Transitions in Care: a medical student perspective

by Eva Catenaccio

“Have you had a bowel movement?” Ms. L smiled, shrugged, and pointed to her colostomy bag as if to say, “You tell me.” So began the first day of my internal medicine rotation as a third year medical student. My first patient was 83 years old and stuck in the hospital after a colon cancer surgery complicated by renal failure and pneumonia. I ended up following her for the next five weeks, spoon-feeding her lunch and bribing her for blood draws with ice chips I smuggled past the nurses.  Muted by a tracheostomy tube in her throat, she still had an emotional and expressive face. She smiled in delight at the ice chips, but winced and looked away when I struggled to find a vein.

Taking care of her, I learned how to harvest a sputum culture from her throat, how to apply the sequential compression devices to her calves, how to check the ventilator settings every morning and trace the tides of each breath in little green lines on the glowing monitor. I sat for many minutes holding her hand and trying to read her lips. She had worked years ago on that very wing of the hospital.  She had never learned to read or write. She had no family. One day she started to cry and could only mouth helplessly, “I’m afraid.”

On my last day on the floor, I knew I should go tell her goodbye. But I didn’t. When the resident told me to go home, I just left.

I spent the rest of the year contemplating how guilty I felt. I sensed, but never fully explored my own feelings of gratitude towards her. For letting me feel that I was helping somebody when I fed her the first real meal she’d had in three months. For making me look good in front of my residents and attending when she reached for my hand every morning on rounds. (That was mentioned in my evaluations three times.) I went back and forth – was I cowardly or lazy not to see her that final day?

Over the course of the following year, I checked occasionally in the computer to see if anything had happened to her. I worried that maybe she had died. I noticed one day that her age was now listed as 84 and quietly updated her one-line case summary in my mind. I felt terrible for hoping that she’d come back to the hospital so I could go say hello.

It’s difficult to know how to say goodbye, to patients or to their families, when your time together, for one reason or another, is up. I didn’t imagine it would be easy and so far in medical school I haven’t received much special training on how to handle these transitions. Perhaps I shouldn’t fault myself for not knowing better. I just hadn’t realized how much it would matter to me afterwards – even though I had known her for more than a month, I still felt that our relationship was defined only by my sudden, unexplained absence. Even though every day I had dutifully recorded her vital signs and electrolytes, gone home and read up on her conditions, and written out detailed assessments and plans, I had failed to provide a fundamental aspect of her care.

Like many of my classmates, I had gone into medicine because I love talking to people and learning about their lives. My mother used to joke that I was “playing therapist” while other children were playing house. But as a medical student, I felt my natural sense of empathy was stifled by my desire to understand what was going on scientifically.  Sometimes I was too afraid of saying something incorrect to say much at all.

But Ms. L was one of my first patients – eventually it got easier. On OBGYN I made sure I followed the new mothers downstairs the day after their deliveries to admire their babies. To my surprise, most of the women remembered me. One new mother correctly guessed that hers was the first birth I had witnessed – “I was worried you were going to faint afterwards,” she laughed – and promised to tell her son the story when he got older. On surgery, most our patients improved and I discovered firsthand that sending somebody home feeling better is one of the best parts of the job.  One patient wasn’t sent home feeling better though – a 90-year-old man gripped by fear before a revascularization procedure to save his leg from amputation. The operation was a technical success, but he had two heart attacks coming out from under the anesthesia. My fellow medical student and I visited him in the ICU the day after. Although he was intubated and unable to speak, he remembered us, reaching out his hand and squeezing each of ours in turn. He didn’t make through the following night.

Finally, on pediatrics, my last rotation of the year, I was determined to get it right. Again, I had found myself following the same patient for all my weeks on the floor. Baby M. was merely months old, but she was suffering from an unidentified genetic disorder, probably the same that had killed her older brother a few years before. Her ears were misshapen and set low on her head, her fingers were almost twice as long as her palms. Her eyes, however, were lovely, big and brown, and she never fussed when I came to examine her.

Her mother, an immigrant from Africa, spoke only French.  She diligently recorded how much formula her daughter kept down or threw back up with each feeding on a paper log I had written out using Google Translate. She watched me closely as I performed the same exam every morning, as each of her daughter’s reflexes weakened. On my last day, using an interpreter phone, we talked about her baby’s weight gain, about whether or not she had noticed any shaking spells overnight, about the decline in kidney function. Finally, I explained that I was going to another part of the hospital and the rest of the team would be there tomorrow, and that it had been a pleasure knowing her and her daughter. The mother nodded, leaving nothing for interpretation, and asked about the weight again.

A month or so later, a fellow medical student was put on the case. From a distance, I was able to follow Baby M.’s story to its sad conclusion. Her seizures worsened and she started losing weight. She eventually succumbed to a hospital-acquired infection. When I heard the news, I cried. Despite the inevitability of the outcome, I wished I had been there for her passing. My presence might have made a difference – not for the baby, or to her twice-devastated parents, but for myself. This time I had professionally handled the transition of care, but I still hadn’t managed to truly say goodbye, to let go of my emotional attachment to my patient.

I realized that by not showing my patients the full face of my concern for them, I had successfully hidden it from myself as well. But only by being honest with my patients about how reciprocal our relationship really was – whether they were interested in this information or not – was I able to be fully honest with myself. We were struggling with the same sense of helplessness against the unremitting onslaught of their illness. I too was afraid. I too wanted somebody to hold my hand.

Eva got her start in medicine when she was born at Weiler Hospital under the eager supervision of an Einstein medical student. She is currently a fourth year medical student at Albert Einstein College of Medicine in the Bronx and will be applying to residency programs in child neurology. Her research interests include neuroimaging and neuroendocrinology. In addition, she is passionate about artistic and literary explorations of issues in medical education and the personal experiences of patients and participants in research studies. She also loves to paint pottery. 
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