I was a fourth year medical student doing my neurology elective at Columbia’s Neurology Institute in New York City. It was an exciting time for me. I had a sublet across from the Blue Note Jazz Club. I took the bus to work by day and the subway to parties by night. The pulse of the city was a far cry from UCONN’s sleepy Farmington snore. I was happy to be there and eager to learn. Learning for a physician, clichéd as it may seem, is a lifelong process. It does not happen at a steady or predictable pace and can be about things you never saw coming. In the first two years of medical school it is force fed through lectures and books organized around subjects (anatomy, physiology) or organ systems (musculo-skeletal, cardio-vascular). In the third and fourth years, and for the rest of a doctor’s life, it comes from contact with patients.
Thirty years later I remember a patient I saw at Columbia. He was a 41 year old upper class New Yorker getting chemo and radiation therapy for an advanced brain tumor. His very attractive, but pale and anxious wife sat nearby as I interviewed and examined him. He seemed happy to see me. Hospitals, especially tertiary care hospitals, are cold and impersonal, and the waiting between contacts with caregivers can be so painful that medical students are almost always welcome. There is something very comforting about their clean white coats, insecure looks and plain ignorance. Patients often open up to medical students while holding back information from their more arrogant and hurried physicians.
Despite his brain tumor, my patient was awake, alert and it seemed, in complete control of his faculties. We talked about his illness, his work, his life. I didn’t really know all the questions I should have been asking, but we both had time and just kept talking. For some reason, one that I still regret today, I asked him about depression and whether he had thought about suicide. I didn’t even ask the question well. There was something about Hemmingway, I think. In any event, he gave me a big smile and started to answer, but his wife started to fidget in her chair, clench her jaw and glare at me. At the time I told myself that I had every right to ask a terminal patient about depression and that asking about suicidal thoughts was a doctor’s responsibility. I now feel that it was unnecessarily cruel to the wife and that as a student, not one really caring for the man, I did not have the knowledge or power to help.
The next day my preceptor told me that the patient’s wife complained about me, specifically my opening up the topic of suicide. She asked that I not see him again. I was not censured in any way. Senior physicians are very protective of their medical students and, at least on paper, I had done nothing wrong. He told me that the patient actually liked me. Sadly, the story did not end there. That night the young man, whom I today imagine wearing a tux out in New York society, went into a coma. His brain had swelled and herniated down his brain stem.
I left New York City with mixed emotions. I loved the Neuro Institute with its bizarre Movement Disorders ward—dozens of people even weirder than the ones who roam the streets downtown. I was proud of myself for braving the late night parties even though the women were way too cool for me. I was surprised and happy to receive an A and a glowing recommendation from my preceptor. Still, I was ready to get back to the normalcy of life in New Britain. On some level I still felt like I had caused a brain to herniate and a wife to be doubly distressed.
One month later I received a letter forwarded to me by my preceptor. It was from the young wife who had just buried her husband. She wrote to thank me for talking to her husband. He really did enjoy my company and conversation. She said that before my visit she did not realize how sick he was or that his death was a near term possibility. She said that my breaching the topic of death in some way prepared her and allowed her to project her built up anger, frustration and fear onto me. I don’t think she apologized for anything. She wished me luck and encouraged me to keep talking to my patients.
I said it already—you don’t always learn what you set out to learn. Sometimes the person you are caring for isn’t even your patient. Sometimes the things you learn are about yourself.
