Innovation Report 7 Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing Clinical Research. 3rd ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2007. 8 Caverly TJ, Combs BP, Moriates C, Shah N, Grady D. Too much medicine happens too
often: The teachable moment and a call for manuscripts from clinical trainees. JAMA Intern Med. 2014;174:8–9. 9 Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systemsbased practice into internal medicine
residency programs: The Interactive CostAwareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26:90–94. 10 Teaching Value Project: Costs of Care, Inc. Published January 1, 2013. http://teachingvalue. org/. Accessed November 20, 2014.
Teaching and Learning Moments Numbers and Narratives My first week in the ICU was rough. “What is her sodium today?” my attending asked on rounds. “Sodium?” I muttered with a shrug, shuffling through my notes to find where I had written it down. “130,” I answered with relief. “We need to bring that up,” he replied without hesitation. Of course we need to bring that up. I was a new third-year medical student, ready to take impeccable histories and pin down the exact stage-of-change my patient was entering on the road to smoking cessation. I quickly learned that the ICU was not a place for such absurdities. Outside each ICU room was a piece of paper, the size of a small coffee table. That piece of paper, I learned, was the gospel of data. And, like any gospel, it took time to interpret. I spent hours each morning looking up doses, calculating totals, and scribbling numbers. These data were crucial to knowing my patients: sodium levels, EVD outputs, PA pressures, and other integers that had no box on my history and physical exam template. In fact, the history and physical exam skills I learned as a warm-blooded first-year seemed to play no role in the ICU. Here, physical exams required only a few simple questions and a pinch now and again. Here, knowing integers meant knowing
628
your patient. At least that is what I presumed. One Saturday afternoon, my team entered the sterile, white room of a patient who recently had been transferred to our team. We had a new attending covering for the weekend and, per usual, he looked to his fellow. He started, “Tell me about …” looking down at the paper in his hand to remember the name, “… Mr. Roberts.” The fellow began: “Nothing overnight. His ICPs remained stable with the EVD putting out 25 cc.” “No,” the attending interrupted. “Let’s hear a bit about Mr. Roberts.” I looked at the fellow, who seemed unsurprised by this vague request. He started again: “Mr. Roberts was born in the Dominican Republic.…” For the next five minutes, I did not learn about Mr. Roberts’s sodium levels, or pupil sizes, or stool consistency. I learned he was an immigrant, a veteran, and a father. I learned that the fellow, who surely knew the gospel of this man’s data, also had taken the time to learn about and share the details of Mr. Roberts’s life. At that moment, I realized that I did not know a single patient on our list that day.
In my efforts to adapt to the strangeness of the ICU, I had forgotten what knowing a patient means—that levels, outputs, and pressures offer a narrow and imperfect picture of the person in each bed. Even in my few weeks in the ICU, I had lost sight of what inspired me to pursue a career in medicine: the unique opportunity to connect deeply with strangers in their most vulnerable moments. I wanted to be a physician who always appreciated, and learned from, the story of each patient. Fortunately, this attending reminded me that both numbers and narratives play an important role in patient care, even in the land of drains, drips, and devices. Mr. Roberts died overnight with his family at his bedside. The next morning, a new patient was in his room. This patient had the same sodium level as Mr. Roberts, but she undoubtedly had a unique story. Author’s Note: The name and details in this essay have been changed to protect the identity of those described. Acknowledgment: The author offers a special thanks to Dr. Elisabeth Wilson for her editing and encouragement in writing this essay. Kevin Padrez K. Padrez is a fourth-year medical student, University of California, San Francisco, School of Medicine, San Francisco, California; e-mail: kevin. [email protected].
Academic Medicine, Vol. 90, No. 5 / May 2015
often: The teachable moment and a call for manuscripts from clinical trainees. JAMA Intern Med. 2014;174:8–9. 9 Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systemsbased practice into internal medicine
residency programs: The Interactive CostAwareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26:90–94. 10 Teaching Value Project: Costs of Care, Inc. Published January 1, 2013. http://teachingvalue. org/. Accessed November 20, 2014.
Teaching and Learning Moments Numbers and Narratives My first week in the ICU was rough. “What is her sodium today?” my attending asked on rounds. “Sodium?” I muttered with a shrug, shuffling through my notes to find where I had written it down. “130,” I answered with relief. “We need to bring that up,” he replied without hesitation. Of course we need to bring that up. I was a new third-year medical student, ready to take impeccable histories and pin down the exact stage-of-change my patient was entering on the road to smoking cessation. I quickly learned that the ICU was not a place for such absurdities. Outside each ICU room was a piece of paper, the size of a small coffee table. That piece of paper, I learned, was the gospel of data. And, like any gospel, it took time to interpret. I spent hours each morning looking up doses, calculating totals, and scribbling numbers. These data were crucial to knowing my patients: sodium levels, EVD outputs, PA pressures, and other integers that had no box on my history and physical exam template. In fact, the history and physical exam skills I learned as a warm-blooded first-year seemed to play no role in the ICU. Here, physical exams required only a few simple questions and a pinch now and again. Here, knowing integers meant knowing
628
your patient. At least that is what I presumed. One Saturday afternoon, my team entered the sterile, white room of a patient who recently had been transferred to our team. We had a new attending covering for the weekend and, per usual, he looked to his fellow. He started, “Tell me about …” looking down at the paper in his hand to remember the name, “… Mr. Roberts.” The fellow began: “Nothing overnight. His ICPs remained stable with the EVD putting out 25 cc.” “No,” the attending interrupted. “Let’s hear a bit about Mr. Roberts.” I looked at the fellow, who seemed unsurprised by this vague request. He started again: “Mr. Roberts was born in the Dominican Republic.…” For the next five minutes, I did not learn about Mr. Roberts’s sodium levels, or pupil sizes, or stool consistency. I learned he was an immigrant, a veteran, and a father. I learned that the fellow, who surely knew the gospel of this man’s data, also had taken the time to learn about and share the details of Mr. Roberts’s life. At that moment, I realized that I did not know a single patient on our list that day.
In my efforts to adapt to the strangeness of the ICU, I had forgotten what knowing a patient means—that levels, outputs, and pressures offer a narrow and imperfect picture of the person in each bed. Even in my few weeks in the ICU, I had lost sight of what inspired me to pursue a career in medicine: the unique opportunity to connect deeply with strangers in their most vulnerable moments. I wanted to be a physician who always appreciated, and learned from, the story of each patient. Fortunately, this attending reminded me that both numbers and narratives play an important role in patient care, even in the land of drains, drips, and devices. Mr. Roberts died overnight with his family at his bedside. The next morning, a new patient was in his room. This patient had the same sodium level as Mr. Roberts, but she undoubtedly had a unique story. Author’s Note: The name and details in this essay have been changed to protect the identity of those described. Acknowledgment: The author offers a special thanks to Dr. Elisabeth Wilson for her editing and encouragement in writing this essay. Kevin Padrez K. Padrez is a fourth-year medical student, University of California, San Francisco, School of Medicine, San Francisco, California; e-mail: kevin. [email protected].
Academic Medicine, Vol. 90, No. 5 / May 2015
