By: Joel Cohen, PGY-2

He came to us overnight; a 40-year-old male transferred from an outside hospital for liver transplant evaluation with a presumed diagnosis of Wilson’s disease. After repeated work-up, it became clear he didn’t have Wilson’s disease at all. He had alcohol-related cirrhosis.

That largely meant starting from scratch. We restarted his transplant evaluation, which quickly became complicated. His encephalopathy worsened and he was often too confused or restless to participate in his care. PT and OT began reporting he was too combative or too somnolent to work with their team. We set up an intensive outpatient rehab program through telehealth, but adherence was tough. He developed bacterial and fungal infections; each new issue seemed to set back the progress we’d made. At one point, we had to intubate him just to complete his left heart catheterization. It felt like we were doing everything the hard way, one step at a time. Meanwhile, his MELD score kept climbing, reflecting how sick he was becoming.

Our daily TOC rounds started to focus not just on his medical issues but on how long he’d been hospitalized. Case management was getting frequent messages about his length of stay.  Was getting him to transplant actually feasible or were we providing expensive, futile care? We considered reassessing goals of care and talked about whether involving palliative care was appropriate. As a team, we could feel the tension between wanting to do everything possible for him and recognizing that required our hospital to support a long, complicated admission.

But after more than a month, the workup was finally done, and he was approved for transplant. Given how severe his disease had become, he received a liver within days of being listed.

A few weeks later, he walked out of the hospital.

Through all the setbacks, delays of care, complexity of getting this patient listed and ultimately transplanted, this case highlighted for me how much of residency is spent navigating the space between individual patients and the larger system we work in. We’re often the ones trying to balance both sides; advocating for our patients while understanding the realities of hospital operations. Occasionally, it does feel like a struggle between two opposing forces; one focused on numbers, statistics, and meta-data, the other focused on people, individual outcomes, and what could be possible. I think the true art of medicine we are all striving to learn is our duty to ensure they are not oppositional forces but are instead two sides of the same coin of healthcare, both essential for its delivery and improvement. Along with our nurses, patient care technicians, and therapists, we’re the most patient-facing human link in that chain. Remembering that role and holding onto it is what makes this work meaningful.