More Than A Medical Note

July 15, 2016

Birmingham;_Hospitals_Centre;_an_elderly_patient__Wellcome_L0002291EABy Alicia Cowley, MD

Ms. R had been admitted late the previous night so I expected that I would have to gently nudge her from her sleep. So as I peeked around the curtain separating her bed from her roommate’s, I was surprised to find a woman alert and freshly bathed. She had assembled a makeshift vanity with a mirror and a small cosmetics pouch that she had propped conspicuously atop her overbed table.

She was about to apply some lipstick when she noticed me. I greeted her good morning and introduced myself. She smiled and offered me a cheery hello. Her hand resumed its lap around her lips. This diminutive, carefully groomed elderly woman clearly liked to look her best when expecting company. I was the first member of our team to meet her, so I proceeded to ask some questions regarding her admission and perform my own physical exam. Her skin was pallid and her cardiac exam was remarkable for two murmurs that indicated severe stenosis. Also remarkable was the color of her fingernails—a bright, raspberry-in-the-sun-too-long pink.

Examining her extremities, I complimented her on the color choice. “Oh, it’s all chipped, but you’re sweet,” she replied. “I have to redo them when I get back home. You know, it’s my favorite color. It’s called mod squad,” she observed matter-of-factly. Her tone was refreshing, completely unassuming, like that of a young girl receiving a compliment on a holiday dress.

This simple exchange of words proved to be the first link in a chain of interactions that would keenly remind me just how critical (and enriching) a humanistic approach is to patient care. Over the course of the week to follow, I would stop by Ms. R’s room multiple times a day—often to check on her physical condition, sometimes just to share a moment in the middle of a hectic day. Each instance was unique. We shared stories. We laughed. She mercilessly exposed the beauty secrets of the stars, taking care to note the afternoon anchorwoman’s hair extensions. I was grateful for the opportunity to connect with this patient not only as doctor but also as friend.

But real human connection is forged in moments of vulnerability. It is more than a string of pleasant notes, a composed cadence of daily chitchat.

Ms. R was proud, not vain. She kept herself primmed and scented, but for those around her as much as for herself. One morning, however, she found herself in a situation well beyond her physical control—a moment of real vulnerability.

The nurse alerted us that Ms. R had suffered a severe episode of melena. I rushed to her room alongside my intern to find Ms. R shaken and embarrassed. This was her greatest nightmare—for Ms. R, a woman who so carefully presented herself, a total loss of bodily function had been an especially jarring experience. In this moment, she needed both doctor and friend. She had always offered a smile at the hardest parts of the day and here was my turn to do the same. I reached out my arms as she steadied herself and told her with my demeanor that there was no shame to be felt in this moment.

Three days in, I had Ms. R’s medical story down pat. By the time she was about to be discharged, my notes read:

MR is an 87-year-old woman with a past medical history significant for chronic atrial fibrillation, congestive heart failure (LVEF 50%, severe aortic stenosis), diverticulitis (status post sigmoid resection in 2002) who presents with 3 days of bloody bowel movements. She has had episodes of lower GI bleeds (LGIBs) in the past, the most recent of which was 4 months prior to admission. Unfortunately, MR’s severe valvular heart disease has placed her at a prohibitively high risk for colonoscopy and sedation. As such, she has had no prior workup for GI bleeding and never had a colonoscopy. Physical exam reveals a frail but lovely elderly woman appearing her stated age. Exam is significant for pallor, including pale conjunctiva; irregularly irregular S1/S2 with a grade 4/6 harsh systolic murmur at the second right intercostal space with radiation toward the right carotid artery and a 3/6 systolic ejection murmur at the apex; and melena. Labs are significant for low hemoglobin (10.3) and hematocrit (31.3), normocytic anemia, and a positive fecal occult blood test indicating active bleeding. Transthoracic echocardiogram is consistent with severe aortic stenosis and mild aortic regurgitation as well as severe mitral annular calcification (AV area 0.6 cm2), severe mitral regurgitation, severe tricuspid regurgitation, and moderate pulmonary hypertension. Given her presentation, lab results, and the frequency of her intestinal bleeds, the etiology of MR’s LGIBs appears to be Heyde’s syndrome. After 2 transfusions of packed red blood cells and serial CBCs to confirm stable hemoglobin and hematocrit, MR is being discharged with arrangements for follow-up with her cardiologist in two weeks’ time to discuss the possibility of open-heart surgery for valve replacement (AVR) or transcatheter aortic valve replacement (TAVR).

But there was another set of notes that I collected. It was a story no less compelling and infinitely more charming:

Ms. R is an 87-year-old woman with a past medical history significant for breast cancer (status post lumpectomy and chemotherapy in 1982), but more significant for her survival. Prior to retirement, Ms. R presented as a professional dress shopper, a profession well served by her keen eye for detail. She reports that she was lucky to have found “a very special man” whom she loved deeply and greatly admired. According to her, “He was an incredible man. A Harvard gentleman, you see. He took me to one of his college reunions; it was lovely, so special. I cared about him very much, and he loved me too.” Unfortunately, she met him late in life. She never married. Never had children of her own. As such, her neighbor is her closest friend and healthcare proxy. Impromptu visits reveal an engaging and lovely woman with an affinity for romantic novels. Exams incidentally reveal that while she is in the hospital she is reading a “light, summertime romantic fiction” and that at home she recently began reading what she believes will be her all-time favorite novel, Jane Eyre. Her activities of daily living are significant for reading, shopping, and dining at her favorite cafe a few blocks from her apartment. Given her dependence on a walker, she admits that her friends do not like spending as much time with her as before, but she adds, “I don’t mind it one bit; I enjoy people-watching and doing things on my own.” After 2 transfusions and serial CBCs to confirm stable hemoglobin and hematocrit, Ms. R is happy to be discharged in time for some spring shopping. Although in the past she has always turned down the option of surgically addressing her aortic stenosis, she eagerly looks forward to a follow-up with her longtime cardiologist to discuss the possibility of open-heart surgery for valve replacement (AVR) or transcatheter aortic valve replacement (TAVR).

It was my heart that was hurting when Ms. R’s hospital course extended past Mother’s Day. It had always been a special day for my mother and me, and though she had no children of her own, I figured that Ms. R deserved a pick-me-up just the same. So when I passed by a rack of nail polishes at the drugstore, I seized the opportunity. Scanning the innumerable variations of pink, I picked the one that most reminded me of the polish I had been privy to all week. I presented the polish and a greeting card to her the next morning. After a short pause, her eyes welled up and she hugged me as tightly as she could. To my surprise, I had nailed the color.

On her discharge day, Ms. R asked me if I had a little time to take a walk with her around the 17th floor. She had more advice to impart on the ways of “love and life.” Soon her neighbor arrived to accompany her home, but before Ms. R made her way to the elevators, she reached into the zippered part of her handbag and pulled out the card that I had given her. “I just want you to know that I’m keeping this in a safe place,” Ms. R said quietly, “and that I thank you for everything.”

Somehow though, I was the one who felt grateful.

Dr. Alicia Cowley is an internal medicine resident at NYU Langone Medical Center

Image courtesy of Wikimedia Commons



One comment on “More Than A Medical Note

  • Avatar of Jerry Goddard
    Jerry Goddard on

    Well written story. You still have the heart of a “people doctor”. I hope you can keep your love of caring for a person and not just a kidney, bone, or heart. Try your best to keep your loving eyes.

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