A Lesson in Two Clinical Vignettes: Laughter Remains a Potent Medicine

The following clinical vignettes were based on real clinical encounters with details modified to protect confidentiality. My First Patient My medical school used a traditional “2 + 2” model, with preclinical didactics comprising the first half followed by intensive clinical clerkships. On my first day of the third year, I entered the hospital to begin my inpatient internal medicine rotation, trembling with trepidation. Despite several months of dedicated intellectual cramming for the prerequisite Step I exam, I still felt ill-prepared for this new beast. With a deep inhale, I walked into the resident office and introduced myself. “Why don’t you preround on Ms. Schmidt?” replied my senior resident. “She was admitted overnight with an intentional acetaminophen overdose.” It didn’t seem to be the worst first assignment—the management of her condition was well-described, and the differential was narrow. I walked down the hallway to Ms. Schmidt’s room, dimly lit with just the beginning of the day’s sunrise peering through the curtains. Not desiring to startle her, I left the curtains drawn and the lights off. As I traversed her room, I was relieved to learn we were not alone. She appeared to have a visitor (I would later learn the term “sitter”) in the corner of the room. Ms. Schmidt was sitting to the left of the bed, with poorly kempt long, brunette hair and a cotton hospital gown that reached her feet. Her elbows rested uncomfortably on her chair’s peculiar polyurethane armrests. “Good morning, Ms. Schmidt. I am Jordan, a medical student on your care team.” I learned in my doctoring course that it’s always ideal to meet patients at their level; thus, I pulled up a nearby chair and began conversing with her. “I see you ate breakfast this morning! How wonderful that you had an appetite,” I encouraged her with positive reinforcement. “What is your understanding of what brought you in overnight?” I was about halfway through the history of present illness when suddenly the sitter interrupted me mid-sentence, “Might I suggest you come back when she is finished using the bathroom?” As more of the morning light filled the room, it became evident that Ms. Schmidt was not, in fact, sitting on an uncomfortable plastic chair, but rather a bedside commode. She had been restricted from entering her lockable bathroom given active suicidal ideation. I was mortified. “Oh my goodness, I’m so sorry. I will absolutely come back later.” It was all I could muster in my crippling embarrassment. I rushed out as quickly as I could. Internally, I was catastrophizing. What is this patient going to tell my attending on rounds? Have I failed this rotation before it even began? As I closed her door, I heard Ms. Schmidt and her sitter erupt into laughter. Well, if I do fail… if I made a woman who attempted suicide last night laugh this morning, it may have just been worth it. The Bad Burrito Years later, with a few more patients under my belt, I was nearly done with my obstetric anesthesia fellowship. Shortly after 9:00 pm, I received a page from a patient’s nurse: “Room 15—ready for consent. Pls read chart beforehand.” Despite always prereading my patients’ charts, this reminder often portended a calamitous obstetric or social history and a significant challenge ahead. Ms. Mamedova was a 25-year-old Azerbaijani-speaking woman who had not previously presented to our hospital. She only had five notes in her chart (so it was a quick read), and the first one was an ED note with a chief complaint: “I ate a bad burrito.” The story went something like this… Ms. Mamedova was in her usual state of health until Tuesday evening, when her stomach began to cramp and she felt nauseated. Having experimented with an adventurous new locale for lunch, Ms. Mamedova suspected she may have had food poisoning and the pain was intensifying. After several unfruitful studies in the ED, the attending physician ordered a CT scan. Prior to entering the scanner, Ms. Mamedova completed an obligatory pregnancy test, which much to everyone’s surprise returned positive. This indeed was not a burrito—it was a baby, and she was in labor. Ms. Mamedova was brought up to L&D, and was requesting consultation with an anesthesia provider to discuss analgesia options. I procured the unit’s interpreter iPad, and shockingly obtained an Azerbaijani interpreter rather expeditiously. Much like with Ms. Schmidt, I tried to maintain an open-ended and judgment-free patient experience. Nevertheless, I couldn’t help myself from asking some questions related to the situation. “So, you had no idea that you were pregnant?” I inquired utilizing my interpreter. “Zero.” “Is this your family’s first grandchild?” “Yes! For both my husband and myself!” “What did your parents say when you told them?” “Something like: ‘Mom, you’re going to be a grandmother!’ ‘Oh, what a blessing! Let’s go shopping next week for clothes!’ ‘Oh no, mom. Like right now. You’re going to be a grandmother right now.” “Do you have any names picked out?” “Given that I found out an hour ago I was pregnant, no I do not.” Ms. Mamedova ultimately agreed to receive labor epidural analgesia, and many hours later, on my subsequent shift, a cesarean delivery was called for failure to progress. As we entered the OR, I retrieved the interpreter iPad again—this time took 10 minutes to find an interpreter. After an exhausting wait, an interpreter in her mid-70s appeared. After the interpreter’s compulsory introductions, I began coaching Ms. Mamedova through what to expect during the operation. “When the baby is delivered, I can lower the drapes so that you can see him/her. Would that be OK?” I asked the patient via the interpreter. “Yes!! I would love to see the baby.” shouted the interpreter. “Not you, ma’am. The patient!” “My shift ends in 10 minutes, but I can stay longer!” she responded. Regardless of how many various ways I tried to rephrase my question, the interpreter persistently responded that she would absolutely love to see the baby. At this point, the entire room is laughing: the technician, surgeon, nurse, and most importantly, the patient. The levity of this moment transformed the patient’s anxiety in front of me. Thirty minutes later, Ms. Mamedova delivered the closest baby I’ve ever seen to an Apgar score of 10 and was discharged three days later without complication. These clinical vignettes bookended my medical training. They do not fit neatly into a case report or oral presentation, and yet they taught me something profound that I carry with me daily. In a medical world inundated with automations, digitizations, and artificial intelligence, many physicians have real concerns about regulation, misinformation, safety, and the potential for (at least partial) replacement by emerging technologies. But what can never be replicated is the human-to-human connection that crystallizes when a physician provides care to a patient in need, nor the humbling imperfections of the human condition that accompany it. Artificial intelligence cannot cry with you during difficult news, it cannot hold your hand when you are crippled with anxiety, and perhaps, most importantly, it cannot laugh with you at times when you least expected it but, in hindsight, may have needed it the very most.