© The Regents of the University of California, 2015
By Jeffrey Chen, MS1
To protect patient privacy, the name and some details of the patient in this story have been changed.
“Kelly Crown is a 48 year old woman presenting with a history of rhabdomyosarcoma in her right leg. She’s in the hospital today for her third cycle of chemotherapy.”
In the medical world, this is how almost any patient presentation begins. Medical students across the country learn how to introduce their patients to more experienced physicians in a set fashion, starting with the identification (ID) and chief complaint (CC).
What was incredible about this particular presentation was that it was only our second week of medical school. We’d just received our white coats, and already, we were going up to the hospital and learning to interview patients as part of our Foundations of Patient Care course.
The main purpose of this inaugural interview was to elicit what doctors call the patient’s explanatory model of illness. As we took the elevator to the 14th floor of the hospital, I reviewed the key parts in my head. Don’t forget to ask her if she’d prefer Ms. Crown or Kelly; try to understand her perspective of being in a hospital; and be sure to ask her what she thinks caused her disease!
As my eight colleagues and I filed into the small room, our patient watched us with weary blue eyes.
“Hi, Ms. Crown, I’m Jeff Chen, a first-year medical student learning to interview patients, and these are my classmates and instructors. First off, what do you prefer to be called?”
She smiled, reaching out to my extended hand. “You can call me Kelly.”
With the initial rapport established, I went on to ask what brought her to UCSF. As the interview went on, our patient revealed her story, bit by bit, unraveling the steps she took to get to the hospital. Kelly first started feeling pain in her right leg about a year ago while walking up some steps near her home. At first, she ignored it, but the pain eventually got so bad that she went to her doctor.
However, her doctor only added to the problem. Kelly had a history of abusing drugs and using methamphetamine. Her doctor, she state, passed off her pain as an attempt to get prescription painkillers, leaving the tumor in her leg to grow for nearly half a year. Finally, a local surgeon diagnosed her cancer and sent her to UCSF for treatment.
I asked her how she’d been getting to the hospital. She began to explain how her two kids would drive her and sometimes bring their children along. “But I can’t stand to watch my grandkids see me in so much pain….” she stammered, tears beginning to roll down her face.
Who would have thought my first-ever patient interview would be so charged with emotion? But here we were—Kelly quietly sobbing, the whole room somber. I put a hand on her shoulder, comforting her while struggling to hold back my own tears.
For the rest of the interview, our patient told us about her triumphs and her fears regarding her treatment. There were no guarantees that all the chemotherapy would work, but she was trying her best to stay strong, even in the face of a potential amputation. Her parents were coming to visit every now and then, and she was going home the following day.
As time ran out, Kelly ended with a clinical pearl on the doctor-patient relationship for us: “Be sure not to distrust your patients. We’re not all just after drugs.” We thanked her for sharing and went back to the classroom to debrief.
“When I was in first year, the curriculum was all basic sciences; no real patient contact,” recalled Sandy Mills, MD, a preceptor in our course small group. “So once third year started, many were not comfortable with the patent care team.” I realized how lucky we are to be given the opportunity to have these early experiences. I was struck with utter humility—for the privilege of hearing Kelly’s story, for the guidance from my classmates and preceptors, for the ability to take the lessons learned and better care for my future patients. Before the proverbial fire hose of medical knowledge, before learning the alphabet soup of the rest of the medical history (HPI, PMH, MEDS/ALL, SOC Hx, etc), we were given the chance to connect with real patients and to learn from them.
Since that first interview, we’ve learned the remaining parts of the medical history. The five other students in my group have had a chance to interview a patient, debrief, and receive feedback from fellow students and preceptors. Over the next year and a half, we’ll be working together to hone these skills in the best way possible: by talking to patients.
“The value of early experience is that it connects your learning to real people,” stressed our co-preceptor, Michele Francis, LCSW. “I hope that it adds a dimension of humility and humanity to what you are learning in the classroom.”