From JAMA

Holding the Hand

1. Jordan M. Gutovich

With the completion of my final neuroscience examination, I expected to experience a feeling of relief. It was the last exam of my first year of medical school. I dreamed of finally being able to relax from the academic rigors and responsibilities that notoriously define one's first year as a medical student. That sigh of relief did not come readily. As I made my way out of the building I decided to pass through the medical library. There, my second-year colleagues were engrossed in preparing for their Step 1 boards. I swallowed deeply with the realization that this would be my last summer of freedom. Still, I had hopes that this summer break would allow me to regroup and spend more time with my wife Riki and our 2-year-old son Yehuda. I also had hopes that I might steal some time to write about some of my experiences of the past year.

The majority of my first-year courses were stimulating and engaging. I found neuroscience and immunology especially interesting, but my favorite was called “Physician and Patient.” The course objectives included acquiring a better appreciation of the social and cultural context of a patient's disease and placed special emphasis on how to conduct a thorough medical interview. For example, we learned how and when to use open-ended or close-ended questions, how to allow patients to tell their story with minimal interruptions, and how to experience and display empathy toward our patients. While each week was packed with lectures and labs that revolved around the basic sciences, there was an island in the middle of the week, a two-hour sanctuary of time that was dedicated to learning about working directly with patients.

Standardized patients were provided to help us practice these skills. However, nothing beat the real thing. Several times a month we had the opportunity to visit the hospital where one student in the group would conduct a thorough interview with a patient while the others watched and listened. Finally, in late December, my turn arrived. Our group waited outside the patient's room while our instructor, Dr C, checked the patient to determine if he was well enough for and agreeable to our visit.

As we waited outside, I reviewed again the long list of questions that we had been urged to memorize. I was confident I would be able to navigate the patient through a complete clinical interview, beginning with the account of the reason for the hospitalization and concluding with questions about his sexual history. After several moments, Dr C motioned to us to enter the room. Taking a deep breath, I led the way followed by my three classmates. As I rounded the corner, I caught my first glimpse of the patient. Mr B was a 64-year-old man whose thinning gray hair lay across his forehead. We gathered in the room, congregated around the patient's bed, and, without speaking, Dr C indicated it was time for me to begin. I approached Mr B, extended my hand, and introduced myself. To his left stood a nurse who was preparing an IV bag of chemotherapy drugs that she would later attach to an abdominal port catheter. I started by explaining that we were first-year medical students and that I hoped he wouldn't mind if I asked him some questions about his illness. Mr B replied that he was happy to participate. I started at the beginning of his illness and he told me that he had been readmitted to the hospital for the treatment of a recurrence of his cancer. As he told his story, he pulled up his loose hospital gown and exposed his abdomen, showing us a scar from a prior surgery, which had resulted in the removal of an abdominal tumor.

As I proceeded with the interview, I concluded that aside from the nurses, we were probably Mr B's first visitors that day. I wondered about his family, which he had not mentioned so far. A bit later, I asked him if any of his family members had visited him since his readmission. In a stoic fashion, he answered that he had admitted himself to the hospital a week before to undergo his current chemotherapy regimen and he had pressed his wife to stay behind. He reported he did not feel it was worth his wife's time to stay with him. He reasoned that he would be home in a week's time and strongly encouraged his wife to avoid missing time at her job and to take care of their house.

On the one hand, Mr B's composure, strength, and determination impressed me. At the same time, it seemed paradoxical. How was it possible for him to cope with a cancer recurrence all by himself? My curiosity got the better of me. I decided to deviate from my memorized list of questions and to explore gently his professed independence. After taking a moment to find the appropriate words, I said, “Mr B, your courage has impressed me and I admire your determination and strength. Can you share with us what it is that is carrying you through this challenging period in your life?” The question had barely left my mouth when his expression changed. The hard lines of his face and the rigidity of his trunk seemed to soften. It seemed like my question had struck a deep chord within him. He briefly glanced up at the ceiling and after a few moments, he looked back and confessed, “The hope of going back into remission is what's carrying me through all of this.” He then began to cry.

Earlier in the year I had observed Dr C holding the hand of another tearful patient. After that patient encounter our group discussed with her the pros and cons of a physician taking hold of a patient's hand. Some of us were more comfortable with doing so than others. Some students expressed concerns about the appropriateness of holding a patient's hand and whether doing so might be deemed an intrusion into the patient's personal space. After facilitating a discussion about the matter, Dr C concluded that a physician has to use appropriate judgment and be personally comfortable with holding a patient's hand before extending his or her own.

There I was sitting next to my crying patient. I was at a loss for words to respond to my patient's tearfulness. Instead, I took his hand and held it firmly. He gently squeezed my hand in reply. The room was briefly silent. Somehow, my gesture, I believe, seemed to confer a wordless message of support and encouragement. Eventually, after a few moments, Dr C stepped forward. She thanked Mr B for his time. Our group wished him well, and we moved into the hall. I was the last to leave. As I did so, I looked back at Mr B, briefly bowed my head, and waved my hand as I stepped outside.

During the first year of medical school students are required to master a tremendous body of knowledge that forms the bedrock of understanding human biology and pathology. In basic science courses students are primarily asked to memorize and integrate information that will later help shape how we approach clinical problem solving. However, courses on doctoring and the opportunity to interact with patients also provide us with essential tools to explore the interpersonal fabric that exists between physician and patient; and help us understand how to provide comfort to patients as they attempt to cope with serious illness and impending death. While I have enjoyed the vast amount of science that I have learned this past year, the most memorable and the greatest lessons from my first year of medical school are embodied in this sort of encounter. I suspect that it may take a whole career to master the science of disease and balance it with both the science and art of patient interaction. I am therefore grateful to have already embarked on that journey and look forward to continuing the exploration for the rest of my career. The summer now awaits me; Riki and Yehuda need my attention.