A Dance With Mrs Chan

As a 3rd-year medical student on the internal medicine service at a major academic medical center, I was excited by almost any patient encounter. There was always something new to learn, and the best I could do was to be unyieldingly more observant each day. The sounds of the heart’s subtle murmurs or the snake-like collateral veins in a liver patient’s abdomen were easy enough to appreciate through the guiding hands of my seniors. But medicine’s true hidden treasure, the person behind the patient, is less apparent and only reveals itself to those who seek it.

It was the 2nd week of my rotation and I was entering Mrs Chan’s room behind Dr S, a man in his late 60s whose balding head of gray hair belied an admirably young pair of legs. Following Dr S’s usual routine, we greeted the elderly Asian woman and her daughter. Dr S reached out his hands to Mrs Chan. “Let’s dance!” he offered with a grin, and she squeezed his hands with joyous surprise. One of the leading national experts in health care services research, Dr S was especially cherished because he was never too important to share a minute or a few with his patients.

And dance they did. He started by gently swinging Mrs Chan’s thin, bony hands from side to side, waiting for her to slowly catch her balance as he hummed what sounded like Van Morrison’s “Brown Eyed Girl” with a twist. She was 85 years old, but for a moment, they looked like a young couple on a warm summer afternoon. They continued on for a few seconds before she tapped his arm to signal that she was done for the day. Mrs Chan’s daughter clapped, a smile stretching from blushing cheek to cheek.

“It’s important,” she said, looking over at me as I stood with a surprised grin, unused to this type of interaction. Patient visits were usually not this…fun? “It’s important to laugh with your patients!” asserted Mrs Chan’s daughter as she embraced her mother’s doctor. “It makes us feel safe,” she shared.

“You’re looking wonderful today, Mrs Chan,” reassured Dr S. In reality, we weren’t sure how Mrs Chan was looking, at least on the inside. She had been hospitalized for rectal bleeding from an unknown source—in an elderly patient, a potential sign of cancer—and we were still awaiting the results of her diagnostic workup. But she had responded to blood transfusions quite well, and appeared noticeably less pale and tired than she had the previous few days. Hearing positive news elicited sighs of relief from the family members and Mrs Chan. Although we hadn’t yet won the battle, it was our attending physician’s imperative to celebrate even small, day-to-day victories with all of his patients.

How important are the so-called “little things” in medicine? Would Mrs Chan have had the same clinical outcome if she had missed her afternoon waltz that day? Much of medicine is spent evaluating patients’ vital signs and laboratory results, but I learned that the sign most vital to care is how much we time we actually spend caring. We are primed in our medical training to document the daily well-being of our patients through structured clinical notes in which the visit is focused on the disease and any serious events. But this is only part of how the patient is doing—we cannot fully appreciate how our patients are if we don’t first appreciate who they are, and what matters to them. For Mrs Chan, this meant holding her doctor’s hands and sharing a special moment.

In my remaining months on the internal medicine wards, I found no lesson to be more true, no mantra more pertinent to the well-being of my patients than to pay attention to the little things. It was easy to allow the little things, which always turned out to be the things that mattered the most, to pass by unnoticed.

I met Mr Jensen several months after meeting Mrs Chan. Although Mr Jensen had a much different clinical need, he shared a very similar human one. I was on the last week of my internal medicine rotation and our team was admitting overnight when we received the request from the emergency department about a very sick younger gentleman. From a quick chart biopsy, I could ascertain that he was a high infectious-disease risk—night sweats, fevers, weight loss, AIDS—and I found myself frantically looking for an N-95 respirator mask. I entered his room slowly, my fingers tightening around the metal nose-strap to ensure that the mask was on perfectly. He was laying still in a hospital bed, a bony man with significant temporal wasting and an almost alarmingly pale undertone. Our conversation started off with the usual set of questions regarding symptoms and how long had he had them, but it was short-lived by the time he sharply asserted: “I’m a disgusting disease.” The words will always stick with me.

Clinically, his body was infested with Mycobacterium Avium all the way to the bone marrow, crowding out his ability to even make red blood cells sufficiently. He had been on the verge of death from radical immune-compromise. He had been admitted with a CD4 count in the single digits just weeks earlier, and had been discharged on an intensive 1-year therapy regimen, but continued to spike high fevers.

Did Mr Jensen pick up on the feeling that I, the person who was assigned to care for him, was in some ways apprehensive? And why was my first reaction solely clinically focused? To treat our patients as people, we must see them as such from the moment we step in the room. The way that my attending physician saw Mrs Chan when he first walked in—he danced first.

Mr Jensen was losing the battle—in part from the fevers, but far more importantly, from his own mental and emotional surrender. He had come to see himself not as infected with his disease, but sadly, as nothing more than his disease. At that moment I caught myself—I distinctly recall blurting out almost reflexively, “No. You are not.”

I shifted the conversation, opting to talk about his life outside of his illness—who was Mr Jensen? He was a single man, the head bartender at a high-end restaurant, and he regained some of himself when he described it—“I can make almost any drink, man!” he exclaimed, the pale in his face giving way to some color, some hope. We talked for some time that day, the conversation not about his disease, but about him: what he liked, what he missed, what he hoped to do when he was out of the hospital.

The next day, I opened the door to his room with my attending walking close behind and I paused—I didn’t recognize the man in the bed. He had showered, combed and styled his thin blond hair, and trimmed his beard neatly. His mother sat on a chair near his bed, smiling up at the group of us. This time I had walked into a room commanded by Mr Jensen, not by a body that was dying. We spoke about the plan for that day, and my attending physician mentioned to the room that I would be switching off service as my rotation had come to an end. As I waved goodbye and walked out, Mr Jensen called out behind me, “You take care now…and thank you.”

Ultimately, the mental and emotional environments that our patients come to occupy are influenced in a large part by our own actions, attitudes, and dialogues—the little things, we might call them. I learned that the way we care for our patients, whether through a dance with an old woman made young again, or a few words exchanged with a bartender in a small emergency department holding room, can truly change how they feel, and this is a very big thing.

• Received for publication September 11, 2015.
• Revision received December 17, 2015.
• Accepted for publication December 29, 2015.

• © 2016 Annals of Family Medicine, Inc.