Reposted from here with permission
She was a petite, otherwise well-appearing woman, apprehensively sitting at the edge of the examination table. Hoping to mask my nervousness about this first, intimate patient encounter, I inquired about the reason for her visit. She told me that she was here to discuss a hysterectomy. She shakily explained her two-year history of heavy, painful menstrual bleeding. She hoped that the hysterectomy would be her saving grace. The insistence on this procedure made me suspicious of stirring waters beneath calm surfaces, so I probed further.
The patient recounted embarrassing obstacles that developed due to her constant, painful menstrual bleeding. I mentally began to form and shift around possible differentials. Yet as the conversation turned to the traumatic experience of her most recent delivery, another category of diagnoses quickly bubbled to the forefront of my mind. Her answers to my questions about abnormal bleeding were tagged onto self-berating tangents where she recounted her perceived failures. Her life centered on the happiness of her family, but it was clear that this was also the root of her mood disturbances. She explained frustrations associated with her recent pregnancy, familial responsibilities and inability to truly be herself. These circumferential rants made it clear to me that her chief complaint was simply the grounding granule upon which all her deeper-seated problems crystallized. The descriptions of anhedonia, erratic behaviors, sleep disturbances and seemingly endless complaints rung the alarm bells for postpartum depression.
After I felt I had a decent handle on the most significant stressors in her life — the strained spousal relationship, the medically handicapped father that required constant care, the chaotic management of multiple children and pets that ran amok in her house without proper spousal support and the current obstacles in obtaining the appropriate special needs requirements for her youngest — I decided to assess the patient’s insight on her condition.
Despite her strong expressions of overwhelming frustration and self-directed hatred, she remained solely fixated on her medical presentation. She seemed profoundly confused when I observed that she must be overwhelmed with her responsibilities. Instead, she saw these symptomatic developments as consequence of her personal failures, rather than the culmination of expectations and responsibilities. She seemed baffled by the idea that all the stresses she described at length could result in medical and psychological ailments. After all, she had been dealing with these problems forever; it just wasn’t a big deal.
She had so many things to be grateful and happy for. She didn’t have a right to feel overwhelmed and depressed.
When she mentioned that she did not have time for therapy because of her son’s never-ending special needs sessions, I tried to point out that personal health often takes a backseat for working mothers. I felt a hint of achievement as I sensed a glimmer of realization in a brief moment of pensive quiet.
When a brief pause gave way, I ushered myself out to update and discuss the patient with my attending. I was slightly taken aback at his surprise when I expressed concern that the patient may be suffering from postpartum depression. He listened attentively as I explained her repeated expressions of self-directed frustrations and her seemingly narrow-minded perception of what the hysterectomy would accomplish. In the brief time my attending and I discussed the possibility of two chief complaints, abnormal uterine bleeding and postpartum depression, I felt a strange sense of accomplishment and humbled acceptance. This warm feeling continued to grow when we decided to start her on an antidepressant and delay the hysterectomy.
At the same time, however, a flicker of uncomfortable disturbance hummed in the back of my mind at the dissonance in the current practice of medicine. The prioritization of medical symptomatology over psychosocial factors may appear benign in the acute setting, but its impact on our patients’ well-being may be more severe than we realize. As trained problem solvers, it is natural that we expect patients presenting to an obstetric clinic to have a major obstetrics complaint, not realizing that other underlying pathology may have precipitated this potentially secondary complaint. Especially from the perspectives of overworked and extremely busy attendings, it is easy to fixate on the most obvious symptoms within their expertise.
Throughout the preclinical years, medical curricula and standardized patients emphasize the importance of “getting to know your patients.” From my short experiences on the wards, I have realized that while this is a true and beautiful sentiment, the reality of rushed twenty-minute appointments create a barrier to hearing each patient’s life story. The reality of medicine prevents us from seeing the intricacies that may be crucial context for each patient. I took more than twenty minutes to interview this patient, but I discovered vital information. I was able to establish rapport, trust and engagement. In exchange, I missed the other two patients that were swept in and out of the office. As a student, I have to question how to best balance the realities of medicine with appropriate and humane care to our patients.
Perhaps, we as third year medical students, can serve as the bridge between our patients and our supervisors. We can make use of our time in the ever-bustling wards to really get to know patients. In these prolonged encounters that our supervisors do not have the luxury of experiencing, we can parse out the psychosocial context that surrounds each clinical encounter. In doing so, we may serve as an important contributor to the team. Too often, I have felt that my lack of knowledge and experience are obstacles to being useful, but this interaction showed me that as students, we might have hidden clinical skills of our own. If we learn how to brandish these effectively during our medical education, we can play an active, vital role in the living organism of medicine.
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