A Medical Economics Web Exclusive

Her last smile, her legacy

The author was a medical student when he lost his first patient. Now, many years later, he still remembers what she taught him.

By Laurent Tao, MD
Internist/Chicago

It was in my third year of medical school that I finally became a true student of medicine. After three intense weeks on the general medicine wards, I was assigned to oncology. This rotation was rumored to be especially difficult, not only because the patients were extremely ill, but also because the attendings were rigorous and demanding.

On my first day, my senior resident paged me with an admission, a woman with a history of lung cancer and known liver and brain metastases who was hospitalized for a workup of recent changes in mental status. I imagined a cachectic woman lying prostrate in bed and unable to speak coherently. When I arrived at the patient's bedside, I was surprised to see a cheerful face smiling radiantly at me.

"Mrs. G?" I inquired.

"Yes, dear," she replied. "Why don't you have a seat and join me."

Her voice was strong and kind, confident and gentle, instantly dispelling the visions of frailty that lingered in my mind. After I introduced myself, I began my interview, and she eagerly replied to my litany of questions. As we spoke, several members of her family entered the room. She bade them to be quiet, only allowing them to speak when providing clarification to her responses. By the time I had finished, we had an audience of 11.

My differential diagnosis was broad and included the possibilities of worsening brain metastases and infectious or metabolic causes. But what was perhaps even more interesting for me to learn was that she was the oldest of six siblings, raised on the south side of Chicago, and had four children and nine grandchildren. Her parents had died when she was in her teens, so she had been the one to raise and support her brothers and sisters. She had eventually outlived her husband and two of her brothers, and she was the authoritative matriarch of this clan.

Now her family was rallying around her in her time of need, happy to return the loving care that they had received over the years. It was clear that they all respected and cared about one another, and it was into this atmosphere that they welcomed me.

I'd almost quit medical school during my first two years. I think I had expected something more than the basic science lecture courses that filled the auditoriums each morning. I imagined that I would learn how to take care of patients and be mentored in the art of clinical medicine, not simply regurgitate minutiae detailing biochemical pathways and subcellular structures.

So it was a relief, if not a godsend, to begin a course in which we learned how to interview patients and perform physical exams. My group of four students was mentored by a psychiatrist, and once a week, he would observe one of us as we interviewed a patient. As much as I was anticipating the experience, it was also absolutely terrifying. I couldn't believe that I had to ask such personal questions of someone I had just met.

Some patients would ramble uncontrollably when responding to simple factual questions, exploring tangents that were completely irrelevant, while others had to be cajoled to answer. Some would refuse to speak to a medical student, and others wanted to be your new best friend.

Yet with each patient, our mentor somehow managed to zero in on the most important aspects of the case and guide the patient accordingly. He was able to gather all the relevant data, but also explored deeper emotional issues of which the students were largely oblivious. More often than not, the patient would end up in tears, revealing the most intimate fears, hopes, disappointments, and dreams of his or her life. It was enthralling to watch; yet, I was always slightly mystified by his performances. Even after he explained the key phrases or the clues in body language that offered particular insight, I doubted that I would ever be able to perform similarly.

The most crucial thing to remember, he would always tell us, is to listen to the patient. Be aware of how the patient tells his story to you and what he doesn't tell you.

Mrs. G's lab results had come back, and her hemoglobin was surprisingly low. She hadn't had any chemotherapy lately, and she denied any evidence of recent bleeding. When the anemia was confirmed by a second sample, and her fecal occult blood test proved to be negative, the next step was to do a nasogastric tube lavage.

I met my resident and intern in Mrs. G's room, where we explained that it was important to see if she was losing any blood in her stomach. She accepted the news calmly, and merely asked her sole visitor of the day, her baby sister, to wait outside.

As the resident gathered the necessary supplies, I chatted with Mrs. G. She was eager to talk. Her sister had brought her a bouquet of flowers in the morning, a simple gesture that had unleashed a torrent of memories: Sunday night dinners at which her mother insisted on freshly cut flowers, springtime trips to the lakefront to wander on the rocky shore with her sisters, the tomatoes that she harvested from her backyard garden every summer.

It was impossible for me to feel sad or stressed in this woman's presence.

On my resident's first attempt to pass the nasogastric tube, Mrs. G gagged and reflexively jerked her head away. "I'm sorry, Doctor," she moaned, fighting back tears. "I didn't mean to do that. I'm so sorry." She reached out for my hand and clenched it firmly in both of hers. "I'm ready now," she said. "Please try again."

The resident readied the tube at her nostril a second time, hesitated momentarily, and then advanced it quickly. Mrs. G's whole body tightened in a violent spasm. She squeezed my hand with the strength of a man twice her size, but despite her best efforts, her head drew back, leaving the tube dangling from my resident's increasingly frustrated hands.

"I don't think I can do this," she said.

"This is very important, Mrs. G," the resident replied. "We have to try one more time, okay?"

She smiled weakly and nodded. On the third attempt, the intern held Mrs. G's head firmly, while the resident forced the tube into position, ignoring the moderate resistance encountered along the way.

"I don't feel very good," Mrs. G breathed. "Please take it out. Please."

We explained that before we could remove it, we needed to irrigate her stomach with saline to see if there was any blood there. Seconds later, Mrs. G heaved, ejecting a gush of bright red blood from her mouth.

Our team froze in place, momentarily paralyzed by the sudden turn of events. A second spasm sent even more blood cascading down her gown. The room erupted into chaos. We plunged a triple lumen catheter into her groin, ran stat labs down to the laboratory, and transfused blood as quickly as possible to maintain her intravascular volume. We pushed fluids, monitored her blood pressure, and infused H2 blockers. Yet she kept bleeding. Finally, we called the ICU for an immediate transfer.

I explained each step of the process to Mrs. G, trying to reassure her, hoping the fear in my voice didn't betray my words of confidence. "Once they stabilize you, then they'll be able to find out what's bleeding and stop it," I told her.

As the nurses prepared to roll her bed down the hall, Mrs. G stared up into my eyes. Her gaze was calm and direct, and she smiled as broadly as I had ever seen her smile before. With absolute clarity and in an unwavering voice, she declared, "This is my last smile."

I was speechless, completely disarmed by her statement. "No, Mrs. G. I'm sure you have lots of smiles left." With that, the nurses wheeled her out of the room, passing by her trembling sister who had witnessed all of the terrible events. Mrs. G's fingers slipped from my hand. She had been holding it the entire time.

The next afternoon, I was surprised to find the hallway filled with Mrs. G's family. She couldn't have recovered that quickly and been transferred back, I thought. As I neared the group, many heads seemed to be hanging low and the general mood was somber. Mrs. G's sister, the one I had seen the day before, spotted me and approached.

She confirmed what I suspected, that Mrs. G had passed away overnight. I offered my condolences, but didn't know what else to say; she was my first patient to die. My medical school experiences couldn't prepare me for this.

The silence lingered for another moment, then Mrs. G's sister said, "She gave you her last smile."

I hadn't realized that she'd heard Mrs. G's last words to me, and my immediate reaction was one of guilt. I braced myself for the anger to follow as I, a medical student that Mrs. G had met just days earlier, had stolen such a valuable and irretrievable commodity from her loved ones. To my surprise, her sister's next words absolved me of that guilt.

"She really liked you, you know," she said and then thanked me for my help, giving me a smile and a handshake that were as meaningful as those I had gotten from Mrs. G. It was a gracious gesture that provided a necessary moment of closure for me. I knew that I didn't have to say anything else to express my feelings or convey my sympathy. She turned back to her family and mourned.

Now that I am finally in practice, I've learned that being a physician doesn't get any easier with time. I'm still learning every day, about new technologies and medications, about the business aspects of the health care system in general. And I'm forgetting every day, too, having to refresh my aging mind with proper antibiotic regimens and diagnostic criteria for collagen vascular diseases. There are far easier ways to make a living, I often tell myself.

Still, the rewards are considerable, and I will always cherish the lessons I learned in my third year of medical school, from both my attendings and my patients. Mrs. G was the first patient I lost, and only then, in that single, defining moment of clarity, did I realize the true power that a physician wields: not only to heal, but to explain, to assuage, and to connect with the patient and family on a human level.

Not every patient has been as kind or friendly as Mrs. G, nor has each family been as supportive and loving as hers, but their memory has lingered on the surface of my consciousness and drives me to listen to and care for each of my patients to the best of my abilities. That is their legacy, and still make me smile.

Laurent Tao. Her last smile, her legacy.

Medical Economics

Oct. 10, 2003;80.