Narrative Medicine Corner
Contribution by Tiffany Fan (UCLA)
Accessible Text Version
As a new MS3 starting on inpatient medicine, I felt anxious as I prepared to see my very first patient. My senior resident and I went to the ED to admit a man with heart failure exacerbation. From a glance at his medical record, I saw that he had a past history of substance use disorder, homelessness, and a stroke several months prior that left him hemiplegic and residing in a nursing facility.
As we gently drew back the curtains and introduced ourselves, the patient abruptly expressed his annoyance. "Again? Are you kidding me?"
"I'm so sorry to have to ask you to repeat yourself. I know this is very frustrating", said my senior resident. Still, the patient would not answer any questions. "Would it be alright if we did a quick physical exam, so that we can get you upstairs to a room?"
He sighed and reluctantly gestured to move forward with the physical exam. I rummaged through my white coat pocket for a small sheet of paper with a basic physical exam checklist, which I still had not memorized. I was eager to obtain a thorough heart & lung exam given the patient’s condition.
“Could you please turn onto your side so I could listen to your lungs?” He refused to turn, so I tried my best to listen for anything on the lateral lung fields, fumbling to position my stethoscope underneath his arms. “Okay, now please take a deep breath in through your nose and out through your mouth.” He rolled his eyes and did not appear to be in a mood to cooperate as he scoffed, “This is taking too damn long. I want to sleep now.” I managed the best I could at the moment, but felt discouraged leaving the room with only a limited physical exam that missed crucial information.
After the patient was admitted and transferred to a room on the floor, I learned from his nurse that he was refusing labs. "Tell him we'll let him have dinner soon if he agrees to get labs after", stated my senior resident, hopeful that he might be more cooperative after being fed. Still, he refused. Despite my nonideal interaction with him earlier in the ED, I decided to see if I could talk to him, though at the same time doubting myself for being just a med student.
"Hi again Mr. W, we were hoping you might agree to get your blood drawn for--"
"No."
"There are just a few blood tests that would be helpful for us to take better care of you so that you can feel better and leave the hospital soon."
He turned his back towards me and pretended to snore loudly.
"Is it alright if I ask why you do not want the tests?"
Again, my words were met with silence. Defeated once more, I was preparing to leave the room. As I stood up, he quietly mumbled, "I'm scared." His tone had completely shifted, the tension in his face had eased, and his seemingly rough demeanor faded.
“Is there anything we can do to help you feel less scared?” I recounted what I saw in his record and wanted him to feel seen as a person outside of his illness. I thought about how vulnerable he must have felt, being faced with his third admission for heart failure exacerbation that year, and with limited resources and support. “I can see you have been through so much and I can’t even imagine how difficult that must have been, but I want you to know that we are here now to help you get through this.” At this time, this man, who at first appeared brash and irritable, softened as his eyes welled with tears.
He finally agreed to the labs and while that was my initial objective in entering his room, that small triumph felt miniscule. I felt a greater sense of victory from establishing a deeper connection to my patient and understanding a bit better how I could support him during his hospital stay. As I left the room, I thought to myself – I’m also scared, but maybe I can actually do this. Maybe I can actually take care of patients. I can do this.
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[Included in our Q4 newsletter. Editor: Tiffany Fan]
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