Disha M. Patel

As a medical student during a global pandemic, it has been an immense honor, but also a heavy burden, to shoulder the responsibilities of a healthcare professional. From battling vaccine misinformation to managing chronically ill patients via telemedicine, I have been able to have these first-hand experiences owing to the longitudinal chronic care curriculum offered at my school. The longitudinal chronic care curriculum at the Medical College of Georgia provides the opportunity to work with a real patient to gain knowledge and confidence, and to experience patient care ownership, in preparation for our entry-level encounters in the hospital setting. This curriculum allowed my student partner and me to follow an assigned patient monthly through our telemedicine chronic care clinic during our first year. During our last scheduled visit, we learned that our unvaccinated patient had unfortunately passed away following a long stay in the hospital due to COVID-19 complications. The experience has left me with lessons learned and unanswered questions that will shape me as a person and a future physician.

The first time we met RP, it was a telemedicine visit in January 2021. RP had an extensive medical history including a previous stroke, heart bypass surgery, hypertension, congestive heart failure, chronic ulcers on his legs due to poor blood flow, and nerve damage in his feet as a result of his type 2 diabetes. However, during this first visit, his biggest concern was his non-healing open ulcers on his legs that had made moving around very difficult. We talked about his pain management and wound care and discussed exercises to help with the blood flow to his legs. At the end of the visit, RP disclosed that he had experienced some right-sided weakness that resulted in a fall around Christmas. This took me by surprise because this was my first visit with a real patient and, from what was being described, it seemed like the patient may have had a stroke. I felt that the weakness and fall should have been the first things he told us about during our visit, though afterwards I realized that he may have not understood the importance of that information. We contacted patient care coordination to get him an appointment to see his primary care physician as soon as possible and get him scheduled for an MRI.

During our second visit, we learned that RP never went to get his MRI due to his claustrophobia. We tried to comfort and counsel him on the importance of getting the MRI, but he never overcame his fear. I realized that sometimes, no matter how hard you try, patients may not do what you want them to, even if it is in their best interests. But I was frustrated, because I wanted to do right by my patient and to help him get better. Our subsequent telehealth appointments with RP mostly focused on wound care, physical therapy, and whether he had experienced any more stroke-like symptoms.

The last time we talked to RP he was in the hospital, though we didn’t suspect that it would be the last time. He had been in the hospital with COVID pneumonia for over two weeks. He had gotten somewhat better, but he still had not fully recovered because of his other chronic issues. He was discharged two days after our conversation but returned a day later due to respiratory failure and shock that led to his passing. I did not learn of his death until it was time for our regular telehealth visit the following month; when I checked the chart before his visit it stated that RP was deceased. This caught me off guard and I did not know how to feel. The longitudinal curriculum had allowed me to get to know this patient and to follow him over the past year, but now he was just gone. He had died only two days after we last saw him. I felt lucky that after all our video calls I had the privilege to see him in person that last time and to meet the man behind the screen because of a missed telehealth visit.

I’m sharing my experience with RP because I need people to see and acknowledge that the medical education I have received during the pandemic is not the same medical education that others before me received. Not only did I have to learn how to navigate the pressures and difficulties of medical school, but I had to deal with unanticipated major life changes brought on by the stresses of the pandemic that were taking a heavy emotional and mental toll on the global population. Starting medical school during the peak of COVID, I was overwhelmed with the frustrations of virtual lectures, the inability to shadow/volunteer in-person, and restricted social interactions. But the pandemic not only affected the structure of the classroom; it made my first patient into my first patient death.

Because of COVID, the many high risk and immunocompromised patients we saw in the chronic care clinic were now predisposed to an additional risk that increased their rates of morbidity and mortality. Many students might not encounter their first patient death until they are well into their clerkship rotations or even into residency. Yet I had to learn how to navigate the emotions of a patient death as a second-year medical student with my first patient. When I first learned that my patient had died, I was not equipped to process my emotions. I could not fully comprehend that the patient to whom I thought I was about to speak had passed away almost three weeks ago without me even knowing.

I had spent the past nine months talking to RP every month, getting to know his health struggles and the challenges in his life. And now he was gone, and those conversations were over. Even though I knew he had many chronic problems, I never really thought about the fact that he could die while he was in my care. I thought he would be there for our remaining visits.

After wrapping my head around the fact that my first patient had died, I began to question myself: Could I have done something different to have changed his outcome? Could I have convinced him to get the COVID vaccine if I had pushed a little harder? And if so, would he still be alive today? I had a responsibility to take care of the well-being of this patient and I felt like I failed him. This is a tremendous burden to carry. Even though I know RP had other physicians taking care of him, I can’t help but wonder if just maybe, if I had said something different or done something different, that he would have gotten vaccinated and could still be alive today. No one can truly prepare you to deal with your first patient death. But entering medical school, I never thought that I would be experiencing a patient death so soon and so remotely.

By Brooke Schwartz

I feel off this morning. My head feels heavy, and my throat is sore. I roll out of bed and reach for one of the at home COVID-19 tests stacked in my bathroom. I discard the instructions, as I have them memorized by now, and wait a few minutes. It’s negative. I put on my scrubs, grab my new monofilament, and head to the free clinic where I am currently rotating as a third-year medical student. 

It’s time to see my first patient of the day. I am excited because he is an elderly man, Mr. E, whom I have seen before. He is a 78-year-old struggling with homelessness, depression, hypertension, peripheral claudication, wet macular degeneration, and sensorineural hearing loss. His gratefulness to our clinic and his warm personality are endearing. I can hear Mr. E in the waiting room asking the volunteer for help filling out his paperwork because he can’t see the small print. The reems of paperwork at a free clinic can be daunting. I listen more closely as the volunteer carefully goes through each question with Mr. E. He speaks with her in Spanish and his voice is deep and strong.

Eventually, the door leading from the waiting room to the central hallway of the clinic swings open, and I see Mr. E dressed in his usual green cardigan and button-down plaid shirt. He waddles into the exam room floating his cane above the ground. “Why does he refuse to use his cane the proper way?”

He reminds me of my grandma who recently passed. She, too, was a strong-minded spirit stuck in a weak, withering frame. She, too, clung desperately onto her independence to the detriment to her overall health. Their refusal to accept their frailty evokes a strong desire within me to protect them.

From what I remember about our last visit, I know Mr. E. does not view his health as a concern, but his lack of employment is at the very top of his priority list. He sees himself as a failure of man, relying on his eldest daughter to house him, which she does—begrudgingly. On the other hand, my priority was keeping him from having a heart attack and ending up unconscious on the side of the street. We will discuss both issues again this visit.

I knock on room number two along with my in-person translator and find my dear patient behind it. We exchange smiles and a handshake. The translator and I have both seen Mr. E four times now, and we are well adjusted to effectively communicating with each other. We know to speak in short sentences and to allow ample time for the patient to express all his concerns before responding.

“Hello again, I am so glad you came back for your follow-up. How have the at home blood pressure readings been?” As the translator begins, I cough. Immediately, I feel guilty. Is my throat still hurting? Did I take the COVID test too early? Do I have a fever? Suddenly, I picture my vulnerable patient hospitalized, intubated, and falling ill to COVID-19 because of me. I quickly pull myself back into the conversation; over the course of my medical school, COVID-19 has forced me to become comfortable with this nagging anxiety of infection and transmission.

Mr. E. responds, “My pressure has been a bit better, but I couldn’t pick up the medication you prescribed at the last visit because it is $18 at Publix, which is just too much right now.” I zone back in as the ever-present difficulty of treating uninsured patients rears its ugly head.

“Did you use the GoodRx coupon we showed you last visit?” He looks confused. “No, I forgot what that is.” I pull out my phone and open the application. “I found it for $6 at your local Winn-Dixie for a 90-day supply.” He reaches up and taps my phone screen to zoom in as I make a mental note to print out the coupon for him this time. There is a look of relief in his eyes, and he says, “That is much more affordable. I promise to pick it up after I leave today.”

We finish the visit and I exit the room to present the patient to my attending. She is concerned he does not remember much of what we talked about at the last visit and suggests we perform a mini-mental state examination. He scores phenomenally, and we are relieved. We send him off with the prescription, GoodRx coupon, and plans for another visit in a few weeks.

My attending sees the despair in my face as I wave goodbye to Mr. E. She allows me a moment to reflect. Elderly patients have always been a difficult population for me to see due to their vulnerability. I feel a sudden urge to walk them to their car, drive them to the pharmacy, and, overall, deliver care I would not consider for others. Unlike most other patients, I saw Mr. E. weekly for a month and spent time in between other patients calling MEDICAID representatives to help with his case.

I must let go of my emotional attachment to Mr. E as the waiting room fills up, but I know it is this compassion that will help to make me a good doctor. I plan to practice in a way my emotions can aid in patient care, and I refuse to allow the hardships of medicine to hinder raw human-human interactions. I will allow myself to feel the emotions of my patients, while also providing them a strong backbone to lean on.

Time for the next patient.

The day progresses and I begin to feel more ill. I excuse myself from clinic and head home. Another COVID test is pulled from the stack and once again, it’s negative. As I fall asleep, I’m worried the test tomorrow might not be. “I can’t believe I shook Mr. E’s hand. I can’t believe I let him touch my contaminated phone! Am I a horrible provider?” The guilt consumes me as I wonder if I have put the very patient I want to protect the most at risk of acquiring the frightful illness of COVID-19.

Brooke Schwartz is a third-year medical student at the Florida International University Herbert Wertheim College of Medicine. She is interested in pursuing Pediatrics.