University of Illinois, Chicago, United States
The door to room 7403 was opened slightly, and a TV inside hummed the midday news - nervous but resolute, we knocked and crossed the threshold. Inside, sitting knees-up in bed, his height accentuating the awkward angularity of his position, sat Mr. C., Bed No. 2, United States Veteran, my first patient and, most visibly, a man in pain. The briefest look of defensiveness (were we another X-ray technician team, or pair of residents, or some other bearers of bad news?) vanished when we introduced ourselves with practiced handshakes (sick patients love firm handshakes, a wise woman once told me, even those with Ehlers-Danlos, it makes them feel healthy). Sitting up in bed and clutching his right foot, Mr. C. rocked back and forth slightly during our introductions.
So what brought you to the hospital, Mr. C.? Constant pain in my right foot. Can you describe the pain, a sharp, stabbing pain or a shooting pain? Like a burning, like my toes are on fire. Has the pain been getting worse over the past few weeks? Oh yeah, it's been getting worse, you bet. Ok, have you taken anything at all to help relieve the pain? Pills, alcohol. Alcohol? Alcohol and pills, nothing's helped.
Confronted with this punishing ailment - how could someone suffer so long this grinding pain which nothing could allay? - we pressed on. More questions revealed the probable cause of the pain, frostbite suffered four weeks back.
Did you see a doctor for the frostbite, Mr. C.? No. Oh, um, is there a reason you didn't go to the hospital after it started hurting? Nope, don't like hospitals. Haven't seen a doctor in a while.
Leaning back he presented us the foot, that traitor to his body, doubtless thinking that we wanted to examine it ourselves like the teams before us, with our convincing coats and clipboards, little knowing that we likely knew less about his ailment than he did. But how delicate the gangrenous toes looked, unnaturally black, the color of piano keys, looking carved out of wood and polished like a lucky chestnut, delicate, but not malignant, not the source of the pain that collected for itself crutches, insomnia, and sapped strength. In the background, filling our empathetic pauses, came word of lotteries won and lost, multi-car pileups on the interstate and color-safe detergents.
Veterans of their own wars, our instructors had told us that diagnosis is compiled continuously during interviews; an interview alone can often reveal pathology. Clutching the disparate facts I considered Mr. C., our patient - 76 y.o., African-American, thin disheveled habitus, Veteran, West Side, alcoholic, frostbite ... homeless? No mention of family members or visitors...homeless? Was this diagnosis or prejudice? We continued with the interview, learning that Mr. C. was waiting for x-rays that would likely determine his candidacy for foot amputation surgery.
Are you worried or scared about the surgery? Scared? No, the operation don't scare me. I just want to be free from this pain. Have the doctors let you know what life's gonna be like after the surgery? Yeah, but I'm used to the crutches and the wheelchair. They're amputating my foot off, what's to expect?
Was he really unafraid? He said so. Reclining at last, he seemed to be resigned to, at peace with even, the impending surgery. This worldly resignation, a long life of hardships, the marginal utility of worry ... homeless? Was the nursing and house staff supportive? Yes, and compliments were paid to the VA system. The VA's really the only place they take care of people like me.
I felt relieved that at least the patient was fully informed about his illness, the procedure and that he felt at ease at the VA, given that I could offer nothing but company and brief company at that. Progressing through the rest of the interview, Mr. C. revealed that he had one big regret - getting frostbitten in the first place. He had thought he could just tough it out, outlast the pain like in a heavyweight fight. But, finally, his wife convinced him to be admitted once the pain had gotten really bad. My partner:
Ok, so your wife brought you to the hospital. It's no easy walk, huh? You're telling me.
My stomach dropped out. Wife, and kids too, we discovered, and retirement from the construction business eight years ago, and two homes in fact, one in Riverside and the other in Calumet City. A loving family and a home he was excited to return to, to relax, he said, and to spend the holidays with his wife and sons. The son whose sump pump he was repairing when he got the doggone frostbite.
Glad me and not him. Son's as stubborn as I am. The frostbite and operation was a lesson to learn from.
Lasting lesson indeed, I thought, as I recorded notes in the clipboard, noting the irony of his full disclosure to me and my professional nondisclosure. Had I stepped, albeit briefly, into the larger problem that Dr. Groopman had warned of so many textbook pages ago? Had I anchored, to use Groopman's term, had I reached my conclusion about the patient based on what I had wanted to hear, to gratify my initial hypothesis? Had my fleeting judgment of our patient's personal life been something even remotely considered by my co-interviewer? Would a reasonable man, to quote the lawyers, have thought the same given the poverty of evidence? WWGT, what would Groopman think, in those early minutes of the interview?
We said goodbye, thanked him for giving us this opportunity and bade him well for the upcoming surgery. Walking back to meet the group, I pulled loose the tie that I had tied twice that morning and considered whether I would have treated him any differently in that laboratory of social interaction, the patient interview, had he actually been homeless and frostbitten from sleeping off some rum rather than from diabetes and home improvement. If a crown is just a hat that lets the rain in, perhaps the stethoscope hangs around the neck to better listen to one's heart through the white coat.
Paul Karagiannis is a 2nd year medical student at the University of Illinois at Chicago College of Medicine. His interests include narrative, poetry and the history of medicine.