During my residency interviews, a question often asked was: “Can you tell me about a case that was meaningful to you?” I initially thought I would share a case of Hypokalemic Periodic Paralysis since it is a rare and ‘interesting’ diagnosis--something to be shared at Case Conference or Grand Rounds. The story also involves a mosh-pit, and as smart as my attending was, she had never heard of a ‘mosh-pit‘ before. This would have been funny to share, and it would have given me some charm points. But to answer the question-- ‘a case that was meaningful’--a different case came to mind.
“I think the most interesting case for me was this girl I met on the Neurology inpatient service at Children’s Hospital,” I began. “She was about twelve years old. And she was having these funny spells--consisting of vague, dull, rather non-descript headaches, some facial flushing, conjunctival injections, tearing--she was photophobic at times . . .”
As I named off her various symptoms, I tried to maneuver around the gaps in my memory--details, like what her exact age was and so forth. But then to my chagrin I realized I couldn’t remember her final diagnosis. Nevertheless, this case felt like the right one to me, and I continued:
“Her primary Neurologist admitted her so we could actually observe one of these spells as they occurred . . . We also got an EEG and tried to see if Klonopin would help, and there was thought as to whether she is having posterior headaches or had Panayiotopoulos syndrome . . .”
I felt very pleased with my usage of medical jargon--saying her symptoms were ‘autonomic,’ and elaborating on how the posterior circulation of her brain may have been involved. I enjoyed saying without stutter ‘Panayiotopoulos.’
“But what was most interesting to me--and I think I made good use of the extra time I had with patients as a third year medical student--was how shy and at the same time rambunctious this girl was. She was quirky--like, she would drink three cartons of chocolate milk for lunch and then line them up on her tray. And after she had one of these spells, she would walk funny.”
My attending called it astasia abasia--meaning she was faking it. Still, it was all the more fascinating to me that this child, twelve years old, with mother cheering at her side shouting, “Come on, you can do it!” was nonetheless unable to walk without attaching her right elbow to her side and bending over as if to lean on it. She folded her hands and walked somewhat like an off-balance flower girl down the hall of the Neurology ward as my attending looked on with a puzzled expression.
“It took me a whole hour to take the history from the mom. She was very ‘circum-loquacious,’ or circumspect, in the way she told her story. Normally, I would have tried to ‘take the bull by the horns’ as a certain Orthopedic surgeon taught me to do, but this mother-daughter dynamic was too interesting to disrupt the flow with my Review-of-Systems-way of interjecting . . .”
“So you never came up with a diagnosis?” The interviewer interjected.
“Well, her EEG was negative for any posterior discharges. But Klonopin seemed to help with the spells . . . maybe it was Verapamil . . . I don’t remember what exactly we called it--the main purpose of her admission was to observe one of these spells and to rule out seizures. I think it did her family a lot of good because we spent a lot of time communicating with the mom about what we were thinking about, and I think it helped her understand that there was some anatomic basis for all this . . . But to answer your question, I think why this case was meaningful to me was that it made me realize how enjoyable and rich the practice of medicine is, and how Child Neurology is interesting, and how invaluable it is to communicate well with patients.”
I tried my best to round out my answer. ‘Maybe this is not what they were looking for,’ I thought to myself. That was the best I could do at the time.
During our White Coat Ceremony, which takes place every August to inaugurate first-year medical students to the field of medicine, the students recite an oath, which is re-written every year by the students to give them a sense of ownership. For our class, as in prior years, we included a statement that goes something like ‘I will be grateful to my patients from whom I will learn.’ By this we mean, ‘I am thankful to have patients I can practice on,’ or, ‘I am glad someone’s willing to be the first person on whom I can practice suturing, or a thoracentesis, or a digital rectal exam.’ And yes, I am eternally grateful for the man who made it possible for me to experience obtaining a stool guaiac for the first time, and the lady who sat with me as I did an entire Review of Systems, head-to-toe, for twenty minutes, and the man who let me bang on his knees with a reflex hammer over and over trying to elicit a patellar reflex--or, the standardized patient who did a superb job of ‘passing out’ in front of me that my teachers laughed at how confused and frantic I became as I froze and stared blankly thinking, ‘was she supposed to do that?’
But arguably there is a whole lot more we learn from our patients. What I continue to think profoundly upon when I think of my patient on the Neurology service is not how her EEG looked or her 5/5 strength in her upper and lower extremities. She was funny, she read books while drinking her chocolate milk, I found out that there are two sequels to the book Shiloh. And even that man who let me do that first digital rectal exam--he had stage IV non-small cell lung cancer, he cried every time he mentioned his daughter, he was the first patient to call me ‘doctor,’ in his delirium he liked to call me ‘John.‘ Such details about his person I cannot forget, though details of his medical history have faded with time.
At first, as my earliest memory of clinical medicine shows, it is easy to think of our patients simply as they appear to us, holding the history and exam findings that we need for our documentation, for our differential, for our Assessment and Plan. But in fact, it is we who are at the periphery, we who are outside looking in, from a distance, at their ordinary and extraordinary lives. We are indeed privy to their vulnerable moments as they discover that they had a stroke, when surgery is indicated, when labor leads to birth, when breaths expire, when affirmation of hope for life as well its destruction sit countered on a balance, ready to tip one way or the other. While the accumulation of clinical acumen and the data churned out by the research machine have no end, what we really learn from our patients--what we are privileged to engage in, what makes all this schooling and long hours worth while, at least for me, and holds me in ecstasy at the prospect of what is ahead in my career--is this ‘reality of experience,’ which James Joyce only ironically referred to in Portrait of the Artist as a Young Man but never fully delved into in practice. This ‘reality’ is not merely an amalgam of details that compose a patient’s existence or some petty gossip, but stories, lives, gateways to a richer reality where we are invited into their experience, their birth, their pain, their faith, their end.
Ars medicina: the ‘art of medicine,’ the ‘art of healing’--to heal, as to mend, to make whole, to restore, to compose, to beautify--how should I carry their stories in my own memory? How should I relate to them? How can I participate, help and restore? How should I live, and what will be my practice? In this sense, medicine to me is an art, and perhaps the most meaningful art. It is not an ‘art’ in the sense that it is based on inconclusive evidence or that imprecise methods are applied. Medicine is an art because it involves the whole of our human conscience--our intellect, our compassion, our ethos, our volition and devotion as well as our spiritual connection to every human being. It goes beyond abstract knowledge or a skill: we mingle and toil amongst flesh and blood--it’s our discipline, our ever-demanding profession in which we take care of the sick.
When seen by lay people, it’s rather obvious that medicine is rich and intricate in many ways beyond the intellectual process of diagnosing or the heroics of intervention. These are real people we deal with; they have families, traditions, individual narratives. And even communicating with them is not so simple: we cannot assume that they use our words--certainly not our jargon--or even think in the same abstracts as we do. More obvious are the language barriers, cultural clashings, religious differences, and spiritual discord. There is much to be mended, more than we ourselves can handle, except with respect and reverence. What we do is not a practice from which patients, for the most part, benefit. We offer a service. Whether it be a cure, palliation, education, counseling, or simple comfort and support, it is our way of interfacing with the reality of suffering in the world, and I, for one, am enthralled to have vocation in something that is at the very crux of life, equipped with knowledge that demands response--a responsibility.
“Think of every patient as undiscovered country,” my Psychiatry professor said to me. “Our patients are more like us than otherwise.” There indeed is agreement among us, a spirituality transcending self-interest, a commonality that far exceeds our individual scope, as common a denominator as death, as simple as a longing to befriend. That, as far as I know, is beauty and meaning--life that is life indeed. And every case, every person, when viewed beneath such loving light, reveals to me hope--the possibility of healing--that I am privileged to know such grace and to call it my own.
notes:
-klonopin: clonazepam. long-acting benzodiazepine. a variety of indications exist including anxiety and seizure disorders.
-panayiotopolous syndrome: seizure disorder involving autonomic symptoms as in the patient described, with characteristic posterior discharges on EEG. see: http://pediatrics.aappublications.org/cgi/content/abstract/118/4/e1237
-verapamil: calcium-channel blocker. effective in migraines, Benign Paroxysmal Vertigo or Benign Paroxysmal Torticollis, which were diagnostic considerations for my patient.
-'James Joyce only ironically referred to . . .'': this is a central idea in the story. the reference may be obscure. the reference to the novel Portrait . . . is to invoke the deep sense of irony in the book. in the novel, the protagonist is compared with Icarus, the mythical figure who flew too high that his wings melted, leading to his drowning in the ocean. similarly, there is much irony in the 'artist' in Joyce's novel. the 'artist' has much 'pure' and 'youthful' ambition. he also refers to notions of 'encountering for the millionth time the reality of experience . . .' and 'finding out what the heart is and what it feels.' these are 'youthful' passions that end up resulting only in vanity. now, what i am trying to convey is that: at this point in my life, although i am also 'youthful,' i am aiming to fully engage in life itself with its toils, highs and lows--unlike the 'artist' in Joyce's book, who became an 'artist' to only intellectualize and sentimentalize in vain/masturbatory ways. Joyce in real life also initially studied medicine but decided to become a writer instead. my choice is on the contrary. i am aware that my story/essay is very youthful and idealistic: so i am addressing the possibility of my turning to vanity. but at the same time, i am all the more highlighting the excitement and how enthralling it is to look at such 'youthfulness' in the face and move forward and choose to serve. also notable is how the 'artist's' slogan is 'non serviam,' which is Latin for 'I will not serve.' this is from the Latin Vulgate, from the book of Jeremiah, in which the people of Israel refuses to serve God. the slogan is also attributed to Lucifer/Satan in other literature. this is clearly in contrast to what i believe.
