Alice Y. Kim
When Teresa showed up forty-five minutes late for her appointment, I sighed. I knew this would disrupt our clinic's afternoon schedule.
That was nothing unusual, though. The clinic treats large numbers of patients who are undocumented, homeless and uninsured, and many must walk or take public transportation to get here. After seven weeks on rotation here as a third-year medical student, I knew that appointment times were flexible.
As I read Teresa's notes and recent lab results, the nurse came in.
"Teresa's blood pressure is 210/122," she told Dr. Fuentes, the attending physician.
Numbers that high are cause for alarm, so Dr. Fuentes began to consider sending Teresa to the emergency room.
"Take her vitals again in ten minutes," he told the nurse. "Then we'll decide."
Ten minutes later, she returned.
"She doesn't want her blood pressure taken," she reported. "She says, 'Why take it again when it'll be just as high? It only makes me nervous.' "
"I'll go and try to convince her," I offered.
So many patients don't know how serious hypertension is, I thought. She sounds a bit rude and demanding....With another sigh, I walked across the cold office hallway.
Teresa was a tall, slender woman. She sat on the exam table, her right knee shaking, and smiled in response to my greeting. On her pale shirt, I spotted some light brown stains.
I sat facing her, hands clasped on my knees.
"What brought you to the office today?" I asked, keeping my voice low and soothing for fear of raising her blood pressure.
"I've been having a lot of headaches," she replied. Speaking quickly and forcefully, and punctuating her words with lively gestures, she described how, as her ailing father's caretaker, she was suffering great personal and financial stress. To my surprise, I found her quite pleasant and likable.
"They told me years ago that my blood pressure was high," she said. "I just didn't have the time or energy to do anything about it." From there, somehow, she wound up talking about how much she loved tending her garden, leaving me a bit bewildered by the change of subject.
There was a short, uncomfortable silence. I smiled and nodded, not knowing what to say.
Then she spoke again.
"My breast cancer is back," she said quietly.
Wait--I thought our primary concern was hypertension! Clinging to the interview protocol I'd learned, I said, "Can you tell me more?"
"I was diagnosed about seven years ago," she said. "I had a left lumpectomy and chemotherapy, and they told me the cancer was in remission. Then I lost my insurance. I didn't have a mammogram for six years. Now I know the cancer's back."
Inwardly, I shrugged this off.
How would she know if her cancer is back? She's probably going to link her headaches to a relapse. Most of our patients are poorly educated; I've seen them make these irrational connections before.
But I was wrong.
I'd never seen or felt a breast like this. The skin was scaly, with what looked like scratch marks here and there. Alongside the lumpectomy scar ran pink nodules. When I touched them, they felt like rocks. The inverted nipple was surrounded by purple-brown discolorations. I tried to stay calm, but I knew this was something dire.
Guilt and horror gripped me.
Why did I doubt her? And how could she wait so long to come in? She must have had no money at all....
Other questions popped up: Who'll take care of her father? How will she pay the medical bills? What's the next step? Is there even an adequate treatment at this point? Wait, what are we doing about her hypertension? Did we even take a second measurement?
So many questions--and I didn't have a single answer.
"The doctor will be with you shortly," I told Teresa. As I hurried to find him, the questions kept coming: Where do I start? What was her chief complaint again? What do I recommend for treatment and management?
I rushed into Dr. Fuentes' office. Having taken so long with Teresa, I'd put him far behind schedule--other patients were waiting. Without letting me present my findings, he walked quickly to Teresa's room, sat down and asked, "How can I help you?"
"My breast cancer has come back," she said. "Can you please examine my breast?"
He glanced down at her chart, which read, "Chief complaint: headaches."
“Sure,” he responded.
As he examined her, his face was impassive; I wondered what he was thinking. After a pause, he looked at Teresa, his eyes direct and steady.
"The exam is concerning," he said gently. "It's very important that you see an oncologist."
Filling out a referral form, he told Teresa where to go and who to see, offered to have a social worker help make the appointment, and confirmed her phone number so that he could call her afterwards.
Teresa seemed reassured by his calm, encouraging manner; as she left, she thanked us both warmly.
Driving home, I couldn't stop thinking about Teresa. I felt so guilty for having misjudged her. And I felt so disappointed in myself--after all, it was my wish to care for people in real need that drove me to become a physician! Now, less than two months into clinic work, I'd absorbed the same prejudices as anyone else.
It's not that some patients don't care about their health, I reflected. It's that, unlike caregivers, they don't always have the resources to do something about it.
The only thing I did right was to listen, I concluded morosely.
I did feel grateful for my medical training, which had taught me to ask open-ended questions and not to interrupt or rush patients. It seemed as if that training, and my fear of raising her blood pressure, were what had enabled Teresa to open up and share her deepest concerns. Remembering this, I felt a bit better.
Maybe I can't let go of all of my prejudices, I reflected. But no matter what, I absolutely must hold onto my willingness to listen.
And I began to wonder: What will my patients tell me tomorrow?
About the author:
Alice Y. Kim is a fourth-year medical student at Herbert Wertheim College of Medicine, Florida International University, Miami. An aspiring surgeon with an interest in cancer care in developing countries, she loves watching and playing basketball and doing photography during her free time. “I was encouraged to write and submit this piece to Pulse by my family-medicine professor, Suzanne Minor, who emphasized the importance of reflecting on our experiences for further growth. Being someone who easily forgets experiences, both trivial and profound, I've taken her words to heart: Writing has become a way for me to relive moments and relearn their lessons."