A PARENT’S TRUST | Prerana Chatty
A few weeks into my pediatrics rotation during my third year of medical school, Dr. F asked me to conduct a newborn visit with Ms. P and her baby.
Before entering the room, I sifted through the chart, entering the mother and baby’s information into the medical record. Normal vaginal delivery. No complications during pregnancy or delivery. Apgars 9/9. Seemed simple enough. As I got to the bottom of the chart, I spotted a hastily scribbled note that read “questionable murmur – reevaluate at newborn visit.”
I pointed out the note to Dr. F, who then asked “how confident are you in your ability to hear it?”
At this point in my training, my difficulty in discerning and evaluating pediatric heart murmurs had plagued me. In a newborn’s chest, the hollow and vigorous breath sounds seemed to meld with the rigorous and tenacious heart sounds – these tiny newborn organs seemed to speak a mystifying, elusive language that my third year medical student ears were only beginning to decrypt.
“Not very,” I responded, timidly.
Dr. F smiled, knowingly. “Time to practice.”
Securing my stethoscope around my neck, I entered the room, introduced myself as a third year medical student, and congratulated Ms. P on her new baby. She greeted me with warmth and excitement. Ms. P was quick to inform me that she was a first-time mother and had a lot of “burning questions” about how to take care of her baby. She expressed an eagerness to learn and a strong will to provide her child with a safe and loving environment. Ms. P conveyed that the baby’s father would not be involved in her care. Though she had financial and social support, Ms. P told me she was afraid of falling short as a parent. I assured her that her love for her baby was evident, and that her pediatricians would provide her with longitudinal support.
As I stood up to begin the physical exam, she added, “I’ve been kind of worried – the doctors at the hospital told me they thought they heard a heart murmur, but weren’t sure and that you guys could figure it out.”
I nodded, “Dr. F and I will both take a listen.”
I began systematically moving through the newborn exam, eventually reaching the heart and lung portion. I felt for the sternum through the newborn’s pink, warm skin. I identified its border, placed my stethoscope over it, closed my eyes, and listened. At first, my ears were greeted by the usual cacophony of the newborn organs functioning together in harmony – the crisp, whistling breath sounds interspersed between the hoof-beat like heart sounds. I held my stethoscope and waited patiently. A few seconds later, from the noise emerged an impassioned, fixed, harsh swoosh between the heartbeats my ears had pinpointed. Suddenly, it was so clear. Swoosh. Swoosh. Swoosh.
Piecing together the information I had just gathered, I ventured that this baby may have a ventricular septal defect (VSD), a hole between the left and right ventricles, that allowed blood to pass from one chamber to the other. Though we would likely send this baby to a pediatric cardiologist if this were the case, I knew that most VSDs closed spontaneously and did not cause significant distress to the patient.
As I wrapped up the exam, excited to present my findings to my attending, Ms. P looked up at me wide-eyed – “so what did you hear?”
I paused. Though I believed I had identified the murmur, I was keenly aware of the limits of my clinical experience. What if I was wrong? What if I had incorrectly identified the murmur’s quality and location? What if there was no murmur altogether?
“Dr. F will take a listen and then we’ll talk about it,” I replied.
“Yes, I know Dr. F will be here soon,” she responded, “but I want to know what you heard. I trust you.”
I was taken aback by her use of the word “trust”. I entered medical school fueled by a desire to collect my patients’ stories and to use my medical knowledge to tangibly impact the course of their lives. During my third year rotations, my belief that uncovering patients’ narratives is a vital component of their care has been tested repeatedly. In a matter of months, I have become accustomed to spending 15-20 minutes with a patient (if that), sticking to an unofficial script, and diverting the conversation from their “unrelated tangents” to remain focused on the medical issues at hand. These interactions have sometimes felt transactional, which I have found deeply unsatisfying.
All the while I have been acutely aware that my limited clinical experience in this early phase of my training prevents me from intervening in my patients’ lives in a productive and lasting way. I have been accruing clinical knowledge at a formidable pace, but rarely have I been afforded the opportunity to reflect upon the fact that this knowledge will empower me to improve the course of my patients’ stories.
Ms. P’s expression of “trust” reminded me of the power of my clinical knowledge and of the meaning in the path I chose to pursue. My investment in Ms. P’s story cultivated our relationship while my medical training enabled me to identify her baby’s murmur. In a single moment, Ms. P had affirmed the marriage of clinical acumen and the human narrative that had brought me to medicine in the first place.
Hesitantly, I told Ms. P that I believed I had heard a murmur, but that I was not confident and wished to confirm it with Dr. F before providing her with more information. She was incredibly gracious and appreciative.
I returned to Dr. F and relayed that I heard a “harsh, holosystolic murmur loudest at the left sternal border that I believed was consistent with a VSD.” I also conveyed that Ms. P had specifically asked me what I heard.
“What did you say?” Dr. F asked.
“I told her I believed I heard a murmur, but that I wasn’t sure and wanted to confirm with you before saying anything more.”
“That’s fair. But just remember you’re not so far away from being the person to make those decisions yourself. Isn’t that pretty amazing?”
I nodded in agreement. Ms. P reminded me that trust is the ultimate form of empowerment. While the responsibility of caring for patients is daunting, I believe that my resolve to treat my patients and their families as complete individuals will enable me to weave my medical knowledge into their beautiful and complex lives. When the time comes for me to lead the way, I know I will be ready.
Prerana Chatty is a third-year medical student at Rutgers Robert Wood Johnson Medical School. Prior to medical school, she received her BA in Biological Sciences with a minor in Creative Writing from Cornell University. She firmly believes that the core of medicine is made up of patients' stories and hopes to continue to integrate narrative medicine into her career. She will be applying for a residency in pediatrics this fall and is looking forward to the next step of her journey. Outside of medicine, she has a voracious love of tea, dogs, and outdoor walks.