Plastic Lessons

I always feel awkward when I talk to plastic patients.  The simulation mannequins are impressive: their eyes blink, their chests expand as they breathe, they have pulses, they bleed, they burn.  A screen monitors vital signs: I administer a pressor and a dipping blood pressure perks up, or I order a beta blocker and a racing heart rate slows.  A physician in the next room lends her voice to play the patient, responding to what I do and say.  A physician in the same room becomes a tech, relaying results of my tests and nudging me through the next steps when I veer off course.

The situations are designed to be overwhelming.  I look helplessly at the “tech” when he asks me how many liters of saline I want to give the patient.  When the patient asks what’s happening or when fear enters her voice, I give automated reassurances while my mind wanders through differentials.  When the patient begins deteriorating for reasons beyond my comprehension, I pause for too long: listening to the beeping of the monitor, watching her oxygen saturation plummet, and waiting for the scenario to be over so I can be rescued.  During simulations, the student usually needs as much rescuing as the patient.

That morning’s mannequin was distraught.  She was bleeding profusely from her vagina and was terrified that she was miscarrying.  Her blood pressure dropped.  She wouldn’t stop crying.  She was asking a lot of questions.  The tech wanted to know what he should tell her boyfriend outside.  I used about 5% of my mental capacity in an attempt to soothe her and deflect her boyfriend’s worries.  The rest I reserved for piecing together the tiny bits of information I had gleaned so far on my ob/gyn rotation on how to diagnose and manage miscarriages.  I stabilized her blood pressure and admitted her for surgery, but she was still crying as the scenario ended.  In my eyes this was success.

Excited to get away from plastic people, I re-joined my team on the floor that afternoon.  I found our next patient in the surgical waiting area.  She had had a miscarriage.

There are eight beds in the waiting area, each separated by a few feet and three quarters of a curtain.  In a span of twenty minutes, the patient meets a slew of personnel: surgeons who explain what recovery will look like, anesthesiologists who verify medications and allergies, nurses who update physicians on the patient’s recent changes, and translators when necessary.  The room is busy but not chaotic; animated but not loud.

And there my patient sat, crying in her bed.

Everyone around me had a task.  Each person gave the patient words of sympathy–which eerily echoed mine from only a few hours before–and moved on to the next aspects of her care.

Although I was technically part of the surgical team, I was also technically useless at that point.  Unlike simulations during which I had to balance medical management with verbal comfort, this time I could allocate my entire brain to the latter.

I only wished it were merely as uncomfortable as it was with my plastic patient.

After introducing myself and uttering the requisite situational apology, my face molded itself into an expression of glum empathy.  I was amazed by the nurses’ facileness in switching their expressions as they moved from bed to bed.  Within my patient’s fifty square feet, they held her hand and lowered their voices.  Then, with their backs turned and sixty seconds behind them, they bantered with the next patient.  The physicians busied themselves writing notes, looking up records, and explaining to the patient what dilation and curettage meant.

With nothing to do but nowhere else to be, I stood silently by the patient’s bedside, unwilling to interrupt the medicine taking place, even when the medicine wasn’t being spoken aloud.  I was convinced that she perceived me as some sort of creepy extra during one of the worst days of her life.  But still, I didn’t speak.  I knew she’d remember a stupid or hurtful comment more vividly than no comment at all.

She seemed to sense that her doctors considered her impending procedure relatively short and safe.  (At twenty minutes and only somewhat invasive, it was.)  Through her tears, she tried to justify her questions.  “I know you do these things every day, but for me it’s new and I’m terrified.”

I desperately wanted to tell her that I wasn’t like the rest of them.  It was new for me too.  Just as she would always remember this surgery, so would I.  But I remembered my superiors’ advice (approaching an order) not to let on to patients how inexperienced I was.

I needed her to know.  As she looked more miserable, my judgment waned.  During a lull in the preparations, I very quietly said to her, “I’m not going to do anything at all during the surgery; I’m only watching.  But it’s my first time too.”

“First time?  Join the club,” she repeated, too loudly.  I knew my intern had overheard. I could only hope that she wouldn’t be the one writing my evaluation.

Did I have anything at all to offer?  “I’m just a student so I won’t know all the answers to your medical questions.  But I have a lot more time than these guys”–I gestured with my head to the rest of the team–“which means I have a lot more time to help you in any way I can.  If you need anything, please let me know and I’ll try to get it for you.”

She nodded, and I realized I had finally found my place.  It wasn’t big–about fifty square feet.  In fact, it was precisely the size of my patient’s world.  A bed.  A curtain.  An IV line and a monitor.  People who faded in and out of their own ever-shifting worlds.  A patient and her mother.  And me.

I thought back to the simulation of a few hours ago.  It was useful, but not immediately so.  With plastic patients, I am learning how to be a doctor and feeling overwhelmed with medicine.  With real patients, I am on the cusp of learning how to be a doctor-in-training and feeling underwhelmed with myself.  At some undetermined time, I hope the two paths will find a way to meet.

As we wheeled her bed out of the holding room and toward the operating room, her mother asked how long before she could see her daughter again.  I was the only one who heard.  Frustrated, I couldn’t even answer that.  I nudged my intern and repeated the question.

“An hour.”  Her mother nodded.

In my eyes this was success.

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Last Monday I sat in a chilly exam center for eight hours and took a very important test.  When I arrived home, I looked at the walls surrounding my desk.  They were cluttered with upwards of seventy hand-written index cards.  Very methodically–and resisting the urge to tear them to pieces–I took them down.  Atypical anti-depressants and their side effects.  The organs behind your abdominal cavity.  Every anti-viral drug and its machinery of attack.  The biochemical pathway an amino acid takes to become a neurotransmitter.  Chemicals that turn your blood dangerously acidic.  Which bacteria need air to live.  What happens in your cardiac cells from hour zero to month two after you have a heart attack.

It wasn’t that I wanted to forget the knowledge that I had crammed and re-crammed into my brain.  It was that I didn’t want it to be the first thing I saw anymore.

The last few months of second year had been a blur of caffeine, question banks, ignoring phone calls, and sighing.  The exam itself culminated in the biggest blur of all, and for this I am grateful.

Two days after my exam, I attended hospital orientation and became a third year student.  This means that I will be an apprentice of sorts (the kind that still pays tuition), working full-time in the hospital until I graduate in two years.  Instead of seeing one patient every week or two, I will be seeing and discussing dozens each day.  Unlike in years one and two, when my entire job was to learn from the patient, now my role has expanded: to help the person in front of me.  All the interpersonal skills that have atrophied over the last few months will become important again as I contribute to patients’ care.  All the medical details that I have tried to file in my brain will become part of a larger picture as I apply them to make people’s bodies feel better.

Since I last wrote in January, I tried to write two separate blog posts.  They started very differently, and they both ended with the first sentence.

One post I wrote at midnight a week before my exam.  “This is not who I am,” I typed, cringing at the clichéd and whiny words.  Then words stopped coming altogether, and I went back to studying.

The second I wrote at noon, several months ago.  I had performed my first (minimally) invasive procedure on a patient, and it was to help a medical team I was shadowing.  It was the first time I had ever interacted with a patient in a way that directly contributed to his care.  On a high, I wrote, “Today, for approximately 60 seconds, I did something that mattered.”

I really want third year to matter.

The walls around my desk are bare now.  The vast white space looks unfamiliar and slightly discomfiting in a place where I am used to seeing smudges and coffee stains.  But there is an energy in the blankness, and a nervous excitement as I wonder what will fill them.

I did keep one small card taped up.  It always looked different from the rest.  It was given to me by a terminal cancer patient I worked with who found her strength in religion.

“Don’t worry that you’re not strong enough before you begin.  It is in the journey that God makes you strong.”

Orientation is over.  My journey begins tomorrow.

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Impersonal and self-absorbed as Manhattan may be, it’s still embarrassing to cry on West 32nd Street.  I looked for a store, any store, and ducked inside.  The pace of my steps and angle of my head as I buried myself into a back corner, thumbing through pants twice my size, gave me away.  A store clerk walked over and asked if I was okay.  I knew I’d have to meet her eyes, unable to hide the tell-tale redness and puffiness of my own.  I asked if they had a bathroom I could use.

Being Manhattan, there was no customer bathroom, but the store clerk very gently led me to the staff bathroom and told me to take the time I needed.  After five minutes of some fairly heavy crying, I spent the next ten desperately trying to disguise what I had just done.  I scrubbed my face until it hurt and molded my expression back into that of stoic, aloof New Yorker.  My insides didn’t feel much better, but at least my outsides didn’t betray that anymore.   I emerged, thanked the clerk, and took comfort in the fact that I’d never see her again.

My little episode had only intensified the all-consuming ringing in my ears.  The tinnitus had started two years ago, suddenly and unrelentingly.  Five doctors and five clean bills of health later, I was left with the unchanging advice: “We’ve ruled out anything organic and tinnitus isn’t dangerous, so you’ll just have to get used to it.”  No follow-up appointment necessary.

I was left to my own devices–which included the Internet, snake oil supplements, and my own obsessive mind–and I wasn’t using them well.  Besides being sleepless, irritable, and depressed, the far more damning thing was that I was without any hope.  I couldn’t imagine being able to live happily in my body.

Thinking back, I still can’t figure out why it didn’t dawn on me to consider a psychiatrist instead of an ENT or a neurologist.  The idea to see him wasn’t even my own.

After getting to know me, the psychiatrist eventually suggested medications.  I wasn’t afraid of the side effects, and I began immediately.

A year and a half later, everything is much better, objectively and subjectively.  Though not gone, the auditory disturbances are manageable to the point where they hardly register emotionally.  I don’t much like talking about it, for reasons better articulated by Russell Crowe’s character in A Beautiful Mind:  “I still see things that are not here. I just choose not to acknowledge them. Like a diet of the mind, I just choose not to indulge certain appetites.”

Of course, most times I go to the doctor, for any purpose, I am asked about the reasons I am on certain medications.  Usually my answer is acknowledged, and the appropriate empathetic response is conveyed.

Recently, I was surprised by one doctor’s version of empathy: “Oh, yes, tinnitus can make you literally want to drive off a bridge.”

Of course, this doctor doesn’t know that 18 months ago, I broke down in midtown Manhattan and wondered how I could live out the rest of my life at this rate.  She assumes by my demeanor that I am well-adjusted and perhaps always have been.  She doesn’t know that sometimes when I listen with my stethoscope for a patient’s heartbeat and I hear ringing, that familiar fear makes my own chest tighten.  Or that sometimes I “indulge” in anxiousness when a tinnitus spike occurs that I cannot ignore.  Or that the very condition she was treating me for was creating such a spike at that moment.

Regardless, I was in “no acute distress,” as the medical lingo goes.  I let it go.

I wasn’t even angry with her off-the-cuff remark.  I say silly things to patients on a weekly basis, and the only reason it isn’t more frequently is that I only see patients once a week.

What reminded me of her remark was a piece by Dr. Danielle Ofri in the New York Times, which was inspired by a New England Journal of Medicine article by Dr. Jerome Groopman and Dr. Pamela Hartzband.

All three doctors rail against the term “provider” instead of “doctor” for a number of reasons: the generic term connotes sterility, commodification, distance, and interchangeability.  “The words we use to explain our roles are powerful,” Groopman and Hartzband explain.  “They set expectations and shape behavior.”

This is all fair.  And, as a medical student, I should be in especially staunch agreement.  But I’m not.  As a patient, I’ve seen far more “providers” than “doctors.”

I went to the doctor who made the unfortunate comment about my tinnitus because I had an unrelated problem.  She took me seriously, she diagnosed me correctly, she prescribed the appropriate medications, and I got better.  Technically, flawless.  She provided excellent care.

But, Groopman and Hertzband write when we use a term like “provider,” it ignores “the essential psychological, spiritual, and humanistic dimensions of the relationship.”

From a patient’s point of view, though, all it takes it one insensitive comment from the physician to lose that humanistic dimension.  When my doctor made that remark, I relegated her to the impersonal role of provider, someone incapable of understanding my experience but capable of treating my physical problem.  I just wanted to get better.  As Dr. Ofri writes, “It makes [physicians] feel like a vending machine pushing out hermetically sealed bags of ‘health care’ after the ‘consumer’s’ dollar bill is slurped eerily in.”  That is exactly how I saw my doctor.

Was I happy with the care I got?  Sure.  If I have another problem, will I see her again?  Probably.  Was I bothered by her remark?  A little.  Did I care?  Not really.  I didn’t care because I depersonalized her immediately after.  If I cared, the remark would hurt.  I don’t want to hurt.  Is that fair to the doctor?  Maybe not, but I care more about me.

This example is far from unique, for me and for others as well.  There are many reasons people dislike doctors, and many of these reasons are not particularly fair.  But when the same complaints are heard over and over again (“He doesn’t listen to me!”  “I can’t believe she said that!”  “He doesn’t understand!”), one has to wonder which came first–the term “provider” or the doctor acting like one.

I’m not dismissing the argument that “provider” is irksome or suggesting that we shouldn’t spend space discussing its consequences.  But I wanted to spend some space on rationalizing why patients may already think in these terms: on how in many cases physical provision of health care is exactly what doctors do, and on how depersonalizing doctors can actually protect patients when their emotional or humanistic care is lacking.  And the term “provider” sometimes fits, even if doctors don’t want to wear it.

“But words do influence us,” Dr. Ofri writes about what doctors are called.  Yes, they do.  Now let’s take those thoughts and apply them to what doctors say too.

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If Harvard had a habit of failing its students, I would have failed my observed patient interview last week.

Take a patient history and do a physical exam.  It was the same exercise we had been doing for the last several months.  This time, a preceptor would be observing me.  Or evaluating me.  Or helping me.  I wasn’t sure; everyone’s style differed.

Unsurprisingly, my assigned patient had been discharged, so I began the manhunt for a backup.  I eyed the room next door, and my preceptor eyed me.  I stopped outside to sanitize my hands.  A tired-looking man walked over to me.

“My mother’s pretty pissed right now.  She was supposed to be discharged today, but they’re delaying it by a few hours.  You sure you want to go in there?”

I was absolutely sure I did not.  I was about to thank him for the warning and make a beeline for a more agreeable patient to prod verbally and physically, when my preceptor said, “Oh, that should be fine.”

This turned out to be a big fat lie.

Forty five minutes later, we emerged from the room with a complete history but no physical exam.  My preceptor put his arm around me and said immediately, “You need to control your patient.”

After throwing myself a private pity party, I complained to my friend that evening.  “What do you mean, you just didn’t do the physical exam?” she said.  It was incomprehensible, what I managed to do.  I managed to run out of time because a) I didn’t clarify with my preceptor beforehand how much time I would be allotted (it was half of what I expected and what my classmates had received), and b) I couldn’t get the patient to stop talking and start doing.  I felt like the world’s worst medical student.

I watched as my preceptor attempted to fill out my evaluation form with me.  He couldn’t even fudge my performance on the exam, since it was non-existent.  Blank, blank, blank, blank.  Patient rapport: excellent.  Blank, blank.

It’s not a new problem, the struggle I have with balancing politeness and aggressiveness, trust and control.  To put it politely, I was frustrated.

I was frustrated that the habits that make me a good listener in most situations made me a lousy diagnostician with a difficult patient.  I was taught not to interrupt (and not just with patients).  I usually wait at least a beat after the speaker finishes before I start talking.  But for an angry patient, that beat is enough time for her to dredge up another complaint and run with it.  Then the game begins anew, and I have to figure out where to intercept her next to get more of my questions answered.  It’s an exhausting game of mental football, and I’m concerned about making her bad mood worse–for selfish and unselfish reasons.

I vividly remember reading the studies that say physicians wait an average of about 20 seconds before interrupting their patients at the start of the interview.  I mentioned that to my preceptor.  “It takes a patient about two minutes to give you what you need to know,” he said.  Touche.  I had overshot that several times.

I was frustrated on a grander scale, thinking about my involvement with health media and my blog, which are distinctly more humanist than scientific.  Had I become too soft, falling for bedside manner at the expense of competence?  There is less coverage in the mainstream media of a major part of health care: correctly diagnosing a set of incredibly non-specific and non-consistent symptoms.  There is little appreciation of the untangling of relevant from irrelevant, particularly when the patient’s narrative may lead you astray and you must rein in the meanderings.

Mainly, I was frustrated that I somehow managed to become too polite to be an effective doctor-in-training.

One of my classmates received similar criticism during a psychiatric interview.  “You took what the patient said at face value and didn’t challenge him enough,” the instructor told him.  That same instructor grilled the patient later in the interview, who immediately became defensive and closed off.  An improvement? I thought, doubtfully.  Is he lying less to you now?

I am frustrated because people who presumably know more than I do are telling me to do things that go against my basic social mores.

“You thanked your patient too much,” my preceptor told me.  “You also asked her too many times if she was comfortable.  That projects anxiousness on your part.”  But she was angry at the entire medical world and I wanted her to trust me, I silently countered.  Plus, I cared if she was comfortable. Plus, she called me adorable.  Plus, I fundamentally disagree with your assessment.

“I want to Eternal Sunshine this entire experience,” I said later to my friend.  But, obviously, Joel and Clementine are doomed to make the same mistakes if they erase wisdom gained from experience.  Embarrassing and painful as it is, I have to mull this one over.

I’m certainly not in denial that I made an uncountable number of mistakes.  I will change.  I will improve.  I will pull off the physical exam.  I will “control my patient.”  But–I will also thank my patient until I’m blue in the face.

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Like a patient etherized upon a chair

“Is it hot in here, or is it just me?”

The patient interrupts himself mid-interview as he shifts in his chair.  He’s sitting directly in the afternoon sun.  He’s squinting.  He fiddles with the zipper on his jacket, pulling the garment halfway off, then back on.

My classmate, the interviewer for the psychiatry session, tells him he is sitting directly in the sun but forgets to suggest he move.

For the remainder of the interview he doesn’t move.  It’s an hour-long interview.  He’s paranoid, suicidal, and incomprehensible.  He lapses into tangents, interrupting those tangents to ask if he’s going on tangents.  Sometimes he forgets the question as he’s answering.  It’s hard to hear what he’s saying because he mumbles.  It’s also hard to hear what he’s saying because the words don’t piece themselves together in structure I can decipher.  Most of what he recalls takes place two decades ago.

He’s still squinting, looking at us curiously, telling us about all the voices he hears at the bus stop.  It’s like they can read his mind.

A large part of me wants to interrupt and drag his chair a foot to his left, or a foot to his right.  Either direction would do.

It’s not hot; it’s just you.

Now he’s quoting a song from 1988.  “Do you understand what I mean?” he keeps asking.  We sense his fervent desire to be understood.  I squint my brain really hard and try to put myself in the literal hot seat with him.  I’m gleaning a vague meaning, but it’s probably not the meaning he means.

And now he’s crying.  He apologizes too much for it.

“Any more questions?” our professor asks as the interview closes, addressing the rest of us onlookers.

What I really want to ask is, why don’t you move?  When you walk out of this room, what other things will paralyze you?  Why can’t I understand your mind’s language, and why can’t you speak my mind’s language?

I don’t have anything to ask, I say.  Not right now.  He’s crying, for god’s sake.  It’s not worth re-opening the topic of his childhood abuse to get another line for the write-up.

After the interview, the professor asks us what we thought of the interaction.  I pause.  The first thought that comes to mind is a rather simple-minded one: I feel really, really bad.

My classmate answers first.  “The patient seemed to have a lot of trouble giving us any sort of timeline.”  I nod in agreement.  The professor talks about the difficulties of having an unreliable narrator.

I feel really, really bad.  I feel really, really bad.  I haven’t said anything yet; I think they’re waiting for me.

Finally, I offer: “The patient mentioned that he was ‘feeling between a rock and a hard place.’  Using an idiom, he seems to have the capacity for abstract thought, which is not characteristic of schizophrenia.”

It’s a good finding.  It’s helpful for diagnosis.  Unlike my original thought, which I eventually share but bury within clinical observations.

I am thinking of T.S. Eliot.  I guess this is how the world has been ending for our patient.  Not with a bang but a whimper.  It’s a series of withdrawals from life, slowly and relentlessly, for decades.  He has no family, no friends, and no home.  He has confusion and sadness in their place.

And he (can’t? won’t?) move his damn chair out of the sunlight.

We draw a concept map on the board to help sort out the 60-minute tangled stream-of-consciousness.

And how should I begin? asks a character in another of Eliot’s poems.


Note: Certain medical, social, and temporal details have been changed to preserve anonymity (while hopefully not altering the narrative and message).

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When the patient jokingly touched my nose, I knew I had muddied the boundaries between us too much and it was too late to go back.

(Note: Except for the aforementioned sentence, all of the patient’s details and quotations have been altered.  Events from the interview and exam have been drawn from a conglomeration of patients to illustrate a general theme.)

It didn’t happen until the end of the interview, but it was not an entirely unsurprising turn of events.

“What can I do you for?” he had asked affably as I entered the room.  The nurse had mentioned that he was a talkative man in good spirits.  I needed someone in good spirits.  He was about to become my body to practice my physical exam skills on, and I wasn’t very good at the physical exam.  Done well, it should take 15 minutes.  Done by me, it would probably take several times that amount as I missed reflexes, shined my penlight in the eyes for an uncomfortably long time, and struggled to remember the order of tests and develop a natural rhythm.

Before entering the man’s room, I asked my tutor, a fourth-year medical student, how long she told patients the interview and physical exam would take.  “There’s no way I can say something that sounds close to an hour,” I told her, remembering the previous week when a patient told me 30 minutes was too long and I had to haggle my way up to 15.

“I just ask if I can ask him a few questions and do a few easy tests on them,” she said.  I laughed, realizing that avoiding the quantitative would probably be my best bet.  Even though this was a teaching hospital, the patients had no good reason to let second-year students near them.  Unlike the upperclassmen, we weren’t a part of their care.  We could be kicked out of the room at any time, if the patient became bored or tired.  Patients would derive no benefit from the exhaustive interview and physical exam other than the vague satisfaction of helping a fledgling physician-in-training become less fledgling.

So, to get the practice I desperately needed, I needed to make my patient want to help me become less fledgling.  In short, I needed to win my unwitting participant over.

My current 60-year-old patient definitely saw me as fledgling.  He grossly underestimated my age.  (I thanked him for the compliment but told him he was off by several years.)  Then I asked him if I could ask him a few questions about why he was in the hospital, and we were off.

It took about 20 minutes to talk about his current illness and the events leading up to it, his past medical history, his social history, and his family history.  I had done this dozens of times first year, so I felt at ease in making transitions and gathering relevant information.

At this point during first year, we would wrap things up and thank the patient for his time.  But I was just beginning.  I reached for my bag, which was heavy with my tools.  It was time to pull out the opthamoloscope and penlight (for eyes), otoscope (for ears, nose, and throat), tuning fork (for ears and nerves), and reflex hammer.

In addition to sticking devices in and near his orifices and banging away at his knees, ankles, and arms to elicit reflexes, I would have to push and pull at all parts of his body, checking his muscle strength, tone and bulk.  I would have to ask him to follow my finger as I traced an “H” in midair to test his visual fields, to tell me if my metal tuning fork felt cool on his extremities to test for peripheral neuropathy, to swallow as I gripped his throat in a chokehold and tried to feel for an enlarged thyroid, and to stay still as I traced along the bottom of his foot to check for motor disease.

I hoped he would still be in good spirits after I was done with him.

Thankfully, he was.  I wanted to make the experience less tedious in any way I could.  I relied on a sense of humor.  I also periodically tried to convey how much I needed him for practice and how grateful I was for his help. Unfortunately, what couldn’t be hidden with words was fledgling, fledgling, fledgling.

He looked at me warily as I approached his nose with my otoscope tip.  “Don’t worry,” I told him.  “You’re not the first person I’ve done this to.”  (He was the second, after all.)

He was happy to help, cheerfully telling me about his newest granddaughter as I poked around inside his nose and tried to see past mounds of nose hair.

I worked my way down his body, complimenting his reflexes and muscle tone.  I laughed at his jokes and bantered with him while I tried to remember each of the eleven cranial nerve tests.  I told him he was being the perfect patient.

I felt comfortable and I felt like I was learning.  I was even having a good time.

At the very end of the exam, I tested his cerebellar function.  Touch your nose and then touch my finger, I directed him, as I moved my finger.  I told him he was doing well as he hit his marks.  Then–probably out of boredom–he decided to touch my nose instead of my finger.

It was such a minor gesture, I doubt he even remembers doing it.  But my face flushed as I realized its significance. A literal boundary had finally been crossed.   Somehow, in the hour we had been together, I had let things decline so that this gesture seemed appropriate and natural for the patient.  How had this happened?

At this point, the exam was over.  He was still cheerful (though exhausted) and had genuinely seemed to enjoy the experience, so I took that as a good sign. I had gotten exactly what I wanted–information and practice in a way palatable to the patient–but I had sacrificed seriousness and stature to get there.  As time passed, the patient had grown increasingly at ease, to the point of informality.  Although I had reacted professionally, I wondered how I could better control the room so I wouldn’t have to be the one reacting.

I acknowledged what I couldn’t change: being young and female.  Then I ran over the 60 minutes in my mind.  Should I have smiled less?  Made fewer retorts to his banter?  Fumbled with the tools less (easier said than done)?  Feigned greater confidence?  Toned down the affability?  I saw the affability as compensation for the fumbling.  If I was going to be the incompetent medical student, then I’d rather be the pleasant incompetent one than the dour incompetent one.  But how to remain pleasant while still being taken seriously?  How to be taken seriously when I couldn’t even make out the eardrum?

I concluded that until I stopped fumbling, authority would be difficult to garner.  And to stop fumbling meant repetition of the tedious on patients with patience.  I wondered who else would decide to touch my nose along the way and how I could stave off the advances while I gained proficiency.

When I applied to medical school, I wrote in my personal statement that I had a knack for being able to quickly gauge my audience and relate to it.  No one could argue that I hadn’t been able to relate to this patient.  But it was precisely this easy familiarity that had blurred the boundaries.

In that room, I made a friend.  Friends touch each other’s noses.  But patients don’t.

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Fragmented Intimacies

His face was four inches away from mine.  I tried not to blink as he shined the ophthalmoscope’s light into my left eye and stared into my pupil as though it were the most interesting thing in the world.  He frowned, placed his hand on my head, and used his thumb to pry my eyelid higher.  He maneuvered for about 45 more seconds while I sat stone still, and then, suddenly, his face broke into a grin.  “I see it,” he announced.  “I definitely see it.”

And then, completely awestruck, “Wow.”

I was my classmate’s first visualization of the optic disc.

Our opthamology instructor previously had shown us dozens of images of the inside of the eye, some normal, some frighteningly abnormal.  “Before I say anything else,” he began, “the first thing I want you to notice is how beautiful the eye is.”

Indeed it was.  Snaking along the back of the eye were tiny red delicate blood vessels, converging to become thicker until they crossed over the optic disc.  The optic disc, a pale yellow standout among the redder hues, is unique because it is the only part of the central nervous system that we can non-invasively see.

When my classmate saw my optic disc, he saw a piece of me that no one had ever seen before.  He saw my central nervous system.

Later that night, I friended him on Facebook.

It’s not surprising that medical school is an intimate experience.  When we learned to test for reflexes, I unabashedly hit my partner’s forearm until it bruised.  When studying for my microbiology final, I and a few others sat in the computer lab eating and complaining, finally shuffling out together at 1 am.   When I interviewed my first patient in the hospital, my partner watched me stumble over the most basic questions–and later told my preceptor he thought I did a great job.

What has been surprising is the complete lack of continuity among these experiences.  I have parents, I have a sister, I have a best friend, I have close friends in my class, I have had the significant other.  These people see me as a person with a complete set of experiences.  They have seen me at my highs and lows and middles, they have listened and re-listened to my secrets and fears, they have offered me unconditional support.

But–still–no matter how hard I try to paint a scene with words, they remain several degrees of separation away.  They see my world through my eyes, their sense of vision stemming from my words.

Then there are my classmates who have seen me on the front lines, seeing a side of me that deals with the emotional or bizarre or just plain new.  But–oddly–for each experience, it is a different and sometimes unfamiliar person who shares it with me.  I am used to creating memories with those closest to me, but in medical school, when the assignments are as random as the patient encounters, no such coherency exists.  The thread of experiences continues but it is broken.  I am the only witness to the whole.

I recently sat on a panel to give advice to first year students.  One of my classmates stressed the importance of finding a mentor.  She was lucky and had found someone she could completely confide in.  Her mentor knew her professional aspirations, her personal goals, and her progress in achieving them.  Sitting next to her, I felt a little less lucky.

“I don’t have one mentor who is my be-all and end-all for every issue I have,” I told the audience.  “I’m interested in ethics, and I have a professor who I respect and can talk to about that.  For writing, I have mentors hundreds of miles away.  My faculty adviser knows the most about my personal issues.

“In short, I guess I don’t have a single mentor.  And I think that’s okay too.”  I wanted to believe my words.  But I admitted to myself that it would be a heck of a lot more convenient to have just the one.

My other experiences in medical school, some intimate beyond words, have been similarly fragmented.

I went to an Alcoholics Anonymous meeting with two of my classmates one night as part of an assignment.  We walked back slowly in the darkness, discussing, avoiding each other’s eyes.  In that moment, all three of us felt that it was just a bit of fortune that separated us from those whom we had met that night.  We were grateful.  We were empathetic.  We had changed.

During anatomy, I was partnered with three different classmates.  Together, we explored every cavity of our cadaver’s body.  We made off-color jokes.  We retracted skin and guided each other’s cuts.  We held the lungs in our hands and marveled.  We scraped the skin off the face and sawed through the skull and disengaged ourselves to do so.  Six weeks later, we had changed.

This year, during a psychiatry clinic, three different classmates and I interviewed a woman with paranoid schizophrenia.  Talking to someone with an illness in the brain is an entirely different experience from talking to someone with an illness anywhere else.  Her story involved violence, abuse, homelessness, isolation, and denial.  The narrator herself, by definition, was unreliable–to the point of ironically insisting that paranoia was the wrong diagnosis.  It was sad.  She was sad.  We were sad.  It was worse than sad.  We had changed.

I am changing, more than I had imagined.  I am grateful that I have classmates who are changing with me, sharing experiences that I can’t do justice with words when I am talking to those closest to me outside medicine.  I am grateful that our paths converge, if only briefly, for those intense moments.  I wonder how they perceive those moments, as time eventually blurs the details.  I’m sure that my classmates have stories of their own: their individual journeys at their individual paces.  I’ve heard some of them.  But in my story, I am the only one who can put the fragmented pieces together.

Sometimes the story is lonely.  Sometimes it’s exhilarating.  But, ultimately–convenience be damned–it’s mine and mine alone to make sense of.

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Return of White Coat, Black Art

A few months ago, I had the honor of reading my “Letter to a Young Doctor” on the medical documentary series White Coat, Black Art‘s season finale.

I would encourage everyone to check out the rather insightful show, hosted by ER physician and medical broadcaster Dr. Brian Goldman, who interviews health care “insiders.”  There is emotion, there is grit, and there is always brutal honesty.

The show recently began another season, and I have another brief appearance on this week’s episode.  Although the episode is about nurse bullying and fairly sobering, my segment was decidedly more feel-good: a recollection on an inspiring patient’s social history (original blog post here and story in the LA Times here. )

Link to podcast (my segment starts at 23:00).

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When my sister brought back a chocolate chip cookie to our table at Au Bon Pain inside the Children’s Hospital, I asked what shelf she had gotten it from.  The second from the bottom, she said.

“That’s exactly where all the kids run their hands over the cookies,” I told her.  She looked dismayed.  “Their parents never watch them,” I added, a trace of bitterness creeping in.

“It’s disgusting.”

I live across the street from the Children’s Hospital, and I go to class next door.  I don’t work there, but I find myself in its colorful lobby at least several times each week.  I pick up my prescriptions from the hospital’s CVS, my sandwiches from the cafeteria, and my late-night desserts from the Au Bon Pain.

I weave around children in wheelchairs, zombie-like looking residents in scrubs, toddlers with balloons, parents with no make-up on, teenagers with head scarfs, elderly couples with slow gaits.  I walk with single-minded purpose.  My private life intersects with the lives of those most vulnerable and with those who are treating them.  But it’s my private life, and I don’t feel an obligation to slow down, mentally or physically.

It’s disgusting, really.

During our Patient-Doctor II class, 15 of us got to interview a middle-aged man with a progressive neurodegenerative disease.  The interview was scheduled from 2:15-2:30.  It ended up running 45 minutes over.

Though I had read about this disease in textbooks and understood its underlying mechanisms, I had never seen a person with it.  I was rapt, listening to his story.  I thought about his neurotransmitters and his synapses and his neurons and how they were all failing him.  Then I just thought about him.

We were learning, so we had the luxury of asking the patient any questions we wanted.  Most were focused on what his life was like living with the disease.  One student asked him how supportive his family was.  I asked him if he needed help with daily tasks.  Another student asked him how he handled the news of his diagnosis.  The questions got increasingly personal, and he answered them all.

I left class that day thinking about him.

Then I went to do errands at Children’s Hospital.

I thought about how slowly that patient had walked, with an unsteady gait.  I imagined trying to skirt around him, frustrated that he couldn’t obey the rules of pedestrian traffic.

I thought about his halting speech.  I imagined him in front of me at Au Bon Pain, trying to stammer out an order while I sighed inwardly.

I thought about his tremors.  I imagined him dropping change over the counter as he tried to pay for his sandwich while I stood behind him, ready with credit card in my own steady hand.

I thought about the half dozen medications he needed to be on and how long that would take him to pick up at the pharmacy, while I tapped my foot and vacantly stared at the cover of People magazine in the meantime.

It is one thing to understand and empathize with a patient during work hours.  It is also one thing to reflect on the difficulties of living with a chronic illness while you sit alone in your room typing out a blog post.

It is quite a different thing to lose the divide between your personal sphere and a hospital’s, when your off hours aren’t anyone else’s off hours.  I have my earbuds in, my tunnel vision, and my head in an entirely different place.  I don’t look at people; I look around them.  I look for opportunities to pass them, to avoid them, to carve out my personal space.  Often, I don’t feel like sharing that space.

Sometimes I stare at the chocolate chip cookie shelf.  Restless children touch and tired parents have their minds on things that aren’t cookies.

I try to remind myself that I’m lucky enough to have the luxury of noticing the cookies.  I try not to glare.  I try very hard not to glare.

It’s disgusting, really.

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Almost exactly one year ago, I began medical school with 199 total strangers.  The only overarching thing we had in common was that we were members of Harvard’s medical class of 2014.  There would be other connections, of course, but none were obviously apparent at the time.

The best way to cement a face, I’ve since found, is to run into that face in an entirely different context.  In the morning she’s in my small group discussion section on pharmokinetics, but at night she’s my good friend’s college roommate, reminiscing about our time in college.  I sometimes sit next to him in Social Medicine, but last Saturday we discovered we had mutual friends at our local synagogue.  Every new connection became an additional dimension to an acquaintance, a personality that only revealed itself outside the confines of a classroom.

All of this is fairly obvious to anyone who has suddenly been thrust into a new city, a new job, a new role.  You strive to build connections, to create multi-dimensional characters in your local cast.  You begin to like people more, each interaction becoming easier, with more to build on and more to anticipate.  Socializing becomes less like work and more like fun.

What I didn’t realize until second year is that this common sense insight did not only apply to people.

I’ve always heard that second year of medical school is by far the hardest academically.  “Drinking from a firehose” is the standard cliche to describe it.  The way I’ve found myself trying to relate my baseline stress levels to those outside the medical field is, “At any given point you’re only going to know 20% of what they expect you to know.  My job is to figure out if I know the best 20%.”

One of the most difficult parts about medical school is becoming comfortable with knowing you don’t know vast amounts of information.  Sometimes your 20% does not overlap with your classmates’, and then you begin to wonder what is wrong with you, and why your brain cannot hold on to factoids like everyone else’s seems to, and what if your 20% is the useless 20%…

But back to the silver lining.

Last year, I met a lot of new molecules, a lot of new concepts, and a lot of new drugs.  It was almost as though I was walking down a crowded Boston street, stopping to chat with a few molecules or muscles, learning as much as I could in a short amount of time, and wondering if I would remember them in a month’s time.  After some polite chit-chat, I usually never heard from them again, and they left my realm of conscious awareness.

Biochemistry was crammed with minutiae, down to amino acids and molecule folds.  Amino acids make proteins, proteins make cells, cells make tissues, tissues make organs, and organs are what we held in our hands in gross anatomy.  We had zoomed out and lost touch with our old acquaintances.  In physiology, we spent one week on each organ system, racing our way through the functions and composition of the lungs, heart, kidneys, GI system, and endocrine glands.  A few months later, we met the microbes–bacteria, viruses, and parasites that lived in our organs.  First year, I met each concept once, in a specific place and within a specific context.

There was so much to memorize I couldn’t imagine how much worse second year would be.

And there is a lot more work second year.

But I’ve already met the characters.  And the new ones are usually friends of friends.

Of course, I don’t remember most of them, at least not consciously.  I find myself having to Wikipedia something I know I’ve been introduced to–and looked up–at least several times before.  I find myself hoping this time will stick.

But–and I wouldn’t believe it if I’d told this to my first year self–it’s also a lot more fun.  I’m more vested in the characters.  Now when I hear that a new drug binds to a kidney receptor I’ve already met, I not only remember the receptor better but I remember the new drug better as well.  And I find myself caring about the receptor, wondering if there are other drugs that can bind to it, or if it has a job that we haven’t yet learned about.

There’s certainly more to know, but this time I want to know it.

Last year, I met classmates in classrooms.  We would do the requisite small talk because that’s the socially acceptable way to build foundations.  Then we would drift away, meeting others.  Likewise, I met molecules in classrooms, learning names and trying desperately to fit them into a mental framework.  Within a few weeks, these would inevitably drift away as well.

It’s always nice when paths cross again.  It’s nice when you hear a big word but realize that it’s still big but not new anymore.  It’s even nice to be frustrated that this is the fifth time you’ve looked up that big word, because at least you remember looking it up, even if you don’t remember what it meant.

I recently watched the last Harry Potter movie.  Somewhere in the middle I mentally took a step back and imagined what the film would look like to someone who hadn’t spent six previous books learning the ins and outs of the fantasy world.  It would be jargon, it would be forgettable, and–worst of all–it would be boring.

Second year of medical school is a lot of things.  But it isn’t boring.  My last year self–as well as probably most of the outside world–wouldn’t quite understand why I can tolerate spending at least eight hours a day studying.  The best way I can explain it is that I’m meeting and re-meeting and re-re-meeting characters I care about.

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