Academic Medicine:
doi: 10.1097/ACM.0b013e3182351dc9
Other Features: Teaching and Learning Moments

The One Liner

Wakeman, Sarah E. MD

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Dr. Wakeman is a third-year resident in internal medicine, Massachusetts General Hospital, Boston, Massachusetts; e-mail: swakeman@partners.org.

Author's Note: The name in this essay has been changed to protect the identity of the patient.

I met John at the beginning of my intern year. He was transferred from the intensive care unit to the medical floor where I was working endless shifts as a new house officer. The pass-off that I'd gotten had been succinct. “Here's the one-liner—He's a 32-year-old IV drug user with hepatitis C who was admitted with MRSA bacteremia complicated by bilateral empyemas and epidural abscesses now status post thoracotomy and spinal washout requiring high doses of narcotics.” Behind the summary lurked the implicit judgment that the patient had done this to himself.

A few months later, sitting in my office clean and sober, John said that he'd read through his medical records. “Every single note describes me as a 32-year-old IV drug user. Like that's all I am, some ... junkie.” I flushed with guilt—my own note had been no different. That key opening sentence, where we're trained to distill the case and the patient down to one line, leaves little room for nuance or empathy.

I had written my admission note on John before knowing anything other than the chart's version of his life. It wasn't until later that I discovered he had started injecting heroin only three months before I met him. In an all-too-common narrative, he'd been a high school athlete prescribed Percocet after shoulder surgery. Hooked almost instantly, soon he was buying Oxycontin for a dollar a milligram on the street. He ultimately followed the well-trodden path from prescription painkillers to a cheaper alternative—first snorting and then injecting heroin.

I learned John's story in the hospital when I went to talk to him about his hepatitis C. It had been a check box on the ubiquitous to-do lists that we carry around as interns, and I walked in rather brusquely to ask if he'd ever had treatment for his liver disease. To my surprise, he burst into tears. Assuming that he was chronically addicted and infected with hepatitis C, no one from our team had bothered to tell him about this new diagnosis. As the tears subsided, he told me about getting hooked on Percocet and his recent introduction to heroin. We talked about his 12-year-old daughter and how terrifying it was for her to see her dad on a ventilator with tubes tethering his body to machines. And we talked about the possibility that he could recover, not only from his infections but also from his addiction.

John recently celebrated his one-year anniversary of being clean. When his daughter called during our last visit, he cheerfully answered his cell phone: “Hey kiddo, how was soccer practice?” But a month later, he hit a rough patch and felt that familiar tug at his sleeve. One evening, he paged me at home and told me that he wanted to use: “I feel like I'm already a piece of garbage, so why not just go get high?” In that moment of renewed despair, John was thrust back into the fear that he was worthless, a message that we had reinforced by limiting his identity to that of an IV drug user. Instead, I told him what I knew—that he was a courageous man and a good father and that he had overcome tremendous obstacles. I told him that I was proud of him. We talked for several minutes and devised a plan in which he would call his sponsor, go to a meeting, and come see me soon in the office.

I still see John monthly to check in, and he has remained clean, even on that difficult night. When he thanks me at the end of each visit, I feel as if I'm the one who should be doing the thanking. John let me into his life and allowed me to play a role in his recovery. But, perhaps more important, he taught me that there is no life succinct enough to be compressed into one line.

Sarah E. Wakeman, MD

© 2011 Association of American Medical Colleges

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