The Family Medicine clerkship asks students to identify and put to paper a key experience seen during their rotation that reflects the core principles of Family Medicine.
Reflection Assignment - Family Medicine
Melissa Weston M3
She is already sitting on the examining table, feet swinging nervously and hands collapsed on her lap. It has been two years since she last saw this doctor for a check-up and as I glance at her "chief complaint" taken by the medical assistant 10 minutes prior, I see that she has much to discuss. She looks at me from underneath her baseball cap and quickly realizes that I am not the doctor but someone else with a white coat and a stethoscope around her neck. As I wash my hands, I say something about the flu season around the corner and ask her about getting a vaccine. Although I am a complete stranger and despite her state of health, she is immediately warm and cordial. When she takes off her baseball cap, I notice that she looks a little like my grandmother; her caramel skin, coarse hair with streaks of gray, and well-worn wrinkles along the eyes and mouth. It seems to me that many of the older women of color that I encounter lately remind me of my grandmother. I wonder why that is.
We start talking and I soon realize that the last two years for my patient have been hard. When I ask her why she has not come in to see the doctor, she simply replies that she has her foster children to take care of and when things got real bad she always had the emergency room at the local county hospital. The last visit was just a week ago when her abdominal pain and constipation got unbearable. I explain to her that with a hemoglobin AIC of 13, her diabetes can ravage many parts of her body including her abdomen. She then points to her toes. "Even those", I say. Peripheral neuropathy had robbed her of their sensation. I move on to ask about the other organ systems we learn diabetes can claim. I go from head to toe. Her eyes, she says, are fine although she has been unable to get to an ophthalmologist to check. For her kidneys, I ask whether she had been urinating a lot more frequently. She nods as I check her labs for her last creatinine and microalbumin. Her blood pressure was not too high so I somehow convince myself that her kidneys must still be working. I carefully explain to her why I am asking all these questions, that uncontrolled diabetes can be a very debilitating disease. That eyesight, feeling in your feet, and working kidneys off dialysis are all things that we are fighting for together. She nods again and replies that this is why she is taking her insulin. So that she would have all of those things and be able to care for her foster children.
This is when I notice some beads of tears in the inner corners of her eyes. When I move to the health maintenance part of the exam, she looks right at me when I ask about her last mammogram. Last month it came back positive for a mass in her right breast and she has a scheduled biopsy next week. Before I can say anything else she says altogether in one sentence, "I had a benign tumor before in the 80s but I don't know about this one, my mom died of breast cancer you know." I look at her and in her eyes I catch this great sadness, perhaps some realization of her own mortality. We sit in silence for a few moments because it seems like the most appropriate thing to do. I squeeze her hand and we sit for a little longer.
We chat for a little while after but after I finish my physical exam, I do not have much else to do but step out and present the information to my preceptor. I somehow synthesize what I have gathered from the chart and in my interview and exam in the appropriate SOAP format. Here is a woman who has not seen her doctor in years after learning of her hemoglobin AIC of 13, presenting with multiple symptoms of possible end organ damage and now with a lump in her breast and positive family history of cancer. I learn then while talking to my preceptor that she also has no insurance. Not quite old enough to reap the benefits of Medicare. When I ask her how the patient would get appropriate treatment if the biopsy was positive, she mentions something about state programs and maybe Cook County hospital.
At the end of the day, I think about the patient again. I wonder if she will be able to make it to the appointment for her biopsy. If she will have to undergo chemotherapy or radiation or surgery. If she will continue to take her insulin and save her toes, kidneys, and eyes. Or if she will put her foster children ahead of her and push all of these other things out and far from her mind. And then I am reminded of my grandmother who did the same. Ovarian cancer in her 40s and she refused to acknowledge it. Instead, putting her four kids and their grandchildren in front of her. And now diabetes, as I try to remind her of the same things I reminded the patient; saving her toes, her kidneys, her eyes… Maybe I see my grandmother in many of my patients because it reminds me that everyone is a whole, complex person with family and friends that ground them. Instead of thinking of microalbumins and AICs, I go beyond just numbers and look at faces and stories and memories that make up my patients' lives. No matter how hard I try to make those numbers "look good", if I fail to acknowledge their humanity, I will never really be taking care of their health. ▪