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(MedEd)itorial: The Hidden P Waves

“What’s the definition of atrial fibrillation?” she began with an air of informality that made me look up to be sure that my attending was, in fact, talking to me.

When I realized she was serious, I replied, “Unsynchronized electrical activity within the myocardial cells of the atrium that ultimately makes it impossible for the atria to beat as a functional unit, manifesting as an absence of P waves.”

(I’m kidding. I stared at her incredulously.)

She looked back at her computer screen for a moment, and promptly swiveled in her chair to ask the nurse standing behind her to retrieve “an extra long rhythm strip” from the telemetry monitor for the patient in 2G41.
My senior resident and I had just finished seeing the patient in question — a sweet 81-year-old gentleman with a history of congestive heart failure and frequent urinary tract infections. He had been in and out of the hospital multiple times in the past year, and was living in a skilled nursing facility, from which he had been admitted that night due to complaints of recurrent episodes during which he felt suddenly “as if the wind had been knocked out of him.” My senior resident and I formulated an entire plan for why this was a simple congestive heart failure exacerbation; I’d submitted my note and was ready to present what I assumed to be a relatively straightforward case.

A few minutes later, the nurse had returned and I was typing away at my computer screen, addressing a cross-coverage page I’d received regarding another patient. As I typed, the attending chatted nonchalantly with my senior resident about marching out the P waves on the rhythm strip she’d just been handed.

“You see that there,” I heard her say. “At first I thought that this was a case of atrial fibrillation. You can hardly discern any P waves, because the rhythm’s so fast and the baseline is so blurry. But the closer I looked, I started wondering about these guys.” She pointed to a few small upward blips from the unsteady baseline in one of the lateral leads. “If you march these guys out here, and these ones in this lead here, you start to see a pattern… do you see what I’m talking about?”

Indeed, there was a pattern. There were small, barely discernible P waves hiding out within the blurry background noise. Measuring the distance between one of the blips and the next one proved that they were, in fact, coming regularly from the sinoatrial node and were not mere aberrations.

We nodded our heads in amazement as she proceeded to the grand finale: “This guy doesn’t need to have more fluid taken off of him. He just needs a pacemaker. We could potentially completely cure this symptom he’s having!!”

And so, it wasn’t just a typical case of congestive heart failure after all. Immediately, I realized with the clarity of retrospect that of course it couldn’t have been a typical case all along. We were the night float residents in a teaching hospital, and she’d chosen the case specifically because she wanted us to learn. And yet, after only a few days on the services, we’d gotten in the habit of stereotyping patients based on the standard approaches to common problems. He was an 85-year-old man with cardiac dysfunction, and we’d effectively written off his case as a lost cause; we were just going to manage the symptoms, having deemed the root of the problem to be unidentifiable or uncorrectable.

We hadn’t been careful.

We had missed the hidden P waves.

If I’m being honest (and I usually am these days because I’m not competing for grades anymore) I’ve always been annoyed by meticulous people. For what it’s worth, I know enough about human nature, especially mine, to understand that this inclination is most likely a manifestation of the fact that I myself am not a meticulous person; I dislike qualities in people that remind me of my myriad shortcomings. And so, as someone with a wandering mind that is quick to make decisions and leaps from idea to idea, meticulousness has always irked me. It makes me uncomfortable, realizing the thoroughness and thoughtfulness of which human beings are capable.

People have a tendency to react a certain way when I tell them that I’m a preliminary internal medicine intern. Of the twelve interns in my class, I’m one of the three who isn’t pursuing a career in internal medicine. Instead, I’m going into dermatology, a specialty around which there is a plethora of assumptions regarding the types of people who enter it. I guess what I’m getting at is that we don’t have the reputation for being the noblest souls, and I feel this tension (or perhaps project it onto those around me) from time to time. [This is not a space for rationalizing why my academic career will be different from the Botox Brigade that is modern dermatology practice, but it does feel like a space for voicing aloud the discomfort that comes from feeling ignoble for choosing to specialize.]

One of the many things that drew me to dermatology was the hope that I would have enough autonomy and time to think adequately about the problem at hand, formulate a plan and make a difference. I like thinking that we “fix” some things in my specialty. I like that I get to see and feel the results of our interventions. I like that my patients are largely motivated to adhere to their regimens because, for better or worse, they often care about their outward appearance than their glomerular filtration rate. It feels selfish to say it, but I like knowing that I don’t have to juggle 15 chronic diseases at once. Combine that with the nightmare of obtaining outside medical records and coordinating with social workers and writing discharge summaries, all while climbing the academic ladder … Geez… I love internal medicine, but I couldn’t imagine doing it forever.

…”That’s why I work nights,” my aforementioned super-attending responded, when I uttered some version of those thoughts aloud. “I work nights so I don’t have to deal with the politics of day shift. I get to focus on the actual medical problems at hand. More importantly, I get to focus on the people with the medical problems.”

She also said things like, “Guns don’t kill people. Doctors do,” and, “Maybe we should quit doing things to people and start doing things for them.”

I spent the remainder of the night scratching my head, dumbfounded by the profundity of her message. As a new intern overwhelmed by adjusting to the new workflow, I’d spent so much time convincing myself that it’s okay that I’m so selfish because nobody else cares deeply, or has time to care deeply, about the problem at hand either.

But she cared. I felt humbled and grateful for the chance to see things differently. The next morning, as we reflected on the night’s events, my senior said, “She’s the reason I don’t mind working nights. People like that should be around young people more often.”

And she was absolutely right.

Two weeks later, I’m still thinking about all the things for which we are too busy to bother looking. I’m still thinking about the hidden P waves.

As a new intern, I’m still coming to terms with the reality that I can’t have it all.

Thoroughness and meticulousness still overwhelm me.

My tendency to rebel against their necessity in the daily habits of a good medical doctor is a manifestation of that fact. But I also know that this impulse is immature, and that I cannot become the person I hope to be by simply ignoring who I am now. Perhaps it’s scary to be thorough because, if things turn out poorly, there’s no excuse or reason for which things could have gone better. It’s scary to care so much when so many factors influencing a patient’s health are outside our control.

For better or worse, I have the insider’s scoop on how incredibly selfish and haphazard I am capable of being. But I also know that what matters isn’t necessarily “who we are” — I mean, how can we even measure this? Instead, what matters are the choices we make every day. It’s easy to get caught up in lamenting the possibility that I’m “just not cut out for this work.” It’s harder to swallow the truth that if I’ve made it this far, I probably am, and I need to quit hesitating, start fighting the resistance and get back to the real work.

And you know what? A strange thing has happened over the last few weeks. For some reason that I can’t explain and therefore will simply state, I’ve started to think less about all the ways I’m going to spend my limited off hours exploring Oregon. I’ve been thinking more critically about the root of various medical problems instead of covering them up with the shallow, streamlined approaches that could pass as good medicine to the undiscerning eye. I guess you could say that I’ve quit trying to have it all, and started trying to do my job by watching out for the hidden P waves.

I suppose that, sometimes, we just for someone to show us that goodness is possible.

What are the hidden P waves in your life?

Sarah Coates, M.D.
Providence Portland Medical Center
Portland, Oregon