Head Above Water

In the week after my USMLE Step 1 exam, I forgot the endless medical factoids I had spent months cramming into my tiny brain much like a patient being induced into general anesthesia – slowly, then all at once. As such, it was with much trepidation that I approached the first day of my family medicine clerkship. I was thoroughly intimidated by the fact that any type of patient could be waiting for me on the other side of the exam room door. I would have to somehow earn their confidence, not trip over the pesky rolling stool, and conduct a focused history and physical without revealing the true extent of how much of a medical neophyte I really was. I hit the ground running my first day, eager to leave the lecture hall behind and experience true “cradle to grave” medicine. I had all my bases covered – or so I thought – as I arrived early, crisp white coat bursting with thoroughly unnecessary tools and references. I spent 20 minutes getting lost in the clinic corridors before finally finding my patient. I mistakenly excused myself from the exam room thinking that he was the wrong patient, then went back to my preceptor’s office to confirm that “yes” (you idiot) he was indeed the patient I was supposed to be seeing, and “he just looks really young for having all those problems.” My medical career certainly felt closer to the grave than the cradle on that day.

Even so, I progressed, learning each day how real life medicine – and real life patients – functioned. I caught a systolic murmur on a postpartum mom. I handed an adult daughter tissues while her aging mother was diagnosed with Alzheimer’s dementia. I was lucky enough to see two deliveries during my morning with the residents in the newborn nursery, and was the third set of hands that wiped the fluid off a newborn boy’s body and suctioned his nose and mouth. As I progressed through the clerkship, the quality of my days depended less on the number of pimp questions I got wrong or errors I made in my notes, and more on the new and meaningful interactions I had, whether with patients, peers, or attending physicians. But one patient encounter in particular stands out for me, and marks the first time I felt I may have made a difference.

Mr. S was booked as the last visit of the day, and after a relatively uneventful afternoon the final patient intake sheet landed on my preceptor’s desk. In the time it took for me to close my review book, he’d already given me the summary.

“Male in his forties. I’ve seen him before. Looks like he’s in for an ER visit follow-up. Uncontrolled type 2 diabetic, won’t go on insulin. His A1c is 12.4, up a point from last time. Go see what’s up.”

Charged with my task, I set out through the clinic corridor at a good clip, now familiar enough with the landscape to know exactly where I was going. Tending to the first order of business, I asked him about his recent ER visit. I listened as he recounted to me every detail of his harrowing near-death experience being caught in an ocean rip current. He was noticeably shaken just talking about his experience, and continually referenced his rescue as “a second chance at life.” In that sentiment, I saw my chance to act. I didn’t want to just kick the can down the road as I had seen done with so many other uncontrolled diabetics. The stakes here were much too high. I saw in this encounter not only a man who had been given second chance at life, but a chance at change.

After reassuring Mr. S that his recent chest X-ray was normal, with no signs of residual fluid or damage, I transitioned to reviewing the results that were a bit more concerning – those regarding his blood glucose control. Oral medications and lifestyle changes were not sufficient, and his primary care physician had been pushing him to start insulin for nearly a year. One by one, we worked together to break down the barriers leading to his refusal of insulin treatment. He worried it would poison his blood cells. I reassured him it would not; insulin is a normal hormone in the body. He worried he would become addicted. I reassured him that insulin was in no way, shape, or form addictive. We continued back and forth for what felt like an eternity, until I could sense his guard surrounding insulin slowly coming down.

Finally, we got to what was perhaps the most salient barrier – the need for daily self-injections. He balked. I’d made too much progress to give up now, and in a last-ditch effort I told him about my childhood friend with Type 1 who diligently managed her sugar checks and injections since her diagnosis at age 11. What I thought to say next was a bit risky, and I think that I was incredibly lucky that it resonated as it did: “if an 11 year old kid can manage injections, what’s keeping you – a grown man – from doing so?”

Mr. S eventually agreed to begin insulin injections that day, at first just a dose of long-acting insulin at bedtime. We set him up with a diabetic nurse educator appointment for later in the afternoon, and he was sent out of the clinic with instructions to go pick up the kit from the downstairs pharmacy and return for a session on how to use it. I honestly don’t know if he ever returned for that second appointment that day, but I like to hope that he did.

During family med, I’ve learned that the way in which I interact with others makes a true difference in patients’ lives in a way my factual knowledge base never could. Explaining to this man how the ailments occur as a consequence of being diabetic can be just as deadly as drowning is something that nobody could have ever taught me in any lecture or quiz, yet it was one of the most fulfilling moments of my third year so far.

While I don’t deny sometimes feeling overwhelmed by the rigors of medical school, these moments, as well as the support of my friends and colleagues, help me stay afloat.