Communication Matters Wednesday, February 22, 2023
”What do you think is wrong with you?” (Lillian)
Lillian was the first person I had ever interviewed in a hospital. I had never even been in a hospital except once to visit a friend in college. I was a third year medical student, a MS III, in a white starched coat on my first day of my first rotation which was in the hospital wards of Internal Medicine. The resident I was assigned to, looked frazzled and had already been on rotation a few days before I joined them as his medical student. I think more than anything, to give me something to do instead of following him around, he sent me to interview a woman named Lillian who had already been in the hospital for a few days. I was told I could read her chart first to catch up with her course, and then “do a history on her” and he would come by and read it when he could.
The chart, which 34 years ago was a paper chart, was not very elucidating. Lillian came in with some kind of epigastric ailment with spasms of intense pain and intractable foul belching. Her lipase and liver functions and other labs were all normal. She had been placed on several medications to try and alleviate her symptoms with no success. The plain film of her abdomen was normal. The 8 slice CT (they now do 40 slices in 5-10 seconds and end up with a three-dimensional reconstructed image in less than a second) had just come into being in our hospital and were done only after very careful consideration and even then take a day or so to schedule and read. She had not had one. It was not altogether clear either her diagnosis or therapeutic treatment plan. Without much information or insight, and no experience, I walked to Lillian’s room.
I knocked and entered Lillian’s room that late morning and sat across from her with my pad of paper and pen. I asked her permission to ask her a few questions, and explained that I was a medical student that would be assisting in her care. She politely nodded. And then erupted a triplet of “Yep, Yep, Yep” while her face contorted. She looked “older than her stated age” and she was “edentulous” and had the kind of face that when she smiled or spasmed, her eyes squeezed tight and her face appeared to fold in half like a rubber toy that compresses and squeaks when it is stepped on. Lillian’s eyes were small dark beans imbedded in wrinkled brown-skinned eye-lids that were purse-stringed around her eyeballs. Her whole face was a map of wrinkles and was always on the move, stretching, contorting, and adjusting itself. I did not know it then, but it was tardive dyskinesia which I would later know as an immediate tip-off that she had been on chronic psychiatric medications. As it was, I was trying to follow the ordinal list of my questions which I had written down, while her face kept squeezing and dancing. And then, as I got to my second or third of my yes/no questions, she frightened me with a yelp of spasms like a dog who had just had its tail stepped on. She was in clear intense pain and began belching like a volcano getting ready to blow. And as quickly as she began her explosive eruptions, she settled back into her rhythmic gyrations of her face. I had never in my life seen such strange movements weaving in and out of barking pain. I tried not to appear alarmed.
I charged forth with my list. For how long have you had this? Is it affected by food? I needed her to simply say “yes” or “no” but she would launch into a tortuous answer that moved around in as many directions as her wrinkled face. And then she began to bare down and hold her breath as if something bad were getting ready to happen. Her entire face collapsed and folded down. I couldn’t tell what was happening when she then let out a sonorous long fart. We were taught to call it “flatus”, but this was not flatus. This was a volcanic fart coming from this old, thin dark-skinned wrinkled dancing madwoman. It was exactly at this moment that I realized that Lillian was having a bowel movement, and she was sitting on some kind of a commode chair. I had never seen a bedside commode. I did not know such a thing existed. I had wondered for a moment when I entered the room, why Lillian was sitting down, and not in her bed. And now I knew. For the past 15-20 minutes, I had been interviewing my very first patient in medicine while she was taking a crap.
I was mortified. My face must have been drained of all blood as beads of perspiration began to pop up on my forehead. I was utterly lost. I couldn’t just walk out. And I couldn’t continue asking this poor contorting grunting crazy woman my list of questions. I just gave up and said “I am so sorry. I did not know…” and I couldn’t even finish my sentence. Lillian’s black bean eyes suddenly focused and became warm. She could tell that I was more helpless than she was, and she encouraged me! She said, “It’s OK honey, I’ve seen a lot of you medical students, and I think you are doing just fine! I like you.” Lillian saved me! A woman who spoke and looked like she was possessed by a demon and was in the midst of erupting a poo on the lue, came out of her writhing self and showed compassion on me. It was just enough to allow me to keep going. But what do I ask now? I lowered my pad of paper and pen and turned back into the person I had been before I was trained as a medical student. I then asked Lillian, “What do you think you have?” And I had zero expectations of any meaningful answer coming from this tortured woman. But in my utter failure and current disbelief in what was happening, I decided to put my half-hearted trust in Lillian. If another student had been with me, I would have dressed my embarassment in a barely visible smirk, inwardly laughing about talking to a patient on a toilet, but as it was, it all just felt just terribly wrong and hopeless.
Lillian immediately yelped in her deep cigar voice, “Yep, yep, yep; they called it a bazon, or a bezeed or something like that.” And then Lillian went into more barking, belching spasms, as her face continued to yawn and twitch. That was enough for me to politely excuse myself with “I think it is time for me to go” and “Thank you very much for your time.” I felt nauseous and ashamed, and my dress shirt under my white coat was drenched in sweat. I went to the doctor’s booth trying to think what in the world would I write in my note, my very first note that I had ever written in a real patient’s chart. There was a row of books on a single shelf in the doctor’s charting area, and one of them was a Stedman’s Medical Dictionary. On a whim, I pulled it from the shelf and went to the “B’s”. I started with the B-a ’s and skimmed through all the medical words that started with Ba. There was nothing. So I went on to the B- e ’s. It wasn’t going well here either—just a big waste of time. And then, I came across the word B-e-z-o-a-r. I had never heard of this word in my life. It sounded made-up. And then I read it’s definition: “a bezoar is a ball of swallowed foreign material most often composed of hair and fiber. It collects in the stomach and fails to pass into the intestines. The risk is greater among people with intellectual disabilities or who are emotionally disturbed.” I blinked in disbelief. I could not believe my eyes. It was like finding a hidden treasure in the very place that seasoned archeologists had been digging for days. I leafed back through all the notes that I had read previously thinking maybe I had just skipped past her diagnosis of “bezoar”. It wasn’t there. No one had even brought up the idea of bezoar in the differential diagnosis. In new found excitement, I began to scratch out my note ending my SOAP note Assessment with “I believe the patient’s history is consistent with a bezoar.”
Later that afternoon, I knew my resident would be reading my note, and signing behind it with possible corrections. I was checking the chart every few hours, and then I saw my resident write “agree with MS III Mosley, consistent with bezoar, with plans to consult GI.” GI ultimately scoped her and removed a grapefruit size bezoar tangled in hair and petrified, fungated food materials. It was so large that it had to be taken out in multiple slices. Even the resident on GI could not stop talking about its unbelievable size and atrocious smell. I had gone from a pathetic tragic figure to a hero, with a procession of notes, “agree with MS III Mosley.”
But what I learned that day from Lillian did not come from my strength of intellect, or my character, or even resilience; it came from my weakness. And in my weakness as a helpless lost medical student, I handed over leadership of information gathering to the patient. I asked Lillian what I now ask the majority of patients I have met on my regular shifts in the ED for the past 30 years— “What do you think is wrong with you?” These eight words have transformed my daily history taking. And after asking that very essential question which was never taught to me in my didactic explicit training, I am on occasion caught thinking of Lillian, and wanting so much to thank her for changing the way I now practice medicine.