Tug-of-War

Jo Marie Reilly

As I teach first- and second-year medical students to take patient histories and to perform physical examinations, I always feel humbled and privileged--energized by their compassion, enthusiasm and facile, curious minds.

Occasionally, I feel particularly challenged--especially when I'm teaching a student who, though bright, is struggling to acquire some of medicine's basic skills. As we journey up the learning curve together, my responsibilities can conflict: as a teacher, I want to nurture an aspiring student physician, yet as a physician, I must ensure that patients receive appropriate care.

Now, sitting quietly in the corner of the room and watching a young medical student interview a county hospital psychiatric patient, I begin to feel this tension.

"What brought you into the hospital?" the student queries nervously.

Small and reserved, she's quite a contrast to her patient--a burly, imposing middle-aged man, his body splattered with tattoos of birds of prey and firearms. He folds his arms tightly across his chest, and a large cross sparkles on his neck chain.

"It's when I tried to commit suicide on the bridge," he responds agitatedly.

There is a long, awkward pause. "So...what medication did you say you take?" she asks.

"I take respiridol. It's for my voices," he replies flatly.

The student clenches and unclenches her hands.

"What about drug allergies?" she asks. "Do you have any drug allergies?"

"No." He stares at her blankly.

"Alternative medical therapies?"

"No!"

She fidgets with her papers, looking through her history-and-physical book for the next question to ask this obviously disturbed man. Her eyes dart around the room's harsh, white walls, devoid of any mirrors and pictures. The stark surroundings make the interview even more intimidating.

As a seasoned clinician, I feel frustrated by the fumbling interaction unfolding before me. But as a teacher, I feel compassion for the student's discomfort with this emotionally fragile man and hope that she can find a way to connect with him. I continue observing silently.

The student locates a phrase on her mental-status sheet that seems to give her comfort.

"Your mood," she blurts. "How would you describe your mood?"

"Angry!" he shouts, picking furiously at some invisible specks of dust on his hospital gown and flicking them off with his fingers.

"Oh." She glances nervously past the bed curtain to the guard watching curiously from his doorway post.

Okay, I think. It's time for an attending-physician rescue. I stand up and walk to the bedside.

"Mr. Adams, " I say, "tell me about the bridge. You must have felt pretty desperate to want to end your life."

He looks at me, relaxing a bit. "Yeah, I jumped from that bridge, but that fisherman pulled me out. Damn well near froze in that water."

Thinking that I've jump-started the interview, I nod to the student, who's been frantically scribbling down our conversation.

"I haven't asked you yet about your past surgical history," she stammers.

He simply looks at her.

"That's quite a story," I interject. "What made you so anxious that you wanted to jump from the bridge?"

"It was those voices again. When those voices come, it's all over."

The student looks at me; I raise my eyebrows encouragingly.

"How about immunizations? Did you receive your childhood immunizations?" she asks.

"Immunizations?" He looks at her strangely and begins to tap his foot against the bed. "What are immunizations?"

"Well Mr. Adams," I say, "I actually think it'd be important to know more about those voices. Tell us about them. What do they tell you to do?"

"They tell me I'm worthless. They tell me to hurt myself." Looking distressed and ashamed, he gazes at the wall.

I pause, giving the student another opening.

"Let's see," she says, looking at her notes. "Did you ever do any military service?"

I look over at her again, trying to conceal my exasperation. Does she just not get it or what? Time to bring this painful interview to a close.

"Mr. Adams, you've been so kind to talk with us this morning. Your voices sound like they are very scary, and they cause you to do some unsafe things. How are your voices now?"

"They've quieted down since I got back on my medications," he says. "They're not telling me to kill myself anymore."

I nod. "I'm so glad that you're feeling safer now. We'll make sure the social worker gives you enough medicine so that when you leave the hospital you can keep your voices down. Can we do anything else for you today?"

"I just want to rest now. I'm pretty tired from all this talking," he answers, closing his eyes.

Out in the hallway, I turn to the medical student.

"How do you think it went?" I ask.

She glances at her notes, looking distracted. "I think it went pretty well," she says. "I got almost everything--but I did forget to ask him if he had a family history of diabetes."

I sigh inwardly. How can I give her feedback that is constructive and tactful? How much of her stumbling is due to her youthful inexperience and to the intimidating environment? With more maturity and less nervousness on her part, will her communication skills blossom?

The inevitable doubts set in. What is my role and responsibility as her teacher? How can I help her "get it"? What if, despite my best efforts, and those of my colleagues, she still cannot adequately listen and respond to patients? I dread the thought.

At such challenging moments, I think of my professional vows--the Hippocratic Oath's admonition, "Do no harm." As a teacher, I am called upon to do no harm to this hopeful, aspiring student physician. As a clinician, I must ensure that no harm be done to the patients she serves.

I must dig deeply for courage, patience and wisdom.

And so continues this tug-of-war.


About the author:

Jo Marie Reilly is Associate Professor of Family Medicine at the Keck School of Medicine of the University of Southern California (USC), where she is Director of the Professionalism and the Practice of Medicine course and Assistant Director of the Introduction to Clinical Medicine course. She is also a member of Pulse's Editorial Board. "Writing helps me connect with the power of humor, joy and compassion in the work that I do, and in doing so helps me balance my professional life, patient care and personal life, which includes spending time with my family."

Story editor:

Diane Guernsey

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