Chunks of Arthur’s gnarled yellow toenails fly through the air. He sits in the plastic exam room chair, his feet planted on a sweat-wrinkled paper towel, looking small in his baggy clothes. My two family medicine preceptors kneel on the floor, each hunched over one of his feet. Their nail clippers are a blur as they trim Arthur’s nails with voracious enthusiasm and utter disregard for the dermatophyte confetti showering the room.
When Arthur told me he needed his nails trimmed, I was apprehensive.“They cut me when I walk,” he told me, “and I just don’t have the flexibility to do it myself.” I examined his nails, impressively thick and layered like the rings of an old tree, and took a deep, steadying breath. The task of leaving the room, walking to the wide preceptor desk, and trying to convince someone to help felt both daunting and futile. Of course I will be shut down, I thought. That’s what happened last time.
During a hospital rotation months prior, I had met another patient who needed nail care. Ms Ruth was a retired church secretary, a frail woman with surprisingly strong grip strength and a soft but commanding voice. Her three daughters loved to visit, gossiping and fretting and knitting in a semicircle around her bed. Ms Ruth’s few requests felt urgent to her daughters and felt critical to me. Even a simple need for a bottle of lotion was a precious opportunity for me to actually contribute to a patient’s well-being on my first rotation of medical school.
Looking back now, I don’t even remember why she was admitted. Was it a heart failure exacerbation? A UTI? What sticks with me were her repeated requests for help with her feet.
“My toenails are too long,” she told me. “They look awful, they hurt, and they need a trim.”
“Of course we can do that! We’re here to help,” I said.
When I presented her case during rounds, I included foot care on her problem list, complete with assessment and plan. I remember thinking, I’m being useful. She asked me for something and I listened.
But my team chuckled, already moving on to the next patient. “Oh, we don’t do that here,” the attending told me, in the same matter-of-fact tone he had used to tell me where the microwave was. “Podiatry would scoff if we asked them for something so simple.” Oh, I thought, how silly of me not to know that.
The next day, Ms Ruth looked smaller than I remembered. The wrinkles in her face seemed deeper, and her words were quieter; I had to perch on the edge of the bed and lean in to hear. Her voice shook slightly as she asked me again, “My feet are just such a bother. Can I please get some help?”
“I asked the team yesterday, and it surprised me to hear that that’s not something we can do,” I told her. Her eyes widened and her gaze fell, and I felt like I had just kicked her in the stomach. “It seems like we should be able to. I’m really sorry,” I added, unsure if I was trying to comfort her or soothe my own guilt. She didn’t make eye contact with me for the rest of our visit.
I brought this image into my mind, picturing Ms Ruth’s white-haired head turned away from me, as I braved asking again for support during rounds. “Can podiatry really not help? What about the nursing team? This seems like it matters a lot to her.” The attending laughed, saying, “that’s not important enough to bother podiatry with. You need to move on.” I swiveled my chair away under the guise of looking at my computer, surprised by the stinging rush of tears behind my eyes. I remember thinking, am I caring about the wrong things?
Ms Ruth was discharged after a week or so, and when I checked her chart a month later, I found out that she had passed away. When I saw her grayed-out picture and the letters “DCSD” replacing her birth date, the first thought that clanged through me was, I wonder if she ever got her toenails cared for.
Back under the fluorescent light of the family medicine clinic, watching my preceptors kneeling among the nail shards at Arthur’s feet, I feel the unfurling of a new professional identity. In my upcoming transition to residency, I know that demands on my attention and time will only increase. I want to stay grounded in trust that caring about what my patients care about is never wrong. I want to give my patients’ needs and priorities the same immediate “yes” that my family medicine preceptors gave when I asked for help with Arthur’s nails. And most of all, I want to be the kind of doctor who will kneel on the floor for my patients.
If I met Ms Ruth again today, I like to think I would bring my own nail clipper from home and get to work.
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