Shortness of Breath, Again

On a typically balmy autumn afternoon in Baltimore City, Mr. S could barely breathe. Throughout the prior week, he had developed worsening cough and severe shortness of breath. His symptoms progressed to the point where he could not catch his breath even at rest. He had several inhalers at home, which he used to no avail, and unfortunately he did not have a primary care doctor or anyone to call. Although he knew the emergency department would help him as they had previously, he was not able to walk the six blocks between home and the hospital, so he took a bus and arrived in respiratory distress.

In the Emergency Department, he was stabilized with the appropriate medications and then admitted to a general medicine service where I met him. Before I met Mr. S, I learned a few things about him through this medical record: he had been hospitalized several times over the past few years for similar symptoms and was previously diagnosed with COPD (Chronic Obstructive Pulmonary Disease).   I could not find any outpatient clinic notes in the system for the past four years, but saw several Emergency Department and hospital notes.

When I walked into his room, Mr. S was eating dinner and seemed to be in a pleasant mood. I spoke to him at length about his symptoms leading to this hospitalization and asked how this episode compared to previous ones. He said “It’s always the same. I get worse and worse, eventually can’t breathe, and then come to the ER. I get fixed up, sent home, and everything’s fine for a couple months before it happens all over again.” Even though I was a relatively new third-year medical student, I had heard similar stories from many patients suffering with chronic diseases. However, this time, I thought I might be able to help.

I asked Mr. S what he knew about COPD and his home medications. His answer, “Not much” did not surprise me. I then spent the next 30 minutes discussing how COPD affects the lungs and how his medicines help his lungs to work better. Our discussion included diagrams, demonstrations, and most importantly, questions. Some of these questions were his, but most of them were mine. As I was explaining the basic pathophysiology of COPD to him, I reverted to my days as a high school biology teacher.

Before medical school, I spent two years as a teacher in Baltimore City Public Schools. I could write several blog entries about my teaching experience, but with Mr. S., I used my skills of checking a student’s understanding to ensure he really comprehended what I was teaching. Through this active question-and-answer dialogue, I was able to meet him at his level of understanding and fill in any knowledge gaps along the way. By the end of our conversation, I was confident he grasped the basics of COPD, including triggers and treatment strategies. For instance, he had been using his rescue albuterol inhaler daily instead of only during acute episodes of breathing difficulties, and he was not using his daily controller medication at all. He thought all inhalers served the same purpose, but after our discussion, he understood the difference.

As we were wrapping up, Mr. S. told me, “No one has ever sat down to explain any of this to me. I really feel like I can get better now for a long time. Can you be my primary doctor?” As a third-year medical student, we’re constantly changing rotations so unfortunately the curriculum does not allow the opportunity to follow patients longitudinally. I told him I would have loved to be his doctor, but could connect him to a primary care clinic near his house. He thanked me for all of the information and was discharged the next day.

Throughout medical school, many students struggle with finding a way to stay motivated because our impact on patients’ lives can seem minimal. I similarly wondered what I could really do. After all, each patient has an intern, resident, and attending physician taking care of him or her, so what could I contribute? Mr. S. showed me that medical students have something valuable that other team members do not always have: time. We have the privilege of being able to spend quality time with our patients, getting to know them as people and educating them about their conditions. Patients like Mr. S. help remind me how special being a medical student truly is.