Abstract

In lieu of an abstract, here is a brief excerpt of the content:Vertical Transmission:The Patient, the Student, the TeacherMiguel PaniaguaHe did not ask for this fate, nor did he deserve it, particularly considering the tragic circumstances. Lì presented to the campus health provider one month prior with fatigue, abdominal pain, and jaundice. He and his parents immigrated to the United States from China when he was a child. He was well aware that he had hepatitis B from what is termed "vertical transmission." His mom unknowingly passed on this virus to him during her pregnancy. In most countries with a high prevalence of the virus, prenatal screening is routinely undertaken, and prophylaxis administered. I am not certain this occurred in Lì's case and at this point it did not matter. Lì knew he would live with this for the duration of his life. In fact, he told me he had gone his whole life to this point without any symptoms whatsoever. What is known about chronic hepatitis B infection is that in most people affected, it can be considered a chronic disease where most live a long full life. The risk of advancing to liver cirrhosis or cancer in general is low. This unfortunately was not the case with Lì.What transpired was what they most feared. As he was studying for his final exams, Lì endured days of worsening fatigue, malaise, and nausea. He noticed his skin was a tinge of yellow and he was having some itching that was unusual. He noticed his clothes fitting more loosely and found he had unintentionally lost twenty pounds. He visited the campus health center and after a series of tests and imaging studies, Lì was diagnosed with advanced hepatocellular carcinoma, an unfortunate sequela of this chronic infection. It was then that he put school on hold and returned home to get further care.I first met Lì in the hospital as a consultant for the palliative medicine service. "He won't listen." "He is so difficult." "He is in denial." These were examples of some of the care team's exasperated assessments of his demeanor as a patient. What I did not realize prior to visiting him the first time was that Lì was a pre-clinical medical student. When I first met him, he did not want to talk very much; he was preoccupied and distant. In retrospect, I can see that he was suffering on so many levels. His appearance was gaunt and cachectic. The lights in the room cast shadows in the concave areas of his temples and his collarbones were the most prominent feature of his torso through his hospital gown. He glowed yellow from jaundice. When I examined him on this first visit, I noticed that his liver, a now grossly enlarged hard and nodular structure, occupied most of his abdomen. I found that speaking to him as a colleague, even calling him "doctor," helped him feel respected and enabled me to build rapport with him. At one point, I described to him the findings I felt in his abdomen. "I can palpate the edge of your liver here, what seems to be eight centimeters below your costal margin. There are many palpable nodularities on the ventral surface." It was at this point I invited him to palpate what I was feeling. I gently guided his own hand over his abdomen and noticed him studying the features as if they were not his own, like a skilled diagnostician.Over the course of three weeks, I visited with Lì when I was on service. The last time I saw him, he had declined rapidly, his disease progressing [End Page 17] cruelly, and he was very short of breath and becoming more somnolent. I noticed his mother in the room, standing by his bed, and crying inconsolably as he lay suffering. I felt deep anguish and remorse, wondering if she said these words to herself "It is all my fault," considering the source of his initial illness. I cannot even imagine.As I assisted the team in titrating his comfort medications, I sat with him. He shook my hand with all the strength left that he could muster and said, "you are a good doctor." I...