I was a first-year medical student, starting my first afternoon at an outpatient clinic as part of an introductory course in clinical medicine. My white coat was freshly washed; I had a rainbow of pens in one coat pocket, and my shiny name tag dangled from the other. I only hoped that I was as prepared as I looked.
I entered Mrs. Carr’s room. A fifty-five-year-old woman, she sat gingerly at the edge of her chair, looking ready to get up at any moment, as if the appointment were already over. She gave me a cursory glance, then went back to folding and refolding the bus-ticket stub in her hands.
I asked a well-rehearsed question: “What brings you to our clinic?”
“Chocolate cake,” she answered.
I froze a little. My classmates and I had learned many things in medical school--anatomy, biochemistry, and countless mnemonics to help us remember key bits of knowledge. But the correct response to “chocolate cake” was not among them.
“For my grandbaby’s birthday,” she said. “I don’t have Internet, so I can’t find a recipe.”
Now I really froze. Having reviewed her chart with Dr. Jeffries, the supervising physician, I knew that Mrs. Carr was here to talk about her depression medication. I knew what to ask in order to gauge her mood; I knew her medication and its side effects. I just didn’t know how chocolate cake fit into the picture.
“How has your mood been lately, Mrs. Carr?”
“Can you elaborate on that for me? Bad in what way?”
“Bad as in bad.”
“How about your sleep? Energy level?”
“Have you been taking your medication as prescribed?”
“Yes. You think I’m trying to make myself feel bad?”
“No, ma’am. Just trying to see what we can do to help you.”
“You can help me by finding that recipe.”
I continued to try to steer our conversation into the templates I'd learned in class. Cranking methodically through the screening questions with Mrs. Carr, I sensed her growing frustration.
Dr. Jeffries appeared at the doorway--a reprieve.
I filled him in on the history that I'd gathered, deftly omitting any mention of chocolate cake. He asked Mrs. Carr some questions, and then we headed to the computer station to check her lab results before determining whether to increase her dose of antidepressant medication.
But as I sat there Googling dosages on the computer, my mind kept drifting back to Mrs. Carr’s request.
Suddenly, the search term “Celexa dosing” gave way to “chocolate cake.”
I found a recipe that looked so good, I got hungry just reading it. I copied it down on a piece of paper and walked back to Mrs. Carr’s room.
She eyed me suspiciously, no doubt expecting more questions. When I handed her the recipe, her look turned to one of surprise.
She began to talk, and I began to listen.
I listened as she told me how she didn’t get along with her son-in-law, how her daughter wouldn’t stand up to him, and how this meant that she could only see her granddaughter once a year. I listened as she told me how she had stopped her Internet subscription in an attempt to make ends meet.
"My granddaughter is turning five, and I crocheted her some headbands, but I want to bake her a cake, too," she said. "No child’s birthday party is complete without a good cake."
As she talked, I realized that the problem wasn't her medication dosage; it was that her real-life circumstances would make anyone feel depressed. It dawned on me that no number of practice encounters with actor "patients" in medical school could prepare me for the conversations I would have with my patients in the real world, and that it wouldn't help me much to know the intricacies of a patient’s disease if I didn't also take the time to hear about his or her life.
If I'd asked Mrs. Carr why she wanted the recipe, instead of trying to fit her history into the checkboxes in my head, our visit would have been more productive, I thought. We could have talked sooner about the stresses in her life, rather than assuming that we simply needed to increase her antidepressant dosage.
Now, knowing more about her situation, I felt that raising her dosage would merely be slapping on a Band-Aid--a quick fix, not an enduring one. Luckily, there was still time to change course.
Mrs. Carr left the clinic that day carrying a recipe for chocolate cake, not a new prescription. She also had an appointment to visit a mental-health professional at the clinic in order to assess her situation more thoroughly and, I hoped, to get her the support and resources she needed and deserved.
Now, going through my first year of clinical rotations, I think of Mrs. Carr often. With modern health care's unrelenting focus on electronic medical systems and efficiency, I'm frequently tempted to use a boilerplate interview script before the patient has said a single word.
Every time I start down this path, though, I remember Mrs. Carr, who taught me not to jump to conclusions--and that, sometimes, the very best medicine is a listening ear.
Or maybe even a recipe for chocolate cake.
About the author:
Sanyu Janardan is a third-year medical student at the University of Minnesota. She loves all things related to sunshine, science, writing and the holidays. "Writing became a big part of my life when I began journaling while being diagnosed and treated for an illness in high school. Journaling helped me reflect upon my illness in a meaningful way, and this has compelled me to integrate writing into my life as a way to help me better process the experiences I have, both inside and outside of medical school."