaningful level, and every morning, most of the communication with her consisted of asking her how she was doing, relaying any relevant diagnostic information we had, and hoping for any response greater than 2 consecutive words. Because she disclosed that she wasn’t allowed to hold her own passport, she didn’t know what her two employers worked as, and she was constantly visited by them, there was an ever growing concern that she was some sort of indentured servant or slave, or worse, a sex worker who had been illegally trafficked. One day, during a lull, I took it upon myself to call a phone interpreter in the afternoon and sit with her to try and get to know her, as she had always been shy yet curt around the entire medical team.
I spoke with her for two hours. I learned about her life in Indonesia before moving to Saudi Arabia to work as a live-in housekeeper for her employers (who she believed were policemen). I learned about her family, and how nobody was able to work, so she contracted with a work agency that sent her overseas. I learned about how her employers helped her send a majority of her paycheck home every month so she could support her family. I learned about how she still called home occasionally and had high hopes for her sons, one looking for work, the other still in school. I learned about how her employers had moved their entire household (along with her) to America to seek American health care due to one of their children’s injuries. I learned about how she not only cooked and cleaned, but took care of the children and felt cared for as part of the family. I learned about how she missed her family dearly, but could not afford to go back to see them, and wanted to keep working for her employers to continue supporting them from afar.
I learned a shocking amount of information, and my team was shocked to find out that I had been talking to just one patient for two hours. I relayed all that I had learned, and several decisions about her care were changed because of what I was able to glean from my conversation with her. There was less concern about involving social work or homeland security for her safety, and we could trust her employers to continue maintaining her health once she was discharged (as she would need lifelong treatment). I truly think it was then that I started appreciating my connections to my patients more than I had before.
The second story isn’t nearly as uplifting. In my time on Psychiatry, I had only dealt with substance use disorders, and I found myself wishing I had seen more “bread and butter” psychiatric diagnoses like depression, anxiety, bipolar disorder, and schizophrenia. However, I came to enjoy and even appreciate the diagnosis of substance use disorder, and I found myself more interested in the care of patients who had substance use disorders. The second patient I found myself developing a strong therapeutic alliance with on Medicine was a young homeless woman with a son not much younger than her, a husband far older than her, and multiple substance use disorders. She had been admitted around ten times in the past year for the same issues, and was having worse and worse liver function from alcohol use, to the point where the team was genuinely afraid that, if she left against medical advice (AMA) yet again, she would likely not live long enough to come back to the hospital yet again. The first day I met her, after we had finished rounding on her and got back to the work room, my intern told me there might not be much work to do with her, as we couldn’t give her the drugs she was requesting and she might just leave AMA again, leaving us with less work. I’m more than a little ashamed to say that I agreed with the sentiment.
Surprisingly, and for an unknown reason to us, she continued to stay in the hospital day after day. Even though we had stopped giving her the benzodiazepines she requested because she was no longer scoring on CIWA, she stayed. Even though she had a prolonged episode of unresponsiveness that was almost certainly precipitated by taking illicit opiates when she briefly had left the hospital for a “smoke break” and we, as a result, had to withhold many of her home medications for pain and anxiety, she stayed. Even though we couldn’t fulfill all of her (many) wishes, she stayed. Day after day, her husband visited her every morning, always leaving for some mysterious appointment after saying hi to me, then hi to the medical team when I came back with them for rounds. I made sure to visit her room often, always stopping by on my way back from another task or another patient’s room. I’d like to think she appreciated my company, though she never acted like it and indeed, seemed confrontational towards me at times.
Truthfully, I’ll never know what enticed her to stay in the hospital for so long, especially when she had made it clear that she hated the environment and wanted to leave as soon as possible. I want to think that it was my therapeutic alliance with her that got her to reconsider leaving AMA every day, and I want to think that my presence in her room and my penchant for giving her my word and sticking to it did wonders for her “compliance” with our recommendations. In reality, it was most likely our stern warnings that she might actually die if she left AMA this time that kept her from leaving as soon as she stopped getting what she wanted. I’ll never really know. But I choose to believe that I helped.
Unfortunately, her stay ended poorly. Being homeless, she understandably did not want to be discharged back to the street, as she felt she would most likely relapse and end up needing to be readmitted. We sought program after rehab program that she could be discharged to, only to have an ever-dwindling list of programs that often failed to meet her strict requirements. Eventually, because she was medically stable and nothing was being done for her care anymore, she could not continue to take up a bed in the hospital, and she had to be discharged back to the street. Many contingency plans were set in place regarding looking for rehab programs, people to contact, shelters to visit, medications to reduce cravings, but ultimately, she did have to be discharged to the street, and that is where my relationship with her came to its sudden end.
Nothing may ever match my first four weeks on a general medicine team. Honestly, my experience was made positive mostly by an incredible team and an irreplaceable workroom atmosphere that made me want to go into work at ungodly hours every day. I wonder what my experience would have been like with a team that was more intimidating, more work oriented, less fun to work with, and less fun to be around. The little things that shape how we view our experiences sometimes end up being the most meaningful, and I’m truly grateful to have been able to work with such wonderful, lighthearted, empathetic, and caring doctors in my first four weeks of medicine. I have to confess that I unfortunately did not enjoy working in the MICU nearly as much. Though there were more interesting things going on, and many procedures that I got to watch and participate in, it was harder to connect with patients that were sedated, altered, or intubated, and it was harder to enjoy myself in such a hectic environment full of people that always seemed to be on edge. I’ve since spoken to several people about my experiences, and I’ve heard over and over that medicine is experienced differently by a medical student than it is by interns, by residents, or by attendings. After medical school, I don’t know if I’ll ever again have the luxury of sitting with a patient and talking with them for hours, and that saddens me, but it also makes me think about different aspects I’ll want to have in my future career.
I’ve found myself wondering what specialty I’ll eventually go into. Before medical school, I had worked in and experienced multiple different medical settings but found myself especially drawn to the emergency department and emergency medicine. This remained true up until my internal medicine rotation, and I started questioning if I could be ok with potentially having less of a connection with my patients. I’m sure that if I asked this of an emergency medicine physician that they would disagree, that they have just as meaningful relationships with their patients (if not more meaningful) due to their presence in a very vulnerable time in patients’ lives. I don’t think I can really compare internal medicine to emergency medicine until I have my EM rotation next year. I’ll have to start making decisions and obtaining letters of recommendation soon, and I already have misgivings about every decision I’ve yet to make, but I’m looking forward to experiencing more facets of medicine, and exploring more of my own inclinations. The friends and physicians I’ve talked to say that emergency medicine has a lot of patient connection and a lot of substance use, both of which grow more and more important to me. To me, there’s large similarities between IM and EM, especially at BMC, where many interests can be whetted in a single patient. I didn’t expect to love medicine as much as I do, but I’m glad I do, and I’m glad I kept an open mind coming into my 3 rd year of medical school. Adapting the words of Bobby Scar, “there’s so much more [medicine] left to be [learned].”
Tim Nguyen, M4 at Boston University School of Medicine.
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