Several weeks of fevers and fatigue. Prosthetic heart valves. Recent dental work. What’s your differential diagnosis? Don’t anchor, I told myself, try to think of possibilities other than endocarditis.
It was the second day of my internal medicine clerkship and my first full rotation of my third year. I was excited, albeit a little apprehensive about the notoriously demanding internal medicine clerkship. I picked up a patient on my first day, but the patient sitting in front of me was my first admission, my first chance to see a patient through an entire hospital visit. She arrived with her son, who helped fill in the gaps in her story. I learned not only about her current illness, but also about their difficult year. The patient’s father recently died a few months before, so she had initially attributed her fatigue to the stress of his death. She presented now because her symptoms had persisted for so long.
I diligently asked her about her fatigue and fevers with the OPQRST mnemonic as I had been trained to do for the previous two years. I checked all of the boxes: past medical history, surgical history, family history, social history, medications, and allergies. As we talked, my differential diagnosis started to arrange itself, with endocarditis at the very top. In medical school, we often learned the typical presentations of diseases as “stories”, and her symptoms matched the “story” of endocarditis almost exactly as I had learned it. After I left the patient’s room on the first day, I was excited not only about the educational experience, but also about the opportunity to hear the patient’s own story beyond her symptoms.
We quickly diagnosed her with endocarditis and followed the blood cultures closely. I saw her twice a day, with a shorter pre-rounding visit in the morning and again for a longer visit in the afternoon. As a medical student carrying only 2-3 patients (a luxury), we chatted about many topics outside of medicine and I got to know her as a person rather than as the patient with endocarditis. We talked about her cats, my apartment hunting, and everything in between. I even met her family when they visited. At one point, she told me that she had waited to talk to me about a noisy infusion pump because she “knew I would actually do something about it”. I felt like a doctor that day.
On the day of her heart surgery, I anxiously checked her chart all day for any updates. When I saw a brief post-operative note, I breathed a sigh of relief. Everything had gone well. I went home that night with a weight lifted off my shoulders.
The next morning, I looked in her chart again to find her new room number. She had switched off of our team, but I hoped to visit her later that day. However, when I read the final post-operative note, my heart sank and my stomach twisted into a knot. As they were preparing to leave the operating room, her blood pressure dropped and they were unable to get it back. She died without ever waking up from the surgery. As I read the matter-of-fact details in the note, I pictured the entire scene in my head, and thought of her family members anxiously awaiting news in the waiting room. My heart broke for them.
That day, I had a hard time concentrating on my other patients. When asked about the complications of cirrhosis, I couldn’t think of a single one. We had done everything right, I thought. What else could we have done? I cried when I got home.
In the days afterward, I tried to come to terms with her death and what it meant to me. We had done everything right: the diagnostic workup, the consultations, the medications, and yet, it wasn’t enough in the end. I objectively knew before starting medical school that there would be situations in which, despite our best efforts, the outcome wouldn’t be a happy one. However, I wasn’t prepared to learn this lesson first-hand so early and so unexpectedly in my third year.
I will be forever grateful that I got to play a small part in her care. In caring for her, I cared for myself. After spending countless hours studying, seemingly without end, during my first two years of medical school, I finally had the opportunity to experience how truly rewarding medicine can be. I am thankful to have experienced a relationship strong enough to make my heart ache as it did.
Talking with her every day reinforced why I wanted to go into medicine in the first place: to form meaningful relationships with patients. Medicine is about stories: the story of your patient’s symptoms, which you take and reconstruct into a different type of story to communicate to your colleagues and document in the medical record. Then there is the equally if not more important story of how the patient’s current symptoms fit into the larger story of their life. It is our responsibility as physicians to hear not only the first type of story, but also the second. I had the privilege of hearing a tiny portion of my patient’s life story every day, which over the two weeks I knew her, built itself into a substantial narrative that I will carry with me for the rest of my training and career.