An unexpected lesson

Amelia Nuhn

Early in my first year of medical school, I was given some valuable-sounding advice: “Treat the patient, not the disease” and “Medicine is more of an art than a science.” Eager to become a good doctor, I took this advice seriously, but it seemed abstract to me; I wasn’t sure how I could incorporate it into my communications with patients.

Its application became clearer when I shadowed a passionate family doctor, Dr P., the following summer. Together, we met with many patients, some faced with life-changing events and grim diagnoses. Interestingly, the patient who made the greatest impression on me was the last patient of the last day of my elective.

Jessica wasn’t a patient Dr P. had seen before. She dropped in during on-call hours because she had developed a rash. We entered the room to find a calm and collected woman of about my age. Dr P. began by asking her what might have triggered the rash. Jessica told us that she had had a medical procedure done 3 days earlier. When Dr P. asked about it, Jessica stated simply, “It was an abortion.” She did not seem distressed about it. I wasn’t sure that there was any need to further explore the topic of the abortion.

However, Dr P. asked Jessica if she was having any regrets. She firmly replied “No” and explained that prenatal testing had revealed that the baby would have Down syndrome, and that she knew she wasn’t prepared to raise a child with this condition. I didn’t expect this response. I realized that I had assumed, perhaps because of her youth, that the pregnancy had been unplanned and unwanted. I imagined that it must have been heartbreaking for her to find out that her baby would have a syndrome that she did not feel equipped to cope with. However, she sounded confident about her decision. Was it time now to investigate the rash?

Dr P. continued with his gentle questioning, asking Jessica how she had been feeling since the abortion. Jessica confessed that it had been very difficult. “Would you like to talk about it?” he asked. She took a deep breath, then told us that her sister, who was also her best friend and only close family member, was furious with her for having the abortion and now refused to speak to her. Jessica’s voice quavered as she explained that her sister had a daughter with Down syndrome who was a blessing and a joy in their lives. Jessica told us that she had also seen the challenges that her sister had faced while raising her daughter, and that she herself would not be capable of taking on the same challenges. She told us that it was a horrible decision to have to make and that she was feeling guilty about it and devastated by her sister’s reaction.

I learned that Jessica had a balanced translocation of her chromosomes that considerably increased her chances of having a child with Down syndrome. I remembered learning about this condition in school; I had found it fascinating and enjoyed working on problems to determine parents’ probability of having a child with a particular disorder. Until now, I had not really thought about what these numbers meant in real-life situations. Clearly, such information was life changing for Jessica. Not only was she suffering from the consequences of her difficult decision, but she knew she might face the same situation in a future pregnancy.

Jessica looked into my eyes as tears streamed down her cheeks. I felt tears welling up and blinked them back with effort. In the 3 days since the abortion, Jessica had been isolated when she desperately needed love, support, and kindness. I felt humbled and honoured that she was comfortable sharing her feelings with Dr P. and me.

By the end of the meeting, the rash had become an afterthought. Jessica seemed to feel some relief and comfort in sharing her story and in acknowledging that she was feeling alone and ashamed. She expressed appreciation for our caring and understanding. Dr P. offered to meet with her again and she accepted.

I greatly admired Dr P.’s ability to gather this information from Jessica. She had seemed so self-assured when we entered the room that it had not crossed my mind that she might be going through something so painful. On meeting her for the first time, Dr P. had intuited that there was more to Jessica’s story. It was the art of medicine that allowed him to ask the right questions, and he had an air of acceptance that encouraged trust and sharing so that he was able to treat Jessica and not just her disease.