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Learning How to Learn on the Wards

Thom, Robyn MD

doi: 10.1097/ACM.0000000000001229
Teaching and Learning Moments
AM Rounds Blog Post

R. Thom is a second-year psychiatry resident, Harvard Longwood Psychiatry Residency Training Program, Boston, Massachusetts; e-mail: rthom@bidmc.harvard.edu.

Author’s Note: The names and details in this essay have been changed to protect the identity of those involved.

An AM Rounds blog post on this article is available at academicmedicineblog.org.

“Mrs. C’s blood pressure is 90/60. Her other vitals are normal.”

“Let’s bolus her and recheck,” I said. Mrs. C was a 97-year-old Chinese-speaking lady who had been hospitalized for a urinary tract infection. Her course had been uncomplicated, and the plan was to discharge her the following morning.

An hour later, my pager read, “Pressure is 66/33.” I sent my senior resident an urgent page and ran up to Mrs. C’s room. She was febrile and barely rousable. We ran more fluids, initiated the workup, and called her son to ask him to consent to a possible ICU transfer. He declined to come to the hospital but made it clear that she should be full code.

A rapid response was called, and Mrs. C’s room filled with people—nurses dashing in with IV needles, ICU residents jostling to auscultate her chest, and techs barking off her deteriorating vitals. My stomach filled with fear. I had never seen a blood pressure so low, and although I had the differential for shock down cold, I felt utterly helpless. As the room filled with briskly moving senior residents, what I could contribute as a medical student felt trivial. Surely she was in good care, so I turned to start my next admission. The prospect of completing the familiar steps of taking a complete history and physical was comforting. At least this was something I knew how to do. I edged towards the door, but my resident grabbed my arm and said, “Stay with her.” So I stayed and helped in the small ways I could. I comforted Mrs. C in Chinese and relayed her clinical course to the ICU team. With fluids, she became more alert, and when a nurse attempted to place a urinary catheter, she said clearly in Chinese: “I don’t want this. I forbid you to do this. No more medications or needles. I’d rather die than continue like this.” As the only Chinese-speaking person in the room, I translated her words aloud, and the team, focused on providing lifesaving treatment, hesitated momentarily but continued on.

It was 3 AM, but I felt compelled to call her son again. I pleaded: “I know it’s late but your mother is deteriorating quickly. She is really distraught and needs you here.” He agreed to come in but wanted assurance that his mother would receive “everything.” When he arrived, Mrs. C was resisting the nurses who were valiantly attempting to place lines and tubes in every orifice. Her son looked at me and said, “I don’t think she wants this.” The team stopped. We ran fluids and antibiotics in the lines we had already established but did not pursue pressors or any other invasive measures. She died a few days later.

Reflecting back, Mrs. C was the first patient who taught me what it means to learn medicine on the wards. I had always thought that learning on the wards meant executing knowledge that I had learned from books, but Mrs. C taught me that medical decisions do not come just from books and that learning opportunities can come from surprising and uncomfortable places. If I had left her room that night, I probably would have read about septic shock. What I would have missed out on, though, was learning how to advocate for a patient’s wishes in a situation as it developed. Since that night, I have attempted to embrace rather than shy away from the discomfort of the unfamiliar. Doing so, I have come to understand how I can participate in and learn from providing care, even as a junior trainee. Listening to the patient is usually a pretty good place to start.

R. Thom

is a second-year psychiatry resident, Harvard Longwood Psychiatry Residency Training Program, Boston, Massachusetts; e-mail: rthom@bidmc.harvard.edu.

© 2016 by the Association of American Medical Colleges