My preceptor would call this a “Pandora’s Box” case. Do not open the conversation if you are not prepared to grapple with all of its consequences. This is what I am thinking as I interview Ms. L.
I have a standard set of social history questions. Ms. L screens positive for nearly all of them. Victim of domestic violence. Victim of sexual violence. Poverty. Addiction. Depression. Thoughts of self-harm.
I try not to cringe as she pulls down her gown to show me scars on her chest where an ex-boyfriend burned her with cigarettes. I am looking at deep bruises, not at the hands of some common enemy we call illness, but at the hands of another human being. What compels someone to do that? We are in a hospital, but this is far from strictly a medical problem.
A few weeks earlier, she had tried to take her own life. Wrapped cord around her neck. Saved only by a fortuitous visit from a home health aide, who convinced her to untangle herself before she could do anything she would be unable to reverse.
Now she is crying. I feel like crying with her. There are only so many times I can say “I’m so sorry to hear that” and “that must have been really difficult.” My words sound trite. I feel inept. She looks at me through tears, waiting for me say something more helpful.
First-year medical students occupy a unique niche in the hospital. My classmates and I wear white coats and ask people about their lives and illnesses, but we cannot answer medical questions or offer anything in the way of treatment. We are in limbo: on our way to becoming caregivers, but unable to provide care.
The hospital is a rehearsal. Patients are practice. I collect their information to hone my ability to conduct an interview, give an oral presentation, and do a write-up. I am not helping anyone. On the contrary – by giving us their time, patients are helping us; they are teaching us how to be become better doctors.
This disruption from expected roles can understandably lead to confusion. Though I always introduce myself as medical student and explain that I am not part of the patient’s care team, Ms. L was not the first patient who has said things suggesting she did not truly understand my role. Some patients ask for advice. Others probe for clues about prognoses. “What are you going to do with all this?” a previous patient asked me at the end of our interview, when I was packing up my notes.
People come in and out of patients’ rooms all day long. It can be difficult for anyone to keep track of who does what. In fact, a common critique of the medical system is that while individual providers are high quality, the problem lies in lack of coordination and gaps in continuity of care, as patients find themselves explaining the same stories over and over, unclear on why.
For someone like Ms. L, misunderstanding hospital relationships could have serious consequences. Sitting across from me is a profoundly depressed woman who spoke bitterly about caregivers abandoning her. I prolonged the interview for as long as I could, but eventually I had to report back to my preceptors. Would she perceive me as abandoning her, too?
I must have looked upset after I presented Ms. L’s case, because my preceptor picked up on it. He told me that it’s easy to “spiral” after an encounter like this – to start questioning whether medicine is worth it, or whether we do any good at all. He told me to do something fun that evening to take my mind off what had happened.
I tried but was unsuccessful. Instead, I thought more about the Pandora’s Box analogy. Sometimes it is not up to you whether it opens. I walked into a room on a general medicine ward, asked a patient a few simple questions, and wound up in an emotional minefield I felt wholly unequipped to navigate.
The challenge in the hospital-as-practice setup is that does not prevent emotional rapport from developing. The hospital dynamic, where one person is vulnerable, and another comes across as a professional, practically guarantees it.
Once a difficult conversation is opened, you cannot just close it. So what do you do?
The answer from my preceptors reminded me of what I was instructed to do when I was a kid and saw someone in trouble: tell a grown-up. In this case, that translated into informing Ms. L’s medical team of her issues so that she could receive appropriate care. In most cases, you probably should not follow up yourself, as it is better to err on the side of not doing further damage when you are not even supposed to be involved in the first place.
Still, it is strange to think in terms of not doing damage. Aren’t I supposed to be actively helping people? Are the only impacts I can have at this stage of my training neutral – or worse than neutral?
My experience with Ms. L shook me. I was fortunate that her medical team was already aware of her emotional health, but I realize there will be cases where I might be the only confidante of privileged and delicate information. And that can happen during any stage of medical training – regardless of how qualified I am to handle it. I am afraid that is the inevitable price of practicing on human beings. On my way to becoming a doctor, I am frankly terrified of doing more harm than good.
(Note: certain details of this story have been modified slightly to protect the privacy of the patient.)