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A recent conference on the topic of hospital and patient safety
addressed the theory that medical students are often the most
vigilant because they know the least in a room full of residents
and attendings. I identified with this, because the desire to
absorb as much information as possible in any patient interaction
is a common theme among medical students. This was further embodied
by a recent patient interaction that I had.
A 46-year-old African American woman with a medical history of
hypertension and chronic left hip pain had been in the hospital for
three days since presenting to the emergency room with persistent
abdominal pain that was associated with vomiting and diarrhea.
Computed tomography revealed fluid filled loops of small bowel,
which was probably caused by a mild ileus or gastroenteritis. A
right adnexal cyst had also been found incidentally and was
evaluated by a gynecology consultant. Pain management, whom she had
seen on an outpatient basis, was also consulted for her chronic
left hip pain.
I met the patient on her second day of admission and took note
of how friendly and appreciative she was of our care. But the
following day, I had noticed a change in her affect and lack of
communication during rounds. The patient always had a family member
in the room, even at 7:00 a.m., but today she was alone. She
mentioned that she did not want to see anyone today. A consultation
mix-up had resulted in the patient going two days without seeing
pain management. The attending went through a routine physical
examination and discussed that the gastrointestinal work-up had
come back negative, her symptoms were most likely due to viral
gastroenteritis, and she could go home either that day or the next.
The plan was to advance her diet before discharge. Suddenly, the
patient began crying and said that she was upset and didn't want to
see any family or friends.
The attending, slightly taken aback, asked her a couple more
general questions and said that we would return soon; then, along
with the chief resident, two interns, and myself, we walked out. A
quick deliberation between the attending and chief resident about
the merits of consulting psychiatry ensued outside of the room. I
had been told to find some tissues for the patient because there
were none in the room. I returned to the room, handed the patient
the tissues, looked her in the eyes, and held her hand. The total
exchange lasted for a couple of minutes, and I just let her talk.
The combination of hip pain, abdominal pain, and three full days in
the hospital had begun to take a toll. At the end, she looked at me
and said thank you. I left the room to find the rest of my team
already discussing the next patient.
One benefit of being a student is that you experience a wide
spectrum of personalities and approaches to patient care from
different attendings and residents. One question that I constantly
find myself asking in difficult situations is whether I would have
handled it any differently if I were the attending. After some
reflection, I realized that all the attending needed to do was sit
down and talk to her for a couple of minutes and reassure her.
Fast-paced rounds can transform patient interactions into
transactions rather than real conversations. This was an
experienced physician with excellent medical skills and knowledge,
but he failed to see the patient's vulnerability and frustration.
Was a psychiatry consultation necessary for this patient? This was
a possibility, but it missed the point.
As medical professionals, we sometimes forget that being in a
hospital is not a joyous experience. In fact, for the majority of
patients, it is the last place that they want to be. This subtle
point can often get lost in translation because many of us spend
more time in hospitals than our homes. A hospital stay can be a
roller coaster of emotions; although this is not necessarily our
job to manage, we should acknowledge the strain that a hospital
stay can put on the psyche.
When seeing patients, I remind myself how I feel when I am sick.
Reflect on a time when either you or a loved one was very ill-the
vulnerability that one feels is incredible. There is no clear
demarcation as to when patient care becomes too personal. Many
argue that personal feelings can cloud sound, independent medical
judgment and end up having a detrimental impact. These are
important points to be cognizant of during patient care, but many
of us can be a bit more personal without compromising patient care.
The humbling ability to heal also bears a great deal of
responsibility, to constantly remind oneself that behind every
hospital gown is a human being. The humanistic aspect of medicine
is the main reason that many of us chose this profession, to care
for the weak, defenseless, and vulnerable.
Medical students are often the least knowledgeable persons in
the room. Yet, we can sometimes perceive the heightened emotion in
the room, not because we have a sixth sense but because it is our
role to be hypervigilant. This ability is present in all
physicians, but it requires us to put ourselves in our patients'
shoes. Eye contact, reflective listening, and exhibiting emotion
can go a long way to strengthen the sacred and personal
doctor-patient relationship. In other words, bedside manner.
Brendan Keleher, MS III
Ross University School of Medicine
September 2012 Issue of IMpact
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