The Reason

(Dedicated to Robert J. Haggerty, MD) 

It was winter and I was almost halfway through my third year of medical school in Rochester, New York. I was enjoying my pediatric rotation, even though it meant I was up much of every third night, and chronically sleep deprived. Getting to bed by 2 am and having three or more hours of uninterrupted sleep was considered a good night. In addition to pediatrics, I was learning to nap, and trying to learn to function despite exhaustion.

Roused from a deep sleep by the phone (medical students did not get pagers) I splashed my face, grabbed my stethescope and note cards, and headed to the Emergency Department. Although the walk to the ED took less than three minutes, the ever present anxiety about what challenge awaited me was enough, as always, that I was awake and hyper alert by the time I got there. The nurse handed me two clipboards with the ED sheets of the two sisters,  ages three and four, there with their mother at 3 am with coughs. 

Viral respiratory illnesses (colds) are common in this age group. The evaluation is simple and straightforward, even for a third-year medical student roused from sleep. A short history and exam convinced me that these were two basically well children with mild viral respiratory illnesses for whom the best treatment was liquids, a humidifier, and time. I called the supervising resident who agreed with my assessment  and plan and I sent them home with a handout about the treatment of colds. Once the energetic sisters were on their way, I collapsed into a chair at the nurses station to document the encounter. While writing the straightforward SOAP notes, I made it plain to anyone who would listen that the visit had been a waste of my time, and that I was not terribly happy about losing precious sleep. 

The next morning, after completing first work rounds and then teaching rounds, I stopped at my mailbox where I found a note directing me to see Dr. Haggerty, Director of Ambulatory Pediatrics and one of the most respected pediatricians on the staff,  before going to my morning pediatric clinic assignment. Despite, or perhaps because of, the lack of explanation, I knew this was not good. 

I still remember his office, especially the cluttered desk with piles of journals and charts, and the enormous map of Rochester and its environs that covered the wall across from his desk and dominated the room. When Dr. Haggerty asked me if I remembered the two girls I had seen the night before, my heart sank. Had I missed a pneumonia, or worse, meningitis? Had I not written complete notes? 

Dr. Haggerty was not interested in my reasons for diagnosing minor viral illnesses rather than some more serious condition. He gently interrupted me to ask if I knew where they lived? I did not, and I’m sure my face made clear I did not see a reason for his question. He handed me the two charts, which he effortlessly retrieved from the mess on his desk, and handed me a red stick pin, with instructions to find and mark the address on the map on his wall. I did so. He gave me another pin to mark the ED entrance at Strong Memorial Hospital. 

He paused and waited. Then came a series of questions: 

  • Question: “How far do they live from the hospital?” Answer: “About a mile and a half.”
  • Question: “How did they get to the hospital?” Answer: “I don’t know.” 
  • Question: “Do you think they drove?” Answer: (After looking at the demographic information on their chart and remembering their clothes) “Probably not.”
  • Question: “is there any public transportation at that time of night?” Answer: “No, sir.”
  • Question: “So, how do you think they got here?” Answer: (After a pause. I was beginning to see what he was asking.) “I guess they must have walked.”
  • Question: “How are uninsured poor blacks usually treated in an ED?  Does the staff welcome them? Offer them food? Thank them for coming?” Answer: “No.”
  • Question: “How’s your imagination? Can you imagine anything that might make a woman walk a mile and a half in the middle of a freezing cold January night with two toddlers?” Answer: (Long silence. My imagination was good. It was easy to provide plausible if horrifying scenarios. But it was hard to give them voice. He waited me out.) “Perhaps the toddlers were keeping an abusive or intoxicated or drugging boyfriend awake and she was concerned for their safety. Or her safety. Perhaps there was no heat or no food in their apartment, and she was hoping that they would be admitted. Perhaps...” But he stopped me.

“Imagination is essential to medicine,” he said. “And it seems you do have an imagination.” He suggested I think about what I might have learned about this family had I been curious enough to wonder and caring enough to ask. What might the mother have been afraid of? What were their home circumstances? Were there other children, and who was watching them during this time?

“Remember,” he said as I left. “They come for a reason. It may not be your reason, but it is The Reason. It’s your job to learn as much as you can about The Reason. Until you understand The Reason, you can’t help them with what they came for.”

My visit in Dr. Haggerty’s office can’t have lasted more than 10 or 15 minutes, but I am eternally grateful. It was painful at the time, but his suggestive questioning and patient pauses led me to discover a truth: patients don’t wake me up in the middle of the night, never mind become ill, because they are trying to make my life difficult. They come and they call because something dreadful - or something potentially dreadful - is happening in their lives.  I have given up counting the times when asking more questions and then taking the time to listen has made all the difference. Almost 40 years later, his message guides me every day: 

It’s about patients, not about doctors. 


 

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