As I leaned back in my chair with my hands crossed triumphantly behind my head, I proudly stared at my empty white board. When I had first arrived for my shift at 10 p.m., I couldn’t have imagined this moment of victory, as the emergency department was bustling at that time. Yet, here I was, basking in the glow of my conquest. It was 4 a.m., and I had won the game.
The Patriots were 18-0. Mike Tyson was on top of the world. The Soviet Union had the best hockey team in 1980. But the New York Giants, Buster Douglas, and the USA Hockey Team didn’t care. Neither did my patient who checked in at 4:15 a.m.
The name appeared on my trackboard, and I was immediately annoyed. They ruined my night. “58F” read the demographics. Well, maybe they’re having chest pain or a stroke. Maybe it’s emergent. And then the final blow was dealt in the form of the chief complaint. “Vaginal bleeding.” Dammit. “x 8 months.”
This wasn’t a great story of an upset anymore. I was Oberyn Martell, dancing gracefully through my night, dodging admissions, striking discharges, feeling joyfully victorious. Until The Mountain – My Mountain – showed up at 4:15 a.m. As the weight of this 58-year-old female’s invisible hands slowly crushed my skull, I remember thinking, Why are you here?
This world is full of wonder, and when wonderment fills us, we tend to ask questions about the mysteries of life, or of other people. Hoping to stumble upon explanations and further our knowledge, we search, listen, and wait patiently as clarity emerges from our sources. This was not a time for wonderment, however. When I presented this case for the first time during a Grand Rounds lecture, the room filled with audible groans as I revealed each section of the chief complaint. Of all times, of all patients, of all chief complaints, of all durations. The worst.
I was annoyed. The patient had ruined my night. My perfect score. My celebration. With this: 58F vaginal bleeding x 8 months. I didn’t have to wonder about this patient. I didn’t want to wonder about this patient. Neither did my nursing staff. Meeting their eyes and performing a synchronized eye roll, I turned back to my computer.
I opened her chart expecting to encounter “anxiety” in the past medical history. Nothing. I opened the previous notes to see what other torment she had caused to others in my department. No prior visits. Ah, she’s been hospital shopping. At that moment, I recognized I felt it: that feeling inside when your thoughts are leading the way, boiling up and creating internal tension. I took a breath. I’ve been doing this long enough, I know it’ll be nothing. Deep breath. At least she’s not keeping you away from patients that need real help. Deep breath. At least the visit will be quick. Deep breath. I composed myself and entered the room.
She was not the demanding patient I expected when I walked in. In fact, she was smiling quietly. Her husband sat closely by her side, but he wasn’t the coddling partner I had expected either. She had been having light spotting for almost a year. I asked if she had told her doctor about it. “I haven’t seen a doctor in ten years. I have a hard time trusting them.”
As I performed her physical exam, she told me she appreciated me seeing her at such a strange hour. Huh. We developed a rapport and as I felt more comfortable, I sat down next to her as I contemplated how to deliver my —
“Do I have uterine cancer, doctor?”
“You know that’s the concern?”
“My mother had uterine cancer when I was very young. It killed her.” Please return your seat backs to their full upright and locked positions. I was transformed into Ed Norton in Fight Club when he starts to realize the truth.
“Why did you come in tonight?” She knew what I was asking. I was asking why she was there, but with wonderment this time. I wasn’t presumptuous or upset like I had been before meeting her. She was a reasonable person, and there had to be a reasonable answer.
She hadn’t had a period in 8 years. At the first signs of spotting she grew anxious. Her fear of doctors kept her away. She had always felt judged when she’d gone to a doctor: told she wasn’t doing something correctly in her life, felt she was wasting their time. I had felt she was wasting my time. With more time, she had become less concerned about the doctors, and more concerned about the diagnosis. Having cancer scared her and she didn’t want to know the truth, even though she already knew it. And as more time passed, she began to feel shame that she hadn’t been checked out in the beginning, despite predicting her potentially fatal diagnosis.
“But tonight, I couldn’t sleep because I was worried. And I woke up my husband because I didn’t care about the shame or the fear anymore, I need to know so I can get treated.” The 58F VB x 8 months suddenly became the woman who finally developed the courage to face her greatest fears and was trusting me with her care.
Since that night, I have begun to think about questions more, both those from my own mouth and from others’. Questions like “how could anyone act that way?” and “why would they do that?” are often not questions at all, but incredulous statements disguised as questions. The truth is, everyone has a reason for the things they do in life, and most of the time, we will find their reasoning to be fully understandable if we ask the questions with wonderment. However, we encounter problems when we ask questions with a presumption that we already know the answer. Worse yet, when we take people’s actions as personal attacks, as I had originally done that night, we often close off that path to wonderment.
My mind had played tricks on me. My patient’s presence had initiated a sequence of thoughts that made me feel like she had ruined my night. But I know I’m not alone in those reactions, given the groans I heard during my lecture. It’s ok, the brain does weird things. Stephen Covey has written extensively about the difference between reactions and response. I could have dismissed her, and truthfully, on another night, or at another time in my life, I might have done just that.
But I thought about it. This woman had never trusted another doctor, and I wasn’t sure she trusted me yet either. I was fairly confident that she had uterine cancer, based on probability. And there was a chance if I didn’t give her what she needed that night, she may not have the courage or trust again until it was too late. This may have been the last chance the medical system got with her.
I did not perform any testing on her, but I kept her in my department for a couple of hours, until it was a reasonable time to call my OBGYN colleague. I led by telling them I didn’t need them to see the patient today, but I was hoping she could be seen soon so she could have the testing she needed. We scheduled an appointment for the next week.
The next week, she saw her second doctor in ten years. That doctor diagnosed Stage I endometrial cancer and performed an uncomplicated hysterectomy the next week, which cured her condition. She then established primary care with another physician and has followed up regularly since.
There is almost always a reasonable and understandable answer if we ask questions without presuming. And while developing presumptions is often our default, entering conversations with those presumptions will often lead to unhappiness, distrust, and frustration on both sides. I am by no means perfect, but I am working on asking questions with more openness. Asking “Why are you here?” can come from a place of irritation, or of wonderment; and I’ve recently seen the beautiful benefit of choosing the latter. That approach has helped me not only at work, but in life.
While I did not perform an acute resuscitation on the only patient in my emergency department at 4 a.m., I am still rewarded by the belief that I saved a 58-year-old female’s life that night.
A fantastic account of what too many of us in the medical field will do at one point in our lives. People come in afraid and scared of what we may or may not find wrong with them.
You are a good doctor and you care. Thank you for telling this story. I hope I can become a better nurse and person from having read this.
Sanjay, what a great piece to read. I was unsure of how the story would wrap up, but I too believe you saved that woman’s life. For without you, she may have never trusted even ONE doctor. Congrats on this well written piece.
Always has and always be one of the best ED attendings I know. I still compare every ED physician who I work with to him…and am sure I always will.
Thank you, Sanjay, for being open and honest and sharing your experience. If we all follow your lead, as you said, we will be better nurses, friends, family members and individuals as a whole. You’re an Amazing doctor and every patient is lucky to have you.
Wow !! You are an amazing Dr. This is something we should all think about in our career and in life. Thank you for sharing.
“There is almost always a reasonable and understandable answer if we ask questions without presuming.”
This is a great mindset to have, beyond the field of medicine. It was a privilege to work with this physician some years ago.
You are a great DR!!!!!
Empathy and curiosity are so important in our work. Thank you so much for putting in words the importance of both.