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Yale J Biol MedYale J Biol MedThe Yale Journal of Biology and Medicine0044-00861551-4056Yale Journal of Biology and Medicine Arts and HumanitiesBeyond the White Coat Ceremony Salameh Maya *Assistant professor of clinical medicine at Columbia University Medical Center* To whom all correspondence should be addressed: Maya Salameh, Columbia University Medical Center, Herbert Irving Pavilion, 177 Fort Washington Avenue, Suite 533, New York, NY 10032; Tel: 212-305-1467; Email: ms3033@columbia.eduMaya Salameh wrote this story while a resident at Yale Medical School.

9 2007 3 2006 79 1 35 38 Copyright ©2006, Yale Journal of Biology and Medicine2006Yale Journal of Biology and MedicineThis is an open access article distributed under the terms of the Creative Commons CC BY-NC license, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. You may not use the material for commercial purposes.Note from Anna B. Reisman, Co-Director, Yale Internal Medicine Residency Writers’ Workshop, Assistant Professor, Department of Internal Medicine, Yale University School of Medicine and VA Connecticut Health Care System: This issue inaugurates a new feature: selected writings from the Yale Internal Medicine Residency Program’s Writers’ Workshop. The annual workshop began in 2003. Abraham Verghese and Richard Selzer, among the best known physician-writers in the United States, have served as workshop leaders, teaching the craft of writing to more than 35 residents. In designing the workshop with my co-director, Dr. Asghar Rastegar, our aim was to make participants better physicians by providing a creative outlet for reflection. The tempo of a resident’s day is typically furious — one patient dies, perhaps, another sickens, a third refuses a necessary procedure, a fourth’s wife cries inconsolably at the bedside — with no time in between to ponder what happened, much less what it meant to the patient or to the resident and how it might shape the way the resident practices medicine in the future. Without time to muse about the experience, many residents take the easy road: They emotionally detach. Writing, we believe, can be an antidote to this tendency. The exercise of writing not only makes us empathic; it also sharpens our diagnostic skills. One of the keys to compelling writing is attention to detail: the nervous twitch of an old man’s eye muscles or the decayed front teeth of a young woman, a former crack addict. Such details not only make our writing come alive but also sensitize us to our patients’ plights and sharpen our diagnostic skills. The stories and essays written by the Writers’ Workshop participants present a range of experiences, real and imagined, and take us deep into the minds of young doctors trying to make sense of what they do.
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Essay
Mrs. Hernandez doesn’t speak English, and Jenny is not here. Sometimes I think the entire clinic would fall apart if Jenny didn’t take the bus every day to translate for the helpless doctors taking care of the large Spanish-speaking patient population. But she’s not here today, and Mrs. Hernandez is waiting. I’ll make do with my broken Spanish. I walk in and introduce myself. She seems pleasant enough. This will be a quick one, I think to myself, an “in-and-out” type of visit. I start by asking her the reason for the visit. That’s mistake number one. The ailments come out one after another, and before I know it, I’ve got a case of “total body dolor” (total body pain) on my hands. I can’t do it. I’m post-call, I’m tired. I can’t go through with this. My mind drifts, and I watch Mrs. Hernandez, speaking earnestly, pointing to her neck, her back, her stomach, her legs, wincing, frowning, moaning. She’s coughing, too, she says. She’s been coughing for a year. I scan her chart while she talks. Ten urgent visits in the past two years for this cough. Chest X-rays have been ordered, ACE-inhibitors have been taken off and put back on, Robitussin with and without codeine has been prescribed. But this cough persists.

I notice she has not coughed once since she started speaking. I start to feel impatient. Before I know it, I don’t believe her anymore. So when she points to her right upper quadrant, wincing in pain, and tells me she has an “inflamed liver,” I feel like I’ve had enough.

Mrs. Hernandez, Senora Hernandez, please sit over here, sientese aqui, I’d like to examine you. I can tell she’s not finished talking, but I’m finished listening.

She hobbles over to the exam table, wincing in pain, clutching at her back as she limps across the room. Once she is seated, I approach her, and, while pulling out my stethoscope, I notice little red marks on her chest called “spider angiomatas.” These are classic for patients with cirrhosis, patients who have advanced liver disease. I ask her about a history of liver problems; I had not seen a mention of it in her chart.

I was about to tell you, she says, I was about to tell you about my inflamed liver.

I don’t know what to say. I sit her back down, take a deep breath, pull out my pen, and the real visit begins. Now I’m listening, but I feel like I’ve already failed her.

***

Mr. Pratts is crying. His entire 380-pound frame is shaking, and he is sobbing like a baby. His legs are swollen again, and he can’t get out of the wheelchair because his knees give way. He’s fighting with his lover.

My life is out of control, doctor, I don’t know what to do.

I look at my watch. I’m an hour and a half behind, and I have two patients waiting. It’s going to be a long afternoon. My pager goes off — it’s the inpatient ward, it must be important. I ignore it.

Have you seen your therapist recently, Tony? He tells me through his tears that he stopped going there. I listen and I say nothing. The minutes go by. Sheila, the head nurse, knocks on the door.

Doctor, Mrs. Rivera is going to leave if you don’t see her now.

Well I can’t see her now, Sheila, she’ll have to wait.

Tony is still crying, but he’s calming down. We talk about adjusting his medications to help with his swollen legs, and he likes the idea. We talk about increasing his insulin to better control his blood sugar level. We talk about weight loss, but Tony is beyond weight loss. And I know that at this weight, we’re fighting a losing battle. We can tweak the lasix and the insulin and the neurontin, but Tony will never really get better. At least that’s what I think as I watch him catch his breath between sentences. But I don’t tell him that because that would break him. Tony is calm now.

Thank you doctor, he says. Thank you for listening.

It’s my job, Tony. That’s why I’m here.

***

Tommy was back in jail last week. They released him yesterday morning and his first phone call was to the clinic to make an appointment with me. I know why he’s here, and I brace myself as I enter the room.

I’m in lots of pain, doc. I need my meds.

Tommy is 45 years old and for some reason, he made some wrong decisions in the past. He can’t recall which started first, the cocaine or the heroin. The drinking came next. Now hepatitis C and alcohol have ravaged his liver. Today he is clean from drugs but in constant pain, dependent on narcotics. We’ve done multiple imaging studies that have revealed no obvious cause for Tommy’s persistent abdominal pain.

The story changes every time. I need my refill early because my car was broken into and they took all my stuff, including my pills. I need another refill because I lost the script you gave me, and now I’ve had to double up on the pills I had at home because the pain is so bad. I just need more pills, doc.

I start to feel frustrated again. I think back to my first day of medical school, to the white coat ceremony I’d attended with an eager anticipation of my life as a doctor. I’d walk into clinic in the morning and cheerfully greet the nurses while putting on my white coat. I’d diagnose and treat. My patients would get better and they would feel like I’d helped them because I’d ordered the right imaging study or prescribed ...

Doc, are you listening?

Tommy has been speaking for several minutes and I find myself again caught in a quagmire of stories that have no beginning and no end. I know what Tommy wants from me. And I know I have to say no because he is addicted.

I can’t give you any more pills but I’d like to help you, Tommy.

He is angry, and the look of desperation in his eyes strikes me. I stand my ground, but I already know he’ll be back tomorrow.

***

Walter stands up as I walk in and extends his hand with a big grin on his face. He is a healthy man in his mid-fifties whom I have been treating for three years for uncomplicated hypertension. He comes every few months; we check his blood pressure and adjust his medications and then we spend the rest of the time talking about his job or something of interest in the news. There was no reason to think today would be any different. Walter’s blood pressure is good, and I tell him to keep it up. As I’m preparing prescriptions for his refills, I ask if there’s anything else bothering him.

Not really, doc, I feel pretty good except for this diarrhea I’ve been having.

Tell me about the diarrhea, Walter.

It’s been going on for a couple of months, no big deal really, just having it a few times a week; in between, everything is normal.

I ask him if he’s lost weight and he thinks he may have but doesn’t have a scale at home so it’s hard to tell. Now he’s on the examination table, and as I examine his belly, I find myself expecting it’ll be normal, so I’m surprised when I press down on the left side and I feel something hard. I press down again. It’s still there. I pause.

Is everything okay, doctor?

I’m just examining you, Walter, don’t worry, just examining.

I know at that moment that this is bad news for him, but I say nothing. The rectal exam is next, and I insert my finger; again, I encounter a hard, rock-like mass. My heart sinks.

Well, Walter, we need a CT scan and a colonoscopy.

But why, he asks, and suddenly he is full of questions that I do not answer. The next day, Walter has a CT scan of his abdomen and pelvis, and I get the page from the radiologist in the afternoon. He has a large mass in his colon, he says, it looks like a neoplasm. Neoplasm. Malignancy. Cancer. That’s what I thought.

Walter, I need to see you in clinic tomorrow afternoon to talk about your test results.

I hang up the phone. He’s coming tomorrow at 1:00 P.M., and, for first time since Walter has been my patient, I’m dreading his visit.

***

Ms. Moore wants me to call her Lucy. I’ve never met her before, she’s not one of my regular patients. I’m seeing her today because she’s having pain in her feet. I examine her. Her feet, apart from being dirty, look normal to me.

Well, we’ll do some blood tests, Lucy.

But what about the pain, doctor, I can’t walk.

I tell her to take Motrin, and she responds with the familiar “I’ve already tried, and it doesn’t work.”

What about Tylenol?

Same answer. I don’t know anymore. I have no idea what’s wrong with Lucy’s feet. Morning clinic is over, and the other residents are gone. I’m supposed to be at noon conference. Before I know it, Lucy is teary-eyed.

What’s wrong, Lucy? She gives me a glimpse into her life. Her husband left her. She has no children. No one wants to have anything to do with her, she says. She was reading the Bible and talking to God and that was helping, but yesterday, in a moment of despair, she asked God if he was still listening and he didn’t answer. Even God didn’t answer.

Lucy, are you thinking of hurting yourself?

She’s clutching at the Kleenex I handed her and her eyes are fixed on the floor. She doesn’t answer.

Lucy, we need to get you some help. I’m going to ask a psychiatrist to talk to you.

I don’t want a psychiatrist, she assures me. I’ll be fine. This has been going on a long time, it’ll be all right.

I convince her that this is the right thing to do, but I already know she has no choice. I step out of the room to call the psychiatric emergency room. When I return, she is gone.

Where did Ms. Moore go, I ask the nurses.

No one knows. We search everywhere, but she is gone. We call the police. We call her home. We are unsuccessful. This is my fault. An hour later, the phone in triage rings, and Sheila picks up.

It’s Lucy. Please tell that young doctor I’ll be all right, she says. I won’t hurt myself, I’ve been like this for years. That doctor, she just took me too seriously is all.

Lucy, wait, let me get the doctor to speak to you. I reach for the phone, but it’s too late. Lucy has already hung up.

