An Interesting Case

"Go meet Dr. Patel in clinic. She's seeing a patient of mine that I think would be good for learning. We're trying to decide whether she has acute or latent TB."

This is what he had been told, and like a good medical student one week into the medicine rotation, he scampered outside, through the snow, and up the stairs to the doors of the clinic.

"Dr. Patel's already in with the patient."

So down the hall and opening the door on his left he slid into a rather small room where the patient was seated in conversation with Dr. Patel.

Dr. Patel was gathering history. Have you any night sweats? fever? weight loss? hemoptysis? No, none of that, she said. She had had a hard life. Extensive medical history compounded by the common American co-morbidities. Any imaging? She thought she had some, but couldn't remember. On and on the history taking went. He picked up her medical records and glanced through them as the chatter continued.

Extensive psychiatric history. Well, given her history, who could blame her?

What did she do for a living again? Disability now, entrepreneur or something like that. They all failed though, her businesses. What were her businesses? He didn't ask.

She had been possibly been exposed to TB when she was a nursing student in the past.

Wait. What?

And then it clicked. He had seen this woman before. She did not recognize him. His memory stirred. Where?

The Ward.

She had wanted to kill herself. She was much more upset back then. He had tried to ask her about her history. She had snapped at him. Too many questions. Why did he want to know? She had left the ward and was supposed to go home but had disappeared according to police reports. That had been the last time he heard of her.

But here she was now. Sharing bits and pieces of a history not so unfamiliar. More psychiatric than medical in some ways, and more human than anything else.

Her most recent imaging turned out to be quite unremarkable. Disappointing from a medical standpoint. She would need further testing and there was no point in risking medication side effects when she was completely asymptomatic and without proper supportive imaging.

Walking back to the hospital, he thought about what she had told him before he left the room. She had told him that he would be a good doctor.

"You have a certain way about you, how you conduct yourself."

Really? Is that all there is to it? He had thought to himself. She didn't know him--just like he didn't really know her. The absurdity.

And then he remembered that this was supposed to be an interesting case. It had been, but not in the sense that he had expected--not medically or in a psychiatric dimension. He couldn't quite put his finger on how it was, and it bothered him. Another time, he would have to revisit it. Perhaps it would make sense then. In the meantime, another morning case presentation. 54 year old woman with a history of diabetes, hypertension, hyperlipidemia presenting with chest pain...

Matthew 26:6-13

And it came to pass that a doctor was on duty at the charity clinic sitting in the office talking with her colleagues when they were interrupted by a nurse

“Doctor, there is a patient here to see you.”
“Oh?”
“Yes, she is in the front right now.”

So the resident left the room and came back several minutes later bearing a fruit basket and a bag of cupcakes.

“Look, the patient I delivered a week ago remembered my birthday and came by with these. Aren’t they beautiful? I feel bad because these are so nice and she shouldn’t have spent money on me like this.”
“Aww, how sweet,” another one of her fellow physicians commented.
“Yeah, and she also had brought me cake and cookies when I delivered her in the hospital. She really shouldn’t have.”
“That’s a nice gesture indeed,” their attending remarked, “Those fruit baskets are really expensive. She probably shouldn’t have even bothered.”

This last physician said this because he knew that this patient had a couple of other children to support and received monthly public aid checks--the same checks that paid for her expensive new cell phone, cigarettes, and the oral contraceptives that enabled her to carouse around with whomever, whenever. Such purchases often left the patient unable to pay her cell phone bill, which prevented the physicians from being able to contact her and follow up during her prenatal care. This was troublesome because her baby had a condition that needed consistent monitoring to ensure that it did not get worse. Of course, all of this was made possible by taxing other economically-burdened citizens who were struggling to make ends meet on a daily basis.

One of the nurses came in to the room.

“Wasn’t she sweet? She even brought cupcakes for the nursing staff. You know, it’s people like this that really uplift our spirits because so many of the people in this clinic just aren’t very grateful.”

And all of them could agree on this. Gratitude was a scarce commodity in the charity clinic. One would think that those without any health insurance would be extremely grateful for the services they received at no cost, but the reality of this situation was that many of them were non-compliant, refused to make lifestyle changes, and would simply come back with a sense of entitlement that would make even the most sympathetic health care provider shudder.

Despite this sobering reality, this was still a day to celebrate and be thankful. The doctor asked one of her colleagues if she wanted to split a cupcake and the other happily obliged.

Marginal Zone Lymphoma with Recurring Abscess

This past Monday I met a marginal zone lymphoma patient and his wife. He had long grey hair that looked like it had seen better days and suspenders that one might find on the old college professor. The first question he asked after my attending introduced me was “So where are you from?”

Here in Central Illinois, my ethnicity is a conversation starter for the predominantly white population. Thanks to desensitization, my hairs no long bristle at the broaching of this topic.

Quickly understanding the question’s intent, I skipped the “Chicago suburb” formality and answered, “My parents are from Taiwan.”
“Oh.” he says, “The reason why I ask is because 12-14 of my students are Chinese. I teach piano.” And as he said this, his long, sinewy fingers played the invisible Steinway as fluidly as one could imagine possible.

The bulk of the appointment dealt with a persistent abscess that had developed in his right lung unrelated to the cancer. Though his cancer had remitted, this pulmonary lesion periodically forced him out of commission. We talked about the limited nature of antibiotics and the possibility of surgery. Our patient obviously hated how his illness forced him to cancel teaching. He pointed to his suspenders as evidence of the amount of weight he had lost over the last year.

On their way out, I felt compelled to speak with our patient again. I asked him what type of piano he taught. “Classical,” he answered. “I used to teach at universities.” When I asked him where, his wife quickly chimed it “He graduated from Julliard.” Her voice dripped with the kind of pride that remembers a spouse’s greatest moments.

I briefly told them about my musical background, and how I had a piano teacher who passed away from cancer. Before I could explain to him just how much she had meant to me, I had already begun to recall the bittersweet memories of our final lessons together. Even as the couple walked away, I could feel my dry hands chapped from freshman year gymnastics—because it always started with the hands—and those frustrated admonishments for not putting in the necessary practice. I could hear her pleading yet stern hoarse voice telling me that I needed to stop wasting both her and my time. I remember being at my sister’s condo on Michigan Ave. when I found out that she had passed, and I remember attending her funeral at her suburban Lutheran church, my back pressed up against the brick wall in the rear listening to her son uncontrollably weep in the middle of his testimony.

But of course you can’t tell all of this to a patient because life must go on (and lest we forget, the insurance companies will certainly remind us). As we age, we learn to be content with vignettes—if we’re lucky short stories—from each individual that steps through the door. Our fellow man, therefore, gives us snapshots by which we extrapolate the past, and we, in turn, are endowed with a memory through which we begin to move forward in the present.

And for a moment I found myself speechless, wishing that time would stop and let me ponder all of this further. Unfortunately, time halts for no one, and as we began to move on to the next patient of the afternoon, I gave thanks for the people that imbue our lives with meaning