I was a nervous first year intern on the internal medicine hospital service. Our team had come down to the Emergency Department to accept the patients being admitted to our service. My resident turned to me: “Room 3 is your next patient. Pneumothorax. We need to care for this patient for a few days and stabilize his lungs until we can remove the chest tube vacuum. Obtain a quick history and exam and place his admission orders.”
I went in to chat briefly with the patient. Since we were busy meeting a host of new patients, I just had the briefest of conversations with him; he had gotten very out of breath, driven himself to the ER, was found to have a collapsed lung (pneumothorax), and had a chest tube vaccuum inserted to re-inflate the lung. Got it. I wondered how it happened, but that mystery would have to wait.
Later that evening, I went back in the room to chat with my patient with pneumothorax. The chest tube was working, he was feeling less short of breath and more comfortable speaking. He had a long history of injecting cocaine, and as a result of frequent use of needles, had scarred all the accessible veins in his arms and legs. During one of his previous hospital stays, he noticed nurses putting IV’s in other patients’ necks, and found out that he, also, could use a neck vein to inject. This worked well for a time, but THIS time he had inserted the needle too far and punctured his lung. He felt the “pop” and then began feeling short of breath, and immediately drove himself to the hospital, where he passed out in the parking lot at the ER entrance. Fortunately, someone saw him, and the ER team brought him in and resuscitated him.
I thought: “this is a cool case. Self-injection into a neck vein leading to pneumothorax.”
My resident agreed. “Why don’t you present this at Dawn Patrol tomorrow morning?”
There it was. It was finally my turn to present to the dreaded Chair of Medicine at Dawn Patrol, the infamous rounds where the post call team would assemble at 6:30am and one unlucky intern would present a selected case history and have a thoughtful ad-hoc pathophysiology discussion.
At 6:30 am precisely, the looming presence of Dr. Silva arrived in the white-scrubbed hallway. “G’ mornin’ everybody! How’re we doin’? Who has a case?”
“Good morning Dr. Silva, I do.”
“Oh good! Okay CJ, go ahead.”
I was so flustered I didn’t even correct his mis-remembering of my name “CT”, and I just plunged ahead. “This is a 31 year-old prisoner, who presents with sudden onset shortness of breath and is admitted with pneumothorax. His history began earlier yesterday when …
“Stop.”
=I paused=
“Pneumothorax. Interesting. What is his educational background?”
“… Um, he is a prisoner. I did not ask.”
“So, he could be a medical student, and you would not know?”
“No sir.”
“Hmm. So you might be speaking disrespectfully to a medical professional and you didn’t find this out. Okay. Is he a rose gardener? You know, sporotrichosis thrives in rose bushes and can cause spontaneous pneumothorax.”
“Um. I don’t know.” (Head hanging lower)
“Or, maybe has he recently purchased or cleaned out a pickup truck he bought from the Forest Service? You know that coccidiomycosis is endemic in the Central Valley nearby, so called “Valley Fever” that can commonly cause spontaneous pneumothorax.”
“I don’t know sir.” (Staring at the ground, hoping it would swallow me up)
“You know what? We need to change this. I have been disappointed this year with Dawn Patrol presentations where we have gathered inadequate Social History. This is going to change today. Starting now, Dawn Patrol presentations shall BEGIN with a FOCUS on SOCIAL HISTORY.”
“Yes, sir.” I mumbled my way through the rest of my desultory presentation, the amazing external-jugular self-inflicted needle-puncture of the apex of the lung forgotten in the shame of inadequate “social history” skills I demonstrated that day.
After rounds, my fellow interns came up, punched me (hard) in the shoulder “Thanks ‘CJ’. Good job. As if we weren’t working hard enough already, now we have Social History to worry about too.”
For the rest of that year, every University of California Davis intern gathered a world-class, comprehensive social history. We knew every patient’s educational background, what schools they went to, what they studied and enjoyed, what occupations they held (every one of them since the beginning of time), what hobbies they had, what their families were like, how active they were, what groups they belonged to, every place they had ever lived or visited.
As for me, for a long time the Social History was my albatross. I wanted to avoid ever getting caught with my pants down again. For the remainder of my residency, my fellow residents never let “CJ” forget what he brought down on all of us.
Over the years, my focus on Social History influenced my interview style. My history-taking skills improved. I did not even notice that I was getting to know my patients better. I saw my patients more as humans and less as diseases.
I learned that one of my patients used to practice-box with Joe Louis, the heavyweight champ.
One of my patients flew with the Flying Tigers who challenged Japanese invaders over communist China at the beginning of WWII.
It turns out, the entire history of the world walked in and out of our exam rooms and hospital beds, if we were just aware enough to ask.
Dr. Silva was brilliant. The surface lesson was: take a good history. Get to know your patients. They’re trying to tell you the answer to the questions you have about their illness.
The second lesson that I only came to understand years later: getting to know your patients, whether through social history, or just being generally curious about another human being, was the gateway to enduring, therapeutic relationships, for everyone involved.
Thanks, Uncle Joe.
