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The Importance of Gaining Insight

Michaelson, Nara Miriam MD

doi: 10.1097/ACM.0000000000002665
Teaching and Learning Moments

N.M. Michaelson was a fourth-year medical student, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, at the time of writing; email: She is a first-year neurology resident, New York-Presbyterian/Weill Cornell Medical Center, New York, New York.

Author’s Note: The name and identifying information in this essay have been changed to protect the identity of the individual described.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

As a fourth-year medical student at Dartmouth-Hitchcock Medical Center, I met Paul. He arrived by helicopter for stabilization of a large variceal bleed and was completely encephalopathic from long-standing alcoholic cirrhosis. I could barely breathe while I examined him. The smell of rum was overpowering; it clung to my white coat and remained hours later. Unable to answer questions coherently, Paul remained a mystery for the first few days of his hospitalization, until his mental status began to clear and his personality—with a keen sense of humor—began to show.

In between his various endoscopic ligation procedures, I learned more about this man. He was in his early 60s and worked in construction with his three sons. Ironically, his biggest concern early on was how his sons were going to manage the family business while he was being treated. I needed to remind him repeatedly that he wasn’t going to be much help in his current state. And if he really wanted to get back to his job, he needed to allow us to do ours, to which he reluctantly agreed.

The other main topic of our conversations was whether he was interested in rehab for his alcohol addiction. The first time I brought up rehab he acted as if he didn’t hear me. Thankfully, a nurse was also in the room and asked him, “Did you hear what she just said?” I tried not to be overbearing but told him that I would continue to bring up the topic with the hope that he would change his mind.

One day when I was sitting and chatting with him, he told me what led him to start drinking at a very young age, ultimately setting him up for a lifetime of addiction. When he was about 10 years old, he was sexually molested by his uncle. Alcohol was the only way that he knew how to cope and continue functioning. He said that he had never told anyone until that day.

I believe it was my genuine effort to understand him on a level beyond his medical imaging, his electrolyte levels, and his hemoglobin values that led him to trust me. At first, I was saddened by the disclosure, thinking of what he must have endured, the undeserved guilt and loneliness. My thoughts turned to the countless friends I know who have also suffered physical and sexual abuse and how it is such a common yet rarely discussed issue in our society, spanning all demographics. But I had a sense that this step was his first towards overcoming his past and achieving empowerment. I shared with him one of my favorite adages, “Patients don’t care how much you know until they know how much you care,” and thanked him sincerely.

Looking back, it would have been so easy to stereotype him and blame his alcoholism on some moral failing. He was, in reality, a victim trying to regain a sense of normalcy. His family later told me that he was often made to feel ashamed during his previous hospitalizations because of his addiction.

A few days before discharge, he told me that he was finally ready for rehab and asked me for some numbers to call. “I’m going to be doing a lot more fishing,” he said with a smile, telling me about the new ways he wanted to spend his time instead of drinking. During our conversations, I gained insight into Paul, and Paul gained insight into himself. And I realized that insight is contagious. I’m hoping we’ll have an epidemic soon.

© 2019 by the Association of American Medical Colleges