Faculty Peer Reviewed
Mr. A is a 91 year old male with a history of hypertension and two myocardial infarctions. He presented with shortness of breath and worsening lower extremity swelling and was subsequently admitted to the medicine floor for a CHF exacerbation. While on the floor, he also complained of painful pressure ulcers on his lower buttocks. He was diuresed and given oxygen by nasal cannula during his 48-hour hospital stay, and his ulcers were cleaned and monitored for infection. He was discharged with a new pharmacologic regimen.
On the second morning of his hospital stay, I asked Mr. A how his night was at the precise moment when my inexperienced hand placed a stethoscope on his chest. My nervous attempt to weave non-scripted questions into the patient encounter resulted in indistinct heart sounds laced with the vibrations from his voice. I had tried too quickly to learn as much about him as I could and, in the process, heard neither what he, nor his heart, had to tell me. I was taken aback, fearing that my oversight had crudely displayed my uncertainty. More significantly, I had a sudden awareness of the wide variety of tools we use to get to know people as I tried to tease out the uniqueness of his emotional and physical rhythms. I appreciated how perceptive all of our senses must become, and how sensitive they must remain, when assessing patients.
The most challenging, and yet fascinating, aspect of transitioning between knowledge and practice is isolating and synthesizing the different ways we examine people. I had felt Mr. A’s edematous ankles, seen subtle ECG changes, smelled his infected ulcers, and heard his extra heart sounds, pulmonary vibrations, and most importantly, his words. Each sensory element of my daily inspection formed my version of his clinical and personal narrative. I had been weighing all my senses, relating them to each other, and looking for combinations and sequences. My senses and the spoken—and unspoken—words of my patient coalesced to form the stories of his illness and hospital course. What we sense from our own experiences with our patients adds immeasurably to the stories we tell, retell, and condense on rounds and for sign-outs. These stories begin as simple accounts of our patients’ activities, but over time, we make them our own.
The strict verbal relay of information between and within teams can only bear so much, though. We prize accuracy and objectivity, but these realities are shaped by the experiences with those under our care. I remember examining a different patient last month and appreciating a subtle, questionable murmur which only half the team had heard. When I wrote my daily progress note later that day, my intern, who had not heard the murmur, made sure I included the abnormal sound as a finding of my physical exam. “It was what you heard,” he explained to me. In a field full of inconsistencies and wonderful surprises, where a possibility can regularly overshadow a definite, the notions of formal truths and certainties can fall by the wayside. There are no absolutes in medicine. It is only through these personalized and individual senses that we can connect to our patients on a more fundamental level and that their stories become our own.
I love that about medicine. I can read stacks of journals and participate in conferences and become genuinely absorbed by Mr. A’s clinical and pathological details. Yet, only my unique experiences with him enable me to add to or appreciate them. During the two days I spent with Mr. A in the hospital, I touched, saw, smelled, and listened. I even tasted his Ensure one morning when he was expressing to me what the hospital felt like to him. I heard his stories and experienced his illness through words, silences, and my own memories of my grandparents as they were stricken with heart disease. My story of Mr. A is not complete, or in my control, without the contribution of each sense. We add authenticity to the stories we tell when they are infused with our own senses and perceptions of their characters. Mr. A’s story remains his own, and was not compromised by my version that I recounted each morning.
My experience with him was personal, and it allowed me to be able to see the patient as a character in the stories he told. I came to understand him based on our interpersonal encounters, and not on what I read in a chart. But the value transcended merely understanding Mr. A as an individual. I came to respect each sense’s ability to contribute to the story and appreciate that the very means with which I navigate the world and my surroundings can connect me to another human being. The story of Mr. A, which I reproduced several times per day, grew out of that bond. Senses, though, require their own time and space to allow for that. I initially tried to sense so many tones at once that I heard none of them. When I finally removed the stethoscope from his chest, Mr. A would tell me his own stories of the sights, sounds, and smells of the army base kitchen where he once spent so much time. And I felt much more connected, much more privileged, much more involved when his own senses were part of his storytelling.
David Ellenberg is a 4th year medical student at NYU Langone Medical Center
Peer reviewed by Ishmeal Bradley, section editor, Clinical Correlations
Image courtesy of Wikimedia Commons