The Script
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《新英格兰医药杂志》
"What happened?" the patient asked. She was coming out of anesthesia after six hours of surgery. A weary resident cleaned dried blood and iodine from the skin around the surgical wound on her abdomen. The anesthesiologist had just removed her breathing tube. The patient, to my surprise, was staring straight at me — the medical student. She asked again: "What happened?"
During the previous 6 months, a rapidly expanding abdominal mass had developed. Early in her surgery, a frozen section had been sent to the laboratory, and 20 minutes later a voice over the intercom had confirmed what the surgeons had surmised: she had ovarian cancer. The tumor had spread through the pelvis and abdomen, attacking the uterus and loops of bowel. The surgeon and residents meticulously resected all visible disease, but the prognosis was grim and everyone in the operating room knew it — except the patient. But surely it was not my place to relay this news.
The surgeon bailed me out. "Your surgery's over," he said in a calm, soothing voice. He told her they would talk more when she had fully awakened. But what — and how, exactly — would he tell her?
In medical school, we're taught to follow a script: "What brought you to the hospital today?" it begins. It's a starting point based on the assumption that you haven't already read a triage nurse's notes, reviewed the results of laboratory tests ordered in the emergency department, or met the patient during a previous examination. We learn to take a detailed history of the present illness before proceeding to the medical history, the social history, and a series of questions: Current medications? Allergies? Surgical history? Prior hospitalizations? "Ask the questions in the same order, and you'll never forget anything," I was advised during my medicine clerkship.
"But I've already answered these questions five times," patients occasionally protest midway through the script. "I'm sorry, but it's important that we don't miss anything," I respond, noting that the patient is alert and oriented. From the first weeks of medical school through the licensing exam, this initial encounter is the focus of medical education. Whether you're examining an elderly woman with diabetes who has a foot ulcer, a young man having a panic attack, or a vomiting infant, instructors drill this script into your head. Taking histories from real patients during the past year has made me begin to feel like a real doctor.
But then the script ends. And the unscripted conversations that follow always remind me that I am still very much a student. As a clinical clerk, I felt well prepared to take obstetrical histories — but flummoxed at the prospect of talking with patients who were actually in the middle of labor.
When I worked in the emergency department as a psychiatry clerk, I took longer histories and became confident of my ability to evaluate a patient's need for hospitalization. But late one afternoon, a young woman presented with a 6-month history of hearing voices and seeing animals in the walls of her apartment. Her mother was worried about her daughter's talking to herself. My training gave me a differential diagnosis and a good sense of which tests and medications might be useful. But after all my questions, the patient had one for me.
"Do you think I'm crazy?"
Just like that, I was in over my head. I had no script — only clinical judgment, that perplexing skill that can't be reviewed in morning rounds or diagrammed on PowerPoint slides. "Well, I think you might very well be sick," I said. "But I think you can probably be helped here." I excused myself, feeling nauseated at this young patient's prognosis, and went off to find an attending.
These are the conversations I find the most difficult — and, I submit, the ones for which medical schools do the worst job of preparing students. They generally happen after the histories are taken, when the patients' questions begin, especially with patients who are angry or frustrated with me, the doctors who are caring for them, or simply their own failing health. Over time, I always thought, I'd learn how to respond as the best clinicians did, defusing confrontational situations with a mix of compassion, authority, and carefully wielded humor. To be sure, this stuff is difficult to teach. There's always a component of improvisation. And it's hard, as a student, to know how much of yourself to put out there: you have to be emotionally involved enough to connect with the patient, but not so emotional as to become overwhelmed. One physician told me, "See another 10,000 patients, and I absolutely promise that you'll improve." Until that happened, I figured, there would always be a wise attending down the hall, ready to take over when I ran into trouble.
But in the middle of my medicine clerkship, a patient I'll call Mrs. Hayworth was transferred to our service. She had presented several days earlier with bizarre behavior and focal neurologic deficits. Computed tomography (CT) had revealed a brain mass and hemorrhagic stroke. Her condition had been stabilized in the intensive care unit (ICU), but she still had no definitive diagnosis. The situation was like many others I'd encountered since beginning on the wards. The patient could not tell me what had happened to her. She couldn't remember any medical history. Allergies? Surgical history? Prior hospitalizations? All question marks. So much for the script. Mrs. Hayworth did have a son, a resident had noted in her chart, but no one had been able to reach him. On her own, she was able to tell me that she used to smoke. "But it's my head that's the matter," she protested. "I've just been confused. It's not like that's the smoking."
This history did not make for a thorough presentation at rounds the following morning, and I apologized my way through a regurgitation of notes from the ICU and from neurology and neurosurgery consultants. "Get in touch with the son and see what he can tell you," my attending instructed. "And send her for a CT of the chest, abdomen, and pelvis."
When I reached the son on the telephone, he had difficulty appreciating the severity of his mother's illness. "Perhaps you could come to the hospital to see your mom, and we could talk in person," I suggested. He agreed to come in the following day after work.
Mrs. Hayworth had her CT overnight. It revealed a lung mass that almost certainly represented her primary tumor. Our team scrolled through the black-and-white images at rounds the next morning and went over the plan: bronchoscopy for a biopsy, and then chemotherapy and radiation therapy or palliative care.
"You'll explain what all that means when the family comes today," the attending said, gesturing to me, the intern, and the resident. But it was another day on a busy medicine service, and we had other new patients to discuss, consultants to call, and lectures to attend. When the son didn't show up at the appointed time, we called and left a message. Eventually, the resident and intern went home, while I stuck around to do some homework. On my way out, I checked on Mrs. Hayworth one last time. I found her crying, more lucid than she'd been earlier, and talking to her son, who had finally arrived. "What's happened to my mother, Doctor?" he demanded.
"Mr. Hayworth, I'm the medical student you talked to yesterday on the phone," I began. My heart was racing. I spoke slowly, trying to imagine what the doctors I admire might say. "I know it's very upsetting to see your mother this way. Let me try to explain what's happened and what we're going to do."
Without a resident or attending waiting down the hall, I felt I didn't have a choice. So I went through the whole story: his mother's neighbor's calling an ambulance, the intracranial bleeding and tumor, the ICU stay, the lung mass the subsequent studies had revealed, and the biopsy we wanted to perform. They would have some decisions to make.
"Thank you, Doctor," he said.
"I'm not a doctor quite yet," I said — returning, finally, to the script that's been drilled into my head. "But you can call me whatever you're comfortable with."(Benjamin Brody, B.A.)
During the previous 6 months, a rapidly expanding abdominal mass had developed. Early in her surgery, a frozen section had been sent to the laboratory, and 20 minutes later a voice over the intercom had confirmed what the surgeons had surmised: she had ovarian cancer. The tumor had spread through the pelvis and abdomen, attacking the uterus and loops of bowel. The surgeon and residents meticulously resected all visible disease, but the prognosis was grim and everyone in the operating room knew it — except the patient. But surely it was not my place to relay this news.
The surgeon bailed me out. "Your surgery's over," he said in a calm, soothing voice. He told her they would talk more when she had fully awakened. But what — and how, exactly — would he tell her?
In medical school, we're taught to follow a script: "What brought you to the hospital today?" it begins. It's a starting point based on the assumption that you haven't already read a triage nurse's notes, reviewed the results of laboratory tests ordered in the emergency department, or met the patient during a previous examination. We learn to take a detailed history of the present illness before proceeding to the medical history, the social history, and a series of questions: Current medications? Allergies? Surgical history? Prior hospitalizations? "Ask the questions in the same order, and you'll never forget anything," I was advised during my medicine clerkship.
"But I've already answered these questions five times," patients occasionally protest midway through the script. "I'm sorry, but it's important that we don't miss anything," I respond, noting that the patient is alert and oriented. From the first weeks of medical school through the licensing exam, this initial encounter is the focus of medical education. Whether you're examining an elderly woman with diabetes who has a foot ulcer, a young man having a panic attack, or a vomiting infant, instructors drill this script into your head. Taking histories from real patients during the past year has made me begin to feel like a real doctor.
But then the script ends. And the unscripted conversations that follow always remind me that I am still very much a student. As a clinical clerk, I felt well prepared to take obstetrical histories — but flummoxed at the prospect of talking with patients who were actually in the middle of labor.
When I worked in the emergency department as a psychiatry clerk, I took longer histories and became confident of my ability to evaluate a patient's need for hospitalization. But late one afternoon, a young woman presented with a 6-month history of hearing voices and seeing animals in the walls of her apartment. Her mother was worried about her daughter's talking to herself. My training gave me a differential diagnosis and a good sense of which tests and medications might be useful. But after all my questions, the patient had one for me.
"Do you think I'm crazy?"
Just like that, I was in over my head. I had no script — only clinical judgment, that perplexing skill that can't be reviewed in morning rounds or diagrammed on PowerPoint slides. "Well, I think you might very well be sick," I said. "But I think you can probably be helped here." I excused myself, feeling nauseated at this young patient's prognosis, and went off to find an attending.
These are the conversations I find the most difficult — and, I submit, the ones for which medical schools do the worst job of preparing students. They generally happen after the histories are taken, when the patients' questions begin, especially with patients who are angry or frustrated with me, the doctors who are caring for them, or simply their own failing health. Over time, I always thought, I'd learn how to respond as the best clinicians did, defusing confrontational situations with a mix of compassion, authority, and carefully wielded humor. To be sure, this stuff is difficult to teach. There's always a component of improvisation. And it's hard, as a student, to know how much of yourself to put out there: you have to be emotionally involved enough to connect with the patient, but not so emotional as to become overwhelmed. One physician told me, "See another 10,000 patients, and I absolutely promise that you'll improve." Until that happened, I figured, there would always be a wise attending down the hall, ready to take over when I ran into trouble.
But in the middle of my medicine clerkship, a patient I'll call Mrs. Hayworth was transferred to our service. She had presented several days earlier with bizarre behavior and focal neurologic deficits. Computed tomography (CT) had revealed a brain mass and hemorrhagic stroke. Her condition had been stabilized in the intensive care unit (ICU), but she still had no definitive diagnosis. The situation was like many others I'd encountered since beginning on the wards. The patient could not tell me what had happened to her. She couldn't remember any medical history. Allergies? Surgical history? Prior hospitalizations? All question marks. So much for the script. Mrs. Hayworth did have a son, a resident had noted in her chart, but no one had been able to reach him. On her own, she was able to tell me that she used to smoke. "But it's my head that's the matter," she protested. "I've just been confused. It's not like that's the smoking."
This history did not make for a thorough presentation at rounds the following morning, and I apologized my way through a regurgitation of notes from the ICU and from neurology and neurosurgery consultants. "Get in touch with the son and see what he can tell you," my attending instructed. "And send her for a CT of the chest, abdomen, and pelvis."
When I reached the son on the telephone, he had difficulty appreciating the severity of his mother's illness. "Perhaps you could come to the hospital to see your mom, and we could talk in person," I suggested. He agreed to come in the following day after work.
Mrs. Hayworth had her CT overnight. It revealed a lung mass that almost certainly represented her primary tumor. Our team scrolled through the black-and-white images at rounds the next morning and went over the plan: bronchoscopy for a biopsy, and then chemotherapy and radiation therapy or palliative care.
"You'll explain what all that means when the family comes today," the attending said, gesturing to me, the intern, and the resident. But it was another day on a busy medicine service, and we had other new patients to discuss, consultants to call, and lectures to attend. When the son didn't show up at the appointed time, we called and left a message. Eventually, the resident and intern went home, while I stuck around to do some homework. On my way out, I checked on Mrs. Hayworth one last time. I found her crying, more lucid than she'd been earlier, and talking to her son, who had finally arrived. "What's happened to my mother, Doctor?" he demanded.
"Mr. Hayworth, I'm the medical student you talked to yesterday on the phone," I began. My heart was racing. I spoke slowly, trying to imagine what the doctors I admire might say. "I know it's very upsetting to see your mother this way. Let me try to explain what's happened and what we're going to do."
Without a resident or attending waiting down the hall, I felt I didn't have a choice. So I went through the whole story: his mother's neighbor's calling an ambulance, the intracranial bleeding and tumor, the ICU stay, the lung mass the subsequent studies had revealed, and the biopsy we wanted to perform. They would have some decisions to make.
"Thank you, Doctor," he said.
"I'm not a doctor quite yet," I said — returning, finally, to the script that's been drilled into my head. "But you can call me whatever you're comfortable with."(Benjamin Brody, B.A.)