He was my first patient — ever. I had seen only a few patients before at my school’s student-run clinics, but never had I conducted a full visit. He was my first patient since starting the second semester of my first year, which meant more independence on my part (theoretically), and that, for the first time, I would be holding the office visit from beginning to end. Without guidance. Of any sort.
Having just learned all the aspects of the physical exam and medical interview, I was supposed to be ready to tackle what I had been training for since day-one of medical school: to talk to a real patient, and to really try to be a doctor.
A young man walked into our clinic for a physical. My preceptor told me it should be easy and ran through some basics with me and – voila – I was in my white coat, welcoming Joe into our exam room.
Predictably, everything kicked off to a shaky start. The words stumbled awkwardly out of my mouth. Good afternoon, Joe.
A pause. What else? What comes next?
I fumbled for the words. Was this the part to ask, “So what brings you in today?” It didn’t sound right. I knew exactly why he was coming in — it says on this paper: “Yearly physical.” OK. Let’s stop pretending. My mind started racing and it was then that every urge to walk through these pretenses left. I decided I would just start our visit like I would start any conversation: How are you?
Perhaps this wasn’t the question he was expecting, or perhaps he felt my nervousness. Or even more likely, he did not know how to utter his following words: “I don’t know, doc, I’m not that great, actually. My mom passed away a few days ago.”
My script from my first-year doctoring course completely fell apart. There was no rifling through the pages of my memory for any doctoring lectures, or any other prescribed method for that matter, on how to talk to patients when they share such personal, touching, and saddening news. And perhaps there was no such need. We’re all human after all. It shook me, though, to have had this news shared with me, a complete stranger. Few life experiences had equipped me for that moment: A first year medical student, watched and graded by her preceptor, needed to perform a routine clinic visit, but suddenly this fell into her lap, just to shake things up a little. Should I continue? How could I offer my help? I felt strongly for Joe, but my attending, and the physical exam, waited.
But the conversation carried on. Joe told me that he hadn’t eaten anything for days, and in fact had been drinking daily since. My preceptor had told me that Joe is an alcoholic, and I looked onto my sheet where I was supposed to fill in more information about his alcohol use. Frustratingly, I saw that more questions were to be asked: How long has the patient been drinking? The quantity? Ever tried to quit? Could I make the executive decision to skip these questions? I just did not feel like right now was the right time to be asking these. It was a different conversation for a different day.
A look from my preceptor told me that I must move on: The physical exam was next. I began, flowing from head to toe. He was slightly febrile, clearly stressed, disheveled, and ungroomed. His eyes, irritated from crying, were documented in my preceptor’s note as demonstrating “mild scleral injection.” In fact, all of what we observed in his dejected form went into the note, which might have made him sound like there was something pathophysiological about him, but really, all we were dealing with was a fellow human being who is in deep grief about his mother’s passing. And yet, here we were, tapping on his knees and shining light into his eyes. My discomfort with the situation was overwhelming.
Really, I still don’t know what the best way to deal with the situation would have been. He still came into clinic. He requested the physical. These all had to be done. The questions had to be asked. And he wasn’t sick. In fact, although he was a smoker and an alcoholic, his physical exam ended up mostly unremarkable, except for his obvious signs of grief. All were documented. My preceptor typed away at the note and described him as having situational depression. And for what he was going through, he still put up with me ever so kindly — an unseasoned first year medical student who could do no better than fumble with her stethoscope and ask a laundry list of medical questions.
I felt humbled by his patience. At the same time, the rest of the visit flowed with much more ease because I felt we had connected. I would have known nothing about him if I had focused on that piece of paper that listed the history I needed to gather and the physical exam information I needed to document. What taught me the most about Joe, and helped me reach out to him and understand his story, was the simplest question of all: How are you?
The author is an anonymous medical student.