Mrs. B is a 68-year-old female with a PMH of small cell lung CA metastatic to the liver s/p last chemo six weeks ago presenting with RUQ pain migrating to her RLQ for the last 24 hours. Physical exam reveals a fatigued but pleasant African-American female appearing her stated age, in obvious pain that is making her eyes water. Exam is significant for R supraclavicular LAD, a distended abdomen, + Murphy’s sign, and exquisite tenderness to palpation and guarding in the RUQ and RLQ. A liver span of 12-13 cm by scratch test is also noted. Labs are significant for T 98.1F, LFTs wnl, and WBC 14.0. U/S, HIDA scan, CT abdomen are consistent with distention of the gallbladder by stones and cholecystitis secondary to obstruction of the cystic duct by periportal LAD and expansion of liver metastases, representing progression of the patient’s primary disease. Patient was discharged on PO antibiotics, with arrangements for laparoscopic cholecystectomy in two weeks as well as follow up with her oncologist for management of stage IV disease.
An open letter to my patient, Mrs. B:
Dear Mrs. B,
I first saw you in the hallway, in your wheeled bed, a silent stranger. You held a closed book with a finger reserving your page. You reached into your pocket for your phone and took a call, suddenly becoming animated and showing the beauty and complexity of your life in your conversation. And then you hung up, smiled to no one, and took up your book again, retreating into your anonymity. And as I watched, I was told by my resident that I would be following your care in the hospital. It was a memorable moment for me, especially because two weeks later, after having listened to your heart every morning as the sun leaked through the window, having traded amusing stories with you from our lives outside the hospital, having felt the hardened lymph nodes in your neck every day and learning their shapes, pressing on your belly and feeling your cancer, measuring your pain and understanding it and coming to hate it as much as you did, it would seem impossible to me that I had ever regarded you as a stranger.
I had become a reporter on the condition of your body. I found the remaining muscle deficits from your ancient Bell’s palsy and wrote about them in a note. I worried about your worsening pain at night after I left the hospital. I followed your white blood cell count religiously and in those two weeks it became the first thing I looked at each morning, a significant number in my life. Our new closeness was obvious and apparent to me. But I was ignorant of its depth, because it did not occur to me until later that I had gotten to know the regularities of your body better than I knew my own. I had never listened to my own heart with a stethoscope before and obsessed over systole, as I had with you. I had never become familiar with the noises of my own breathing. I did not know whether I could feel my own liver or spleen, and I had never before assessed with any degree of precision my own ins and outs.
I had never seen people like that before, as measurable and observable, full of physical exam findings waiting to receive the accolade of documentation in a medical student note. But after examining you twice a day for two weeks, Mrs. B, it soon became difficult to see people in any other way. It was as if a whole realm of detail on the human body had gradually come into existence. There was the dip of a stranger’s clavicle as they hailed a cab. Two of the four dreaded traits of a mole on someone’s back on Lexington Avenue. Perfectly accessible veins on the forearm of the barista handing me a cup of coffee. Something that looked like Russell’s sign on the knuckles of a teenage girl at a restaurant. Strabismus. Bulging neck vessels and swollen legs, those classic stigmata of heart failure, in the owner of my favorite carryout place. The barrel chest of a homeless man. Anisocoria in a cab driver’s mirror. Vitiligo on the subway.
These accidental physical exams disturbed me. I was quietly invading the private space of strangers, and I knew details about their lives without having ever met them. Perhaps I even knew things about them that they did not know: the unusual mole, the swollen legs, the barrel chest. It would never be appropriate, obviously, to approach them with an unsolicited evaluation. This worried me. I had never before understood what people meant by the phrase ‘burden of knowledge’. It had not occurred to me how knowledge could be a burden, but suddenly here it was, burdening me. Those precious details at the hospital bedside, the physical exam findings celebrated in medicine as proof of a doctor’s meticulousness, were following me home and adding strange color to my life.
Over the course of the past two months, Mrs. B, this unexpected feeling of guilty trespassing has gone, and in its place remains something even more unexpected: a tenderness towards the sick and the confidence of knowing that I am not only learning the art of medicine but practicing it every day, unintentionally. A surgical scar on a passerby now prompts a search in my head for an explanation. Abnormal gaits are scrutinized, converted into the starched nomenclature of neurology, and confronted with the question, where is the lesion? Recreational diagnosis no longer seems the burden it once was. It now offers an opportunity to heighten the senses, to practice, to improve.
It was you, Mrs. B, who started to open my eyes to this world of detail that previously went unnoticed, for a very long time, right in front of me.
Vivek Murthy is a 4th year medical student at NYU School of Medicine