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J Gen Intern Med. 2009 May; 24(5): 688–689.
Published online 2009 March 13. doi:  10.1007/s11606-009-0943-7
PMCID: PMC2669868


We had ruled out the most pressing potential causes of Mr. C’s chest pain over the first week of his hospitalization and were now tending to his severe chronic leg ulcers secondary to intravenous drug use. His chest pain, however, was still present. Each morning on rounds, the team would ask about the status of his pain. Later, we would huddle in our team room deciding whether it sounded more musculoskeletal or gastrointestinal of origin that particular day and devise our plan accordingly.

I would stand behind the team during these visits to his room, donned in a disposable cloth contact isolation gown. Only after the resident finished talking would I exert my subtle attending presence. “Mr. C, we’re going to try you on a stronger pain medication today, so please let the team know if your pain is improved.”

A bright, capable medical student was assigned to follow Mr. C. As his hospitalization marched on, complicated by processes only secondary to his presenting complaint, the student’s subjective assessments began to hint at some weariness. Mr. C was growing impatient, less agreeable. One day he would not allow her to take down the dressings to examine his leg wounds. The intern experienced the same curt responses, and our team hoped we could soon discharge him to subacute rehabilitation once we cemented his antibiotic regimen.

One afternoon, the student appeared in my office doorway with tears in her eyes. She had been assisting the resident establish intravenous access on Mr. C and thought she may have been stuck by the needle. There was no puncture wound, but she had felt something. Her voice trembled as she spoke, teetering on the brink of collapse. I had been in her shoes before, studying a naked finger tip with quiet desperation. I knew the absolute terror of possibility.

Of course I would help, I reassured her. I sent her to Occupational Health where they would draw the necessary labs and arrange for the patient to also be tested.

About an hour later, she returned to my office, eyes now bloodshot. The occupational health clinic had sent her to the laboratory, where her blood was drawn for the routine panel of needlestick tests. That part had gone smoothly. But, before the lab could run the tests on Mr. W’s blood sample from that morning, we needed to inform him of what happened and obtain his consent for the HIV test. She admitted feeling uncomfortable coming to him like this and wanted help proceeding. I took the consent papers from her and told her I’d get it done. Thank you, she said, eyes glistening. It’s my job.

In this moment, I was an educator. I was a student mentor. I was a mother.

So charged, I arrived at Mr. C’s room. The resident was cleaning up from another failed attempt trying to establish intravenous access. I requested to let the patient have a break from further attempts and to speak with him privately.

“One of our team may have been accidentally stuck with a needle while trying to help place the intravenous catheter in you. There’s a routine panel of tests that we run on both staff and patient when this kind of situation happens. One of the tests is an HIV test...”

“I don’t have HIV,” he cut in.

“This is just a routine procedure. We run the HIV test on everyone...”

“I told you, woman, I don’t HAVE HIV. I was tested a few months ago.” His voice grew louder.

“You may have been tested at an outside clinic, but would you let us run this test again? We wouldn’t even have to draw your blood again. The lab can run the tests on the sample from this morning. Just for everyone’s peace of mind.”

“What about MY piece of mind? You assume that I must have HIV since I use drugs. You wouldn’t run this on anyone else.” His contempt for me was palpable.

“No, we run it on everyone,” I said, silently urging the conversation back around.

“Leave me ALONE.”

I stood there, impotent, remembering the terrified student who waited just outside the door. The consent papers rested on his bedside table, inches away from us, but so far from our current reality.

“Can you please just let us run it again? I know you recently had the test done, but we have a staff member who, in trying to help you, got stuck with a needle and is very upset. Can you do it for them?”

He shot me a look laced with hatred. “No. You all don’t care about me. All you care about is your staff getting stuck. WHAT ABOUT ME?”

I saw a monster. How could this person, this human, not want to help? How could he not see we were all trying to help him, that this student got stuck while trying to help him? A flurry of anger and disbelief rose up, spinning, within me.

“Can you think of someone other than yourself for one minute?” The words came out before I could censor. I shouldn’t have said it.

I shouldn’t have said it.

I shouldn’t have said it.

But, it was done.


I left.

Before I could regroup, I faced the medical student who had been waiting just beyond the door. Instantly, I knew she had heard him yelling. I told her it did not go well.

I knew I had to remove myself from the situation. Back in the team room, I filled in my resident who went back to speak with the patient.

As minutes passed, my mind raced. How did it go so wrong so quickly? How could I lose control of the situation? How could I let my emotions compromise my professionalism?

Mr. C was understandably frustrated. After all, we had not resolved his presenting complaint: his mysterious chest pain. To him, we had done nothing for him. Perhaps if I were more sensitive to his perspective and not so emotionally invested in protecting my trainee, our interaction wouldn’t have been so strained.

There’s a tension that exists between my multiple identities as a clinician, educator, and researcher. It usually lies just under the surface, exerting its various pulls without my conscious awareness. I realize, now, the potential danger of having these vectors pull in different directions, of following one strong pull without holding onto the others. They exist for a reason, if only to ensure an acceptable equilibrium.

Mr. C eventually gave his consent to run the test. But, there was no sense of victory in the end. Only the haunting of a conversation gone awry and the feeling of being stuck.

Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine