Work Hurts

I vividly remember the first patient who made me cry. Armed with two years of knowledge in the basic sciences and a white coat overstuffed with penlights and tiny medical books, I walked down the hallway towards Room C with confidence. I was on my Family Medicine clerkship, feeling like I had finally started to get the hang of outpatient medicine. The nurse closed the door softly as she exited the room. She whispered:

Her vitals are normal. She’s here for severe pain that she’s been having in her hands. She’s also deaf, so she communicates by writing things down. There’s a pen and paper already in there.

“Michelle” was an unassuming Latino woman in her upper 40s. She sat quietly as I entered the room, hands folded in her lap, wearing gray sweatpants and a solid, navy hooded sweatshirt. Her black shoes were scuffed. She appeared embarrassed that she had to come to see a doctor. I held out my hand and smiled. We began quickly, compiling her history and physical via a sheet of yellow, wide-ruled notebook paper. Each question was asked individually. Question-answer, question-answer.

I hear you are having pain in your hands. When did it start?

A while ago.

Is the pain getting worse?

Yes.

What made you decide to see a doctor today? The pain was just too much?

Work hurts.

Work hurts. I asked her what she did for a living. I sew buttons on shirts, and I do packaging. How many hours do you work? She was working every single day, Monday through Sunday. Sewing and packaging, and packaging and sewing. She was averaging about 12 hours of work on a good day and living on her own.

She had tried taking painkillers, but just a couple Tylenol here or there. After going back and forth gathering her history, I wrote that I was going to take a look at her hands. I put the pen down and mimed the motions I wanted her to make. I inspected, palpated, pressed on her joints, looked for good pulse and sensation, and tested range of motion. She squeezed my hands. They were coarse and calloused. They were working hands.

I’m going to get the doctor in charge. I will be right back.

She nodded. My preceptor joined us after talking quickly about the case. She did a full examination, and then wrote out her diagnosis and treatment. She wanted to start with a trial of 800 mg of ibuprofen three to four times a day, and a splint for work. We ran a couple of lab tests, with a follow-up scheduled for next month. Each instruction was carefully laid out:

Take four 200 mg tablets at a time. You can take these 3x a day for 1 week with food, and then use them only as needed.
Ok. I have no insurance.

We found samples and a splint.

I need a note for work. Michelle wanted only this morning off though, as she absolutely needed to return to work by the afternoon. She could not even ask for the whole day, much less rest her hands for a week. My thoughts began to race. “How can I make this situation better? Can’t we prescribe a better pain medication? Does she need medical leave? A new job? Get some rest! Come back and everything will be just fine! Please, just get better.” But she needed to work. The note was written for the morning only.

I was lost in a daydream as my attending physician and Michelle conversed via pen and paper. I had been annoyed that this afternoon, on such a beautiful fall day, I would have my nose buried in Harrison’s Principles of Internal Medicine, preparing for an upcoming case conference. I would sit and read in some fancy coffee shop sipping an overpriced coffee. I would return to my apartment to prepare a home-cooked meal, and then spend the evening ironing my dress-shirts. Ironing. That was my “annoyance” for the day. Ironing. I felt sick. Michelle was about to spend the next eight hours sewing buttons on shirts in pain, and studying and ironing was my “work hurts.” I snapped out of it when I realized my eyes were tearing.

I do not know why this visit affected me like it did. There are many patients who are just as needy; so many who make us realize how much we take for granted. Why was this different? Looking back, I realized that even though I was going to be a doctor, I could still feel helpless. Were ibuprofen and a splint really going to make a difference in this woman’s life? What if she needed radiology or referral to a hand surgeon? My thoughts harkened back to the oath we swore as new medical students, receiving our first “white coat.”

 

I will use my skills to care for all in need, without bias and with openness of spirit.

I will strive to alleviate suffering.

I will place the needs of my patients above my own.

I pulled out a laminated note card with an outlined history and physical exam. I could find no questions related to Michelle’s predicament. I saw, “Do you feel safe in your home?” But I could not find, “Do you have a home?” During the social history, one should ask, “What is your occupation?” But there was no question asking if paying for medical care would mean not buying groceries. In our brief, 15 minute encounter, I did not ask Michelle any of these questions. I barely knew her.

As she got up to leave, all I could think to do was write, “It was very nice to meet you – take care!” It felt so inadequate; a pathetic attempt to show that I cared. I mustered up the best smile I could, but all I wanted to do was hug her.

I didn’t. She nodded and walked out the door, heading back to work. She was going to sew buttons onto shirts.

Later that afternoon, when I realized I probably would never see her again, I cried.