Tales Out of School
I am a professor of family medicine at the University of Minnesota Medical School. During their third and fourth years, students must complete a four-week clerkship in family medicine. The clerkship includes a "significant-event reflection" project, in which students discuss patient encounters that they've found especially meaningful.
Over nearly a decade as a facilitator for these groups, I have heard many powerful and emotional stories. I've often felt deeply moved--and admiring of the students for their honesty, courage and humanity. Here are three of many whose stories I carry with me.
"Sure, I'll go first!" said Rob. A fourth-year student, he was about to enter a radiology residency. Rob had a bright, open face and quick smile, and knowing that family medicine wasn't his chosen specialty made me appreciate his enthusiasm all the more.
"I haven't ever had a chance to talk about this, even though it happened nearly two years ago," he began. It had taken place during his first clerkship, emergency medicine. He was in the ER one night when word came that a young man from a nearby town was being helicoptered in; he'd suffered a serious motor-vehicle accident.
"When the patient arrived, he was barely alive," Rob said. "He had massive trauma to his head and chest."
As Rob spoke, his face grew increasingly strained. His chin began to tremble, and his eyes teared up. He tried to press on, but kept having to stop.
"I can't believe I'm getting emotional," he said. "It was nearly two years ago." After a few more tries, he broke down and sobbed loudly. Some of his classmates cried too, or took his hands and offered comforting words.
Ultimately, Rob couldn't finish telling us what had upset him so. Was it seeing an otherwise healthy young man from a small town--a young man like himself--die so quickly, so easily and so traumatically? Typically, radiologists have little direct contact with patients. Could this have been a factor in motivating Rob's choice? His profound response to his patient's death took me by surprise, but it was inspiring and so refreshing to see a physician-to-be with such a big heart.
Anita, another fourth-year student, was someone I'd known since first year. Although she was engaging and gregarious, my feelings about her were mixed. She'd championed every possible social cause--the outreach team for the homeless, the student-run free clinic, the pro-choice group and many more. When a classmate's academic failures had put him at risk of dismissal, she'd attended his hearing and had castigated our faculty for being heartless. Now I wasn't quite sure what to expect.
The minute her words began, so did her tears. In family-medicine clinic, she'd seen a middle-aged patient named Tom. Her open, encouraging approach had enabled them to connect quickly, and when asked why he was there, he'd confided that he was a longtime alcoholic and was trying to quit yet again. On his last few attempts, he'd suffered seizures and had needed to be hospitalized--very scary. He'd come to ask for a prescription for an anti-seizure medication to "cover" him during this withdrawal.
"That sounded reasonable," Anita said. "I said it was great that he was being proactive, and that I was sure the clinic could help."
She'd presented Tom's history to the chief resident. "While I talked, he reviewed an online textbook. He said, 'There's a twenty-percent risk of death during alcohol withdrawal.'
"We went to the attending physician, and she insisted that a patient who has previously seized shouldn't withdraw at home." The attending strongly recommended hospitalization.
"I felt so sad as we went back to Tom--I felt that I'd let him down," Anita wept.
Tom's response was swift: "I'm not going into the hospital." He started to leave, but the resident asked him to wait. He and the attending put Tom on a "transportation hold," which authorized sending him to the ER, against his will if necessary, to be evaluated for admission.
Despite her horror, Anita had voiced no protest. I felt intrigued that she, of all people, hadn't fought back.
Sobbing loudly, Anita described how the security guard had come, how Tom had protested before finally giving in, and how the paramedics had strapped him into a gurney and wheeled him out.
"He gave me this look of betrayal as he went by...it felt like a dagger in my heart," she cried. "Later I learned that the ER just discharged him home, without any medication." Her suspicions that the attending had acted defensively, rather than from real concern, left her feeling even worse.
Hearing this, I felt my attitude towards Anita change. I could better understand what motivated her passion for justice, but didn't say anything beyond thanking her for her sharing.
Alexandra was someone I'd never met before. Reading to us from her laptop, she'd clearly taken time to craft a beautifully composed reflection.
"As a second-year student, I was assigned to shadow a pediatric nephrologist," she began. "It was exciting for me to meet children who had kidney disorders--especially since I'd had a similar condition as a child. One day, my preceptor met with a young girl's parents to explain that she had an uncommon form of kidney disease called glomerulonephritis."
Alexandra looked up at us and smiled. "I was happy to hear it, because that was the same condition I'd had at her age." After prolonged courses of steroids and several years of follow-up in a renal clinic, she said, she'd gone into remission.
"I was really dismayed when I heard the nephrologist give the family a bleak prognosis," Alexandra continued. "She emphasized every possible negative outcome: the patient could develop kidney failure; she might need dialysis. I wanted to offer my own experience as a counterbalance, but I was just there to shadow. Then the doctor got paged and left the room. After a moment of silence, I told the family, ‘I had this same illness.' "
She shared her own experience with them. "I felt guilty saying that I thought the nephrologist had painted too negative a picture, but I did. Then the doctor came back and picked up where she'd left off. When the family left, they thanked me even more than they did the nephrologist."
When the doctor asked for her thoughts, Alexandra replied, "I believe that the prognosis is better than what you conveyed."
"In my view, chronic kidney disease is a more likely outcome," the doctor countered. "I feel obliged to share that with a new family."
Alexandra gazed at us with wide, tear-filled eyes.
"I know that little girl is going to do well," she said, quietly but firmly. She confided that she herself had suffered a flare-up a year ago and was back on steroids.
Still, here she is, looking straight ahead, expecting the best–-and smiling, I thought. Listening to this brave, young soon-to-be physician, I felt my own eyes fill up.
I don't know where Rob, Anita and Alexandra are now, or how sharing their stories affected them, but I'll never forget them and the emotional sharing that revealed so much about their personalities.
I hope that sharing their stories helped them to remain compassionate and whole as they continued their medical training. I know that listening to students' stories always reminds me of my humanity--and of why I chose to practice medicine in the first place.
About the author:
David Power directs the medical-student education activities in the department of family medicine at University of Minnesota Medical School and sees patients two days a week. In 2012 he received the University of Minnesota Award for Outstanding Contributions to Postbaccalaureate, Graduate and Professional Education. A graduate of the University College Dublin School of Medicine, Ireland, he has published over thirty peer-reviewed publications on an array of educational and clinical topics. This is his first narrative essay. "Many of the stories I've heard students share have remained with me, and maybe there is some therapy in finally taking the time to publish my memories."