To Render the Lives of Patients

To Render the Lives of Patients* Rita Charon This is die first CPMC Columbia Presbyterian Medical Center admission for this eighty-diree-year-old woman with a chief complaint of syncope. The patient was well prior to admission with no history of heart disease, diabetes, seizure disorder, stroke, or odier neurological abnormality. She was on no known medication and she neither drank alcohol nor used illicit substances. On die afternoon of admission, she was found unconscious on the sidewalk in front of her house and was brought to the Emergency Room by ambulance. The diird-year medical student was presenting a case to me at attending rounds. It was 10: 00 A. M. He looked tired, his whites rumpled, his strong features blurred from die night without sleep. This woman was "his" patient. He knew that he was important to her and that his superiors would judge his competence on die basis of the care he provided. Hence, he hoped for a good outcome for her sake as well as for his own. When he had first met her in die Emergency Room he had felt proud, protective, and terrified of her. Social history: the patient is a German immigrant who lives alone in an apartment in an elevator building. She has no help with activities of daily living. She has no family close by. Their night togedier had not been an easy one. The patient did not want to remain in die hospital, and every step of the admission process was complicated by her refusal to cooperate. Instead of die professional * With one exception (see Note 5), the students and patients described in this essay are composites, and their stories have been sufficiently embellished to protect their anonymity. Literature and Medicine 5 (1986) 58-74 C 1986 by The Johns Hopkins University Press Rita Charon 59 interview and physical exam the student had hoped to perform, he had ended by bullying and threatening the patient's history and physical findings from her. He had had to tie her arms to die bed to draw her blood. Physical exam: blood pressure 170 over 100; patient did not cooperate for orthostatics; heart rate 96 and regular; respirations 24 per minute; and temperature: diermometer refused by patient. Mental status: patient alert and oriented times two; she was oriented to person and time but thought she was in die police station. Mood, hostile; affect, agitated. No evidence of thought disorder, no evidence of hallucinations, but positive paranoid ideation and combative behavior. By morning, the student was defeated by this elderly woman. Instead of feeling compassionate and helpful toward her, he felt only angry and fed up. He had been reduced by this night on call and blamed the patient for his failure. She had willfully wronged him, and he wanted revenge. Formulation: new onset syncope in an elderly woman widi no known cardiac or neurological disease who presents with an abnormal mental status. Must rule out arrhythmia, MI, seizure disorder, TIA, intracranial mass or bleeding, meningitis, dementia, psychosis. Plan: serial EKG's and enzymes, Holter, LP, CT, EEG, dementia work-up, psych consult. Haldol 1 milligram IM q8h prn agitation. Begin plans for nursing home placement. It may have been, I mused as I listened to this case, that die woman was more intact than she appeared to be to die admitting team. After all, admission to a hospital can be frightening and disorienting, especially for elderly patients who rely on familiar surroundings and routines for balance. Yet the doctors' impressions could lead to drastic changes in her life. I wanted to know what she thought had happened. How would she have told die story? "Paul, present that case in the first person. Tell it asif you're die patient, and explain to me what happened before you fainted, and what you think is going to happen next. " "But I don't know what happened before she fainted. " "Well, then, make it up. " 60 LIVES OF PAHENTS The student was floored. Never before in his medical training had he been asked to use his imagination. He didn't have a practiced routine with which to fulfill my request. Nor did he comprehend die. . .