Fleeting thoughts

the highs and lows of medicine

I don’t remember much about the first day of my internal medicine rotation, but I remember Mr. C’s shoes. He had a collection of brand new Nikes, Adidas, and Hokas that would make any sneakerhead jealous and they were sitting there, perfectly lined up in his hospital room. In the corner, a stack of shoeboxes towered haphazardly. The residents started discussing his condition with him but I heard nothing, too engrossed in my own thoughts about the shoes. Why did he have new shoes here? Can you order things to the hospital? Where is he going to wear these?

When we left the room the residents asked, “med students, any questions?”

“Yeah, what’s up with the shoes?” I heard myself say. I immediately cringed. What an insightful, thoughtful question, perfectly demonstrating my medical prowess!

“He has been buying them with the hope that he can wear them once he gets his liver transplant.”

With that covered, we moved on to the next patient.

I would be lying if I said the first few days of my internal medicine rotation weren’t filled with slightly painful moments like this. As a third year medical student who had never been on an inpatient service before, the hospital felt uninviting. Patient rooms were crammed with equipment that I couldn’t identify and I often stood wedged between poles and wires and the wall, watching residents tell patients about their treatment plans. If I was lucky, I found my way to the whiteboard where I could be useful by writing the plan in bullet points for all to see. But it was often difficult to navigate the language the residents were speaking. GDMT? TIPS? INR? If I wrote that down would anyone understand? Are these things I should know? If I ask about them will they think I’m stupid? Or tell me that I should look it up on my own? I went home crying several times during those early days, feeling like a failure before my work had even really began.

But I didn’t feel like that during our daily visits to Mr. C’s room. Mr. C wore his own clothes instead of hospital gowns, had comfy blankets on his bed, and an assortment of snacks that he would offer us. Stepping into his room felt like he was welcoming us into his home, and for a second I could forget about the hospital and my anxiety and just listen to his stories. He was happy to chat with me and the other medical student and let us practice our exam skills on him. Mr. C’s room was a safe space to learn; obviously about medicine, but more importantly about how to connect with your patients.

As I became more comfortable, I was able to piece together why he was at the hospital. He had liver failure, kidney failure, and an abdominal infection and was being evaluated for a liver-kidney transplant. His liver failure caused accumulation of fluid in his abdomen and legs, making his feet too swollen and tender to wear shoes. While that sounds dramatic, he didn’t feel sick. Even with dialysis tubes attached filtering all of the blood in his body, he would happily tell us that he felt great and that he couldn’t wait to get a liver so he could go home and wear his new collection. We all wanted that for him too.

But the days ticked on. It turns out that liver transplant evaluations aren’t quick or super interesting. As I became more confident in my ability to handle patients, I picked up people sicker than Mr. C who required more attention. On days when Mr. C didn’t have much going on, the residents would round on him alone. When we saw him as a team, he vocalized his growing anxiety that he wouldn’t get selected for a transplant. For him – like most people getting evaluated for transplant – not getting a new liver would mean dying of his disease. We couldn’t promise him that that wouldn’t happen. Yet, despite the palpable fear in the room, his shoe collection kept growing, a sign that his hope for return to normalcy was still there.

Then one morning, I walked into the team room and the residents were buzzing. Mr. C had been selected for a liver-kidney transplant! He had struck the lottery. We fought with his transplant team over who got to tell him the good news, and though we lost that fight, we walked into his room and cheered anyways. He would get a second chance at life. A second chance to enjoy the little things like eating salty meals, swimming in the lake, and wearing shoes. We celebrated his win like it was our own and floated through rounds with smiles on our faces.

That day was one of the first days where I could really picture myself as a doctor. Working with my team to diagnose and treat patients, making patients feel heard, celebrating their wins and helping them navigate losses – this was why I wanted to practice medicine. I had spent much of my third year agonizing over how much I didn’t know, how lost I felt and how far I had to go. But celebrating with my team and Mr. C, I recognized that I was right where I was supposed to be. I didn’t understand all of the details of his disease or the transplant he would get, but I did understand his background, his priorities, and his shoe collection and for right now, that was enough.

I tried to keep that in mind as we cared for him while he waited for a transplant. Being on the transplant list is painful. There were many mornings where we told him he had a potential match and prepared him for surgery, just for things to fall through. Each “match” that came and went resulted in new heartbreak. All we could do was listen and support him through it. And make shoe recommendations, which he happily ordered to his room.

Then one morning, he had a match that didn’t get cancelled. “Mr. C, which shoes are you going to wear first after surgery?” we asked during our rounds. By then, his collection had doubled in size and included tevas, vans, converse, and more.

“We’ll have to see what I’m feeling when I wake up,” he replied. We collectively held our breath and waited for him to go to surgery. Then, he fell off our list.

“Where did Mr. C go?” I asked.

“Since he’s getting his transplant, the transplant team will take care of him now,” the resident responded. Another reality of patient care that I was unaware of. I thought we would get to see him through his recovery and eventually send him home. I thought we would celebrate more. But in the hospital, no one is your patient forever. The transplant team would know more about how to manage his care after surgery, so our expertise was no longer needed. The residents had said cautious goodbyes when we saw him at rounds, and I now understood why. I was a little sad that our role in his journey was done, but elated that his second chance was beginning. Mr. C would leave the hospital, go home, and enjoy life again. I would work with new patients and continue to grow as a physician, using the lessons he taught me along the way. A happy ending.

Not quite.

“Mr. C lost 80 units of blood during surgery. His abdomen is still open and it’s not looking good,” the resident told me the next morning. I was shocked. He had always been relatively healthy, given the circumstances. He was prepared for this. Just like that, the hope and the excitement and everything he looked forward to was gone?

My team reflected on our final lessons from Mr. C – that patients will often defy your expectations. They can be healthy one day and sick the next. Sometimes the best case scenario is still a bad option. A transplant gave Mr. C a second chance, but there was also always the chance that it didn’t work. Nothing is inevitable. I recognized that patients would teach me about the magic and heartbreak of medicine, and Mr. C had taught me about both. After sharing our disappointments and thoughts, we moved on to our other patients, and the cycle started again.

In the days that followed we checked on Mr. C a few times but his condition remained tenuous. When I started a rotation at a different hospital, I accepted that I would never know the end of the story. I focused my energy on my new patients. I couldn’t let myself dwell, even if I selfishly wanted to know what happened.

Months passed. His case sparked a passion for inpatient medicine that only grew, so I started my fourth year with a nephrology rotation to continue to explore the field. As always, it was hard. I had many patients who were in the ICU, sicker than any patients I had ever worked with, and I had to navigate the intricacies of dialysis orders. The work was demanding and the days were long. I saw many patients with liver and kidney failure who were not transplant candidates and felt defeated that there was nothing we could offer them. I wondered if anyone with liver disease ever really recovered.

Then Mr. C’s name popped on our list.

When we entered his room, I was amazed. His skin wasn’t jaundiced, his abdomen and legs weren’t swollen, and he looked healthier than I had ever seen him. In the days after I had left, he had recovered. He was still on dialysis because his surgical complications prevented him from getting a kidney transplant (hence why he was at the hospital), but his liver transplant worked. He had been able to go home, see his family, and enjoy the lake. I beamed as I thought about how we had both grown since we last met. Him with his miraculous recovery enabling him to achieve his goals, me with my renewed energy for medicine and growing ability to care for patients. A serendipitous finish to a story that I had hoped would have a happy ending.

As we left the room, I took one last look and saw him tying the laces of his yellow Hokas. I remembered how stupid I felt on my first day when I asked about his shoes. But the shoes mattered, and without asking I would have never known how special it was to see him sitting in bed with his sneakers on.