On the best evaluation I received during my medicine clerkship.

“Sick or not sick?”

This is one of the many phrases that I learned quickly during my third year of medical school. Hospital teams use it as a shorthand to decide who to round on first in the morning, who needs immediate attention, which patient gets the first echocardiogram of the morning.

Of course, most patients in the hospital are sick by definition, but most of them look not sick. It’s not a perfect shorthand, as any connoisseur of television medical dramas knows because patients can be conversational one minute and coding the next. But the visibly sick patient, especially the patient appeared who appeared not sick upon admission - that patient demands another physical exam, an additional set of labs, a new CT scan. That patient is the one that can easily spiral. That patient may not make it till tomorrow.

I met Mr. J on my first day on the general medicine team at a hospital I had never worked at before. His wife of 32 years had brought him in because of an acute change in his mental status. At baseline (another colloquial phrase meaning what the patient was like before entering the hospital), he was conversational but bedbound due to a previous stroke. When I met him, he was lethargic and confused. He had difficulty speaking and answering our many questions. However, looking at him, he was not sick - which isn’t to say we weren’t working him up - he’d already received an ECG, head CT and was awaiting an MRI. We suspected a new stroke and therefore seemed to have time to find the correct diagnosis and figure out how best to treat him.

Five o’clock came soon enough and I had dinner plans with my classmates so I was eager to leave the hospital for the evening. Before leaving, I went to “set eyes” once more on my patients - another piece of lingo meaning actually looking at the patient and not just their chart. With the demands of the electronic medical record, reading up on our patients, placing orders, following up on consults and studying for the next board exam, actually leaving the resident workroom proves challenging. Interacting with our patients can unfortunately feel like we are getting behind in the day’s work. Horrible, isn’t it?

We have to remind ourselves that face-to-face time with the patient is our most important task. "Setting eyes" is indeed the only way to determine "sick or not sick." Despite the technology at our fingertips, all our white coats are stuffed with folded pieces of printer paper with each patient’s name on it and tiny checkboxes next to the day’s tasks including "consult psychiatry, meet with social work, order TSH, etc." I’ve taken to writing at the beginning of the day, every day:

# See patient pre-rounds.
# Call family after rounds.
# Set eyes late pm.

This helps me avoid the temptation, even subconsciously, to think that time spent with the patient is not time well spent.  Non-negotiable to-do's are without a doubt time well spent. My readers in the medical profession likely know this feeling. Other readers may be appalled. I ask your sympathy for the residents and medical students running hospitals - we are tired, overworked and we are doing our best. In the months that I have been on the wards, I have already seen incredible, behind-the-scenes advocacy for patients from the workroom, while the patients are probably wondering, “Where the heck are the freaking doctors all day?” Hannah Roth, a favorite resident among the medical students, physically ran a urine sample to the lab across the hospital so that a patient who wasn’t even hers wouldn’t have a delay in their procedure. The patient and their family never knew it happened. It won’t be documented in the EMR but that’s the kind of thing that happens every day, quietly and without recognition. It's the kind of small heroism that no one ever sets eyes on.

That evening when I set eyes on Mr. J, I knew he had become sick. His heart raced and his stomach heaved up and down with every breath. Most strikingly, he looked frightened. The facial expression of a nonverbal patient hyperventilating is what I imagine a drowning person to look like. His wife look at me with desperation. I did the first, and it turns out, incorrect thing I could think of, which was to ask his nurse to administer his daily inhaled steroid for his chronic COPD. Even if he was having an exacerbation of his chronic shortness of breath, a maintenance inhaler would not improve an acute exacerbation. Realizing that I was out of my depth, I assured his wife that I would be right back, walked slowly out the door and then proceeded to run to the resident room. Punching the door code, I alarmed my residents saying, “Uhh, can you come help me? Now.”

My instincts were right. Mr. J was very sick. Despite a normal ECG on admission, he was found have acute heart failure, was transferred to the ICU and intubated. I was late to dinner and Mr. J was no longer my patient.

After general medicine rounds the next morning, I went down to the the ICU to find his wife. I found her sitting alone, Mr. J having gone to another test. I let her know that we were all sorry that her husband had experienced such an abrupt decline and that, reflecting on our actions in the previous day, truthfully there was not anything we should have done differently. I told her that we looked forward to Mr. J being transferred back to our team on the general medicine floors once he recovered. I told her this despite my doubts that that would ever happen. Three months into the wards and I already brace myself for the worst. I checked off the box on my to-do list next to “f/u with patient’s wife.”

To everyone’s surprise, Mr. J recovered in the ICU and returned to our team two weeks later. When I entered his room the morning of his return, he blurted out, “How do I know you?” I told him I was part of the team that admitted him to the hospital. He said, “Well, I don’t know about that, but you smell great!” As the days went on, he became more lucid and every morning greeted me with a cheerful “There she is!” I accompanied him to his surgical procedures and held his “Best Dad Ever” baseball cap for him while the surgeons worked. We enjoyed our mid-morning “spa time” when I lotioned his legs and feet with the hospital-grade aloe - his skin fragile and thin after years of immobility and weeks in the dry hospital air. Soon he could follow a conversation and tell me his favorite color was orange and that his favorite dessert was chicken pot pie, which he still insisted should be considered a dessert because “It’s a pie, ain’t it?” By my last day of the rotation, he was ready for discharge to a rehab facility. One only had to set eyes on him to see that he was sick, but not sick.

There’s a lot in medicine that we can just never know. Why did Mr. J present to our hospital with confusion and stroke-like symptoms when he actually had acute cardiomyopathy leading to cardiogenic shock? What caused the cardiomyopathy to begin with? Why didn’t his initial ECG reveal the changes his heart was going through? Why, when we performed an echocardiogram two weeks later, had his heart miraculously fully regained its “ejection fraction,” a measure of how well the heart is pumping? When I asked Mr. J’s cardiologist these questions, he said, “I don’t know. Sometimes these things just happen.”

Other things I don’t know: If I hadn’t set eyes on Mr. J before leaving the hospital that day, would we have lost precious minutes between intubation and pulmonary failure? If I hadn’t gone to talk to his wife that first day in the ICU and he had died, would she have blamed us for not acting sooner, exposing us to litigation and her to emotional suffering? It may very well be that our conversation, something I had added to my to-do list for the day, something that went undocumented in the electronic medical record, was the single best bit of medicine I practiced during my three months on the clerkship.

Indeed, the best evaluation I received for my work on medicine was the bitmoji his wife texted me after his discharge. It said, “I appreciate you!” It was definitely worth being late to dinner for.