When learning medicine is not enough

“Hey, doc,” our new patient grinned at me without teeth. He wears his teeth to eat peanuts, he explained, but today was hankering for a ham sandwich, so left the teeth at home. Here in the clinic straight from the logging job that he had worked for the past fifty years, he wore steel-toed boots, hands covered in dirt. Clarifying that I was a medical student, I asked if he had any medical concerns. “Just the usual stuff, nothin’ too bad,” he replied.

He then revealed what “nothin’ too bad” meant: chest pain that took his breath away. Eyes going black without warning. Pain in his fingers and toes, with two amputated digits. Clothes hanging loose; waking up drenched in sweat.

I left my patient’s room and frantically relayed his list of problems to my preceptor. She asked what I wanted to do. A flurry of medications, diagnostic tests, and lifestyle changes turned my mind into a white-out.

“First step,” she filled in, “is saving our patient’s life by giving him clear instructions on when to go to the emergency room. Can he read?”

It was my first day rotating at a Federally-Qualified Health Center (FQHC) in an underserved, rural area of northern Michigan. During my prior rotations, in the bustling academic bubble of a quaternary medical center, I had witnessed astounding medical complexity: liver transplants, autoimmune encephalitis, premature infants as small as my hand. Unsavable lives, miraculously saved.

Learning the intricacies of the human body is fascinating, challenging, and all-consuming. A strong scientific and clinical foundation is critical for becoming an excellent doctor. But it is not sufficient. In the resource-rich setting of the quaternary medical center, I had largely been shielded from the social complexity that underlies health care. Rotating at the rural FQHC was my first significant experience caring for an underserved population, and it exposed critical gaps in my patient care knowledge and skillset.

For example, when caring for this particular patient, I learned that there’s no point in recommending a vegetable-filled diet if my patient doesn’t have teeth. There’s no point in orchestrating referrals to far-away specialists if he doesn’t have reliable transportation. There’s no point in writing a meticulous treatment plan if he can’t read.

When I returned to my home-base quaternary medical center for the remainder of my clinical rotations, I noticed that my month at the FQHC continued to permeate my approach to patient care. For instance, while rotating in a subspecialty clinic with patients from across the state, I found myself on Google Maps to understand how far a patient had to travel, and whether frequent follow-up appointments were feasible. When admitting a teenager in status asthmaticus, I found myself asking his family about financial barriers, and learned that his medications had indeed become too expensive. When seeing a child with a rash who had recently moved to a new home for financial reasons, I found myself asking about cockroaches, which turned out to be the cause of his rash. I use the phrase “found myself” deliberately: these questions have become nearly automatic, taking their place alongside the typical symptom-focused checklist of questions that we memorize in medical school.

Spending just one month immersed in a low-resource population changed the questions I ask: of my patients, of myself, of our society. These questions have fundamentally improved my approach to patient care, as well as my commitment to being an advocate for society’s health. I urge undergraduate medical educators to provide all medical students with clinical experiences caring for underserved populations.

Hanna Saltzman is a medical student and can be reached on Twitter @hannasaltzman.

Image credit: Shutterstock.com

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