The powers that be had spoken and I felt powerless

As a medical student, one quickly learns not to question the wisdom of authorities, and appropriately so. Do your work quietly and conscientiously and study hard. Take all criticism enthusiastically and graciously. Do not speak unless spoken to. Beyond the compassion and empathy we are all expected to champion, these are the proverbial medical student keys to success. In our roles as the lowest rung on the medical ladder, this indoctrination comes from a combination of both trial and error and, put frankly, fear. I was no stranger to the age-old horror stories passed down from one anxious student to the next about encounters with particularly hardened attendings.

I was told Sarah (not her real name) had a clot in her left arm; as the sub-intern on call, it was my job to admit her to the medicine service. Sarah was quiet – super quiet – and curt in her answers to my attempts at open-ended questioning. The little that I did glean was that she had first noticed a bump in her left arm one month ago and now it had gradually enlarged, becoming tender. A month and a half ago, she had been hospitalized for pseudoseizures while on vacation in Puerto Rico. She apathetically denied every other question I asked, including about ten specifically intended to evaluate her clot risk. Aside from her left upper extremity exam, her vital signs, physical exam, and admission labs were all normal.

Ultrasound confirmed that she had a large superficial venous clot in her left mid arm. A quick online search refreshed my memory on the subject: superficial clots, when provoked, cause discomfort but do not require a large medical workup; unprovoked clots, however, are rarer and indicate risk for hypercoagulability. Sarah had denied all of the questions I asked about clot risk. Yet despite our half-hour long conversation, I remained unsatisfied with the small amount of information I had gathered. In standard medical student fashion, I returned to her bedside to clarify her history.

“So I know we talked about this before, but I just want to make sure. They did not get any blood from your left arm or hook you up to an IV when you were in Puerto Rico, correct?”

“Oh no, they did,” she replied coolly. “I had an IV in for the two days I was there. Sorry. Did you ask me that before? I guess I just wasn’t paying attention. I’m tired. I’ve been here a long time.”

With a provoked superficial clot, Sarah could be followed as an outpatient. Yet when I told the resident about this new development, she felt there was little she could do: the ER doctors had gotten a vascular consult and it was the vascular attending who had recommended that Sarah be admitted. Put mathematically, this is basically what happened:  Vascular attending > (ER attending = admitting attending = medicine attending) > resident > me. The powers that be had spoken, and I felt powerless.

She got therapeutic deep vein thrombosis treatment. There were progress notes, nursing orders, and thousands of dollars in lab work. We called in the weekend ultrasound tech from home to evaluate for clot extension.

I got to practice my communication skills when the resident let me call the vascular attending a day later to see what he wanted to do about anticoagulating the patient upon discharge since her clot had not extended.

“What do you want?”

He answered, reminding me of my place in the hierarchy. Was he the dreaded attending from those stories? I took a deep breath and explained that I did not think Sarah needed to be anticoagulated given the nature of her clot.

“Are you kidding me?”

He was angry. I was scared.

“I explicitly asked the ER attending, and he told me it was unprovoked. God, she didn’t even need to be admitted. Discharge her, please. Now.”

He hung up. I did as I was told. Or at least I thought I did. Sarah’s name was still on my list when I went to round on my patients the next morning. Dumbfounded, I asked the resident if she had co-signed my discharge order as I had requested before leaving the day prior.

“Oh my gosh, I totally forgot,” she said.

My heart sank. Sarah, true to form, had been too passive to say anything to her nurse. And yet why should that be her responsibility?

Despite everything we had done, we all had been too passive. Communication counts at every level, now more than ever.

Jessica Heney is a medical student.

The powers that be had spoken and I felt powerless

This post originally appeared on the Costs of Care Blog. Costs of Care is a 501c3 nonprofit that is transforming American healthcare delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

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  • Suzi Q 38

    Doctors wonder why I ask so many questions.
    Sometimes, it is just to remind them of what I need, why I am there, and who I am. Oh, and I also tell them what I want to do and ask if that is O.K.
    They usually say yes.

    Not to make fun of a sad situation, but doctors are sometimes to busy to know “who’s of first?” Base, that is.

  • Elvish

    Your encounter is is very common and it doesn`t seem that the “powers” had done anything wrong nor you were powerless.
    If any, it seems that you need to work more on your communication and history taking skills and be more assertive.
    A patient needs to be discharged per the Vascular surgeon, and your duty was to convey the message and make sure it happens.

  • azmd

    Another thing you could have learned from this, which might have been more useful than some ideas about “the powers that be” and “powerlessness,” is that a patient with a history of pseudoseizures (or, as they are called these days, non-epileptic seizures) will frequently have personality issues which can complicate their medical treatment in a variety of ways. It might be interesting for you to read up on that aspect of this case, as non-epileptic seizures are fairly common.

    • SBornfeld

      Well, yes…but then how do you know the diagnosis of pseudoseizure is accurate?
      At the same time, there are plenty of non-seizing patients who are crummy reporters.

      • azmd

        I guess you could think of it this way: a history of pseudoseizures is sensitively but not specifically associated with being an unreliable historian.

        • SBornfeld

          Fair enough–thanks.

  • meyati

    Then you can be labeled as a difficult patient if you try to get your med history out. Often the medical staff doesn’t ask the right questions. Some nurses get upset if you try to add anything. My current HMO didn’t ask about cancer history-not one question. It was all focused on heart and diabetes, which is not in my family-cancer is. I’ve been told to shut up, so they can ask me the right questions. I ended up in the hospital 50 hours after being told to shut up, they were polite-but I was told that I didn’t have relevant information. Let’s put it this way, I wasn’t charged for the ER visit. By the way, my family history of cancer caught up with me. Believe me, I told all concerned that this was the first time their system asked me about cancer-and it was in the same building-same health system.
    I hope that Sarah wasn’t charged for the extra stay in the hospital-

  • Kerry Willis

    ad but typical that no one bothers to take an adequate history or do an adequate physical exam and wonders why the vascular surgeon make a less than stellar decision with less than adequate information……ITs not the medical student who should feel bad….there’s a host of others who should hang their heads in shame

    Keep working hard and don’t repeat the same arrogant mistakes when you are the Doctor making the decisions. One of my mentors always told me to listen to my patient that they would tell me what was wrong .

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