MS1 [Medical Student Year 1]

The first day of medical school, I spent the first half-hour in the bathroom, patting myself dry with paper towels and waving my button-up in the air, locked in a stall so no one would see me shirtless.

Turns out, there wasn’t any parking close to the university that day, so I had to park a mile and a half away.  Took about twenty minutes of walking in the hot, sticky, Minnesota-summer heat before I arrived at the front door. I had made the poor choice of choosing a light blue denim button-up which now had a large circular stain in the middle front and back of my shirt, and two baby wings which trailed down like dark, shadowy glimpses of hell down from my armpits.

I ran straight to the bathroom, locked myself in a stall, took of my shirt, and flapped it until it was dry.

That is my first memory from medical school.

A few months later, and ten-thousand memorized facts later, I came in on a Saturday to finish our dissection of the hand.  I had preserved the delicate nerves, the arteries which wrapped like pale vines – that subtle life which grows in the moist corner of an empty basement – up and along the sides of each finger. Each tendon white, mother-of-pearl.  To test your dissection you would tug each one in turn and watch as each finger would bend and curl.

I remember not the particulars of those two-and-a-half hours alone in a room on the third floor, but the very end of it.  Finishing, filling a bucket with water, and, like baptism, washing the body in it, from toe-to-head, spilling the last of it along the arms. Taking the cloth to keep in the moisture, pulling it up the body, where the head was kept in a black bag so we would not feel too much emotion. I remember her hand – her hand… isn’t it strange to give a gender to a thing no longer alive? – and the way it protruded from the cloth.  And I remember hesitating before I closed the top, laying my hand on top of it and feeling…  I don’t know what I felt. I know only that it was the only time in that room I felt a sort of resonance inside myself, the same sort you get at dusk, running through a forest, that sort of spiritual vibrancy, that sense that time and space have the flush and tone of personality, and…

It was just a body.  Nothing more.

Just a body.

A month later, I was driving to meet my boyfriend at his place in St. Paul when I suddenly got a call from him.  He sounded ill, detached.  “You need to get here now.  I’m a block away.  Find me.”  His words filled me with dread and I pushed my car up to 85mph as I cruised eastward on 94.

When I found him, he was standing twenty feet from a man, face-down, his face smashed in where his nose had collided with a balustrade.  I ran up to his prone frame and felt the skin of his neck for a pulse.  He was ice cold.  It must have happened at least an hour earlier.  We called the police.

My boyfriend still stood on the sidewalk in shock, unable to function.  I felt nothing inside, and it frightened me.  I thought of the body at school, the scalpel tearing through flesh.  Death now had the aura of the mundane.

I suddenly noticed a woman pacing back-and-forth on the sidewalk, eyes vacant, nearby.  I walked up and began to talk to her.  She was the man’s girlfriend of two months.  They had met at a tango class.  He would invite her over once a week to cook her a dinner. He was a phenomenal cook.  Or as she worded it to me then, “He is such a phenomenal cook.”  She referred to him throughout the entire conversation in present tense.

My boyfriend could not function, but I told her there was a coffee shop nearby.  I asked her what she needed.  I wandered to the shop and bought a tea, grabbing an extra sugar, as directed, and just a splash of cream.  I walked back to her form huddled on the front lawn, the police swarming the area now, red and blue and white flashing lights, like a fireworks display but without the pop of the flares, the noise, just a heavy silence, and those dark forms speaking with authority and demarcating the event like a work of fiction, detaching themselves through acting in roles and not seeing the humans, the human huddled drinking her tea on the front lawn.

I put my arm around her and we talked about a man she knew, talked about him in the present tense.

That summer, the last real summer of my life, I made two trips.  The first was to Montana, to the mountains.  On the second-to-last day, we made the six-hour hike to the peak of the divide.  The first half of the trip we walked through the burnt shell of a forest.  The twisted limbs, the shortened, charred spires, the scent of ash.  In between, needle-like wildflowers bloomed, this foot-high prairie of life spreading lush-like between the trunks, those scars.  Thirty switchbacks…

The scent of pine.  A forest of evergreen.  In the center, a small clearing covered with white wildflowers.  A breeze, glacial.  You could taste the snow of the peaks in the chill.  An eagle coasted a foot above the ground, flew off without a sound.  I left my two friends, went to the overlook, where the peaks stretched far into the distance and sat alone.  I heard the wind in my ears.  There were no other sounds.

The second vacation was a backpacking trip through Europe.  I got drunk with other solo backpackers in London, wandering, stumbling, dancing through the streets.  The bus driver hated us but we just talked louder.  We sat in the lobby of the hostel talking until 6am.

Later, a hostel mate in Berlin convinced me to take a caffeine pill with him that turned out to be ecstasy.  I was furious until the drug hit my brain.  We partied in the haze, neon glow, the graffitied twilight that is Berlin.  I only slept four hours the three days I was there.

When I landed in Rome, it was late afternoon and I wandered alone with only my backpack the hour stroll to my hostel.  When I walked in, the owner greeted me, offered me a tray of nutella-filled pastries and an espresso.  He gave me a map, showed me the route to take over the next few days to see the whole city.  I met two of my roommates and we agreed to meet in four hours by a cross-section in the Vatican.

I wandered alone into the muggy, humid air of Rome.  I wore shorts, some boat shoes dirtied from a dozen-cities wandering, a light-blue vneck, that, well-chosen, did not show off my sweat.

As I wandered among the people who did not meet my eyes, I became conscious of my own anonymity.  Without the social milieu, the familiar, the penumbra we call the known, the popular, the desirable, who was I?  No one knew my story, the point A to point B successes of my life in the states, the years scramble to know more, run faster, play better, party harder, network broader, be MORE than, MORE to excess, MORE to identify yourself, to be wanted to be desirable to feel like you matter because you’ve checked off all the boxes for God’s sake look at me look at me and know who I AM…

I ate alone, some gnocchi, stared at the lovers, the couples sharing wine around me.  I felt a sense of completeness then, a sense of belonging that only someone who’s been entirely alone in a country, alone where no one knows his name, could feel.

I wandered the streets aimlessly.  The Parthenon appeared out of nowhere between streets with nameless boutiques and cafes.  The doors were locked past dusk.  A woman, mad with illness, played an accordion without rhythm or melody, yet smiled at me as I passed.  A homeless man with a cup in front of him laid prostate on the ground.  I put a euro into his cup.  I left a man and a woman behind knowing I would never know their stories.

Across a bridge I wandered into the golden lights of the Vatican.  The obelisk at the center.   I walked slowly up to it.  Small groups of people huddled around their cell phones.  As I approached it, a woman next to me clutched a rosary between wrinkled fingers and, head bowed, muttered mussitations to her God.  I thought of Dostoevsky’s Sonya, a prostitute who needed faith not to be healed, but simply to live, who needed faith because it is the only way to live a life of sin and still burn with innocence, an openness to love and to the world.

As I stood next to her, this spiritual interlocutor, I was overcome with emotion.

I thought of bodies, a head wrapped in black, a hand beneath shroud which I touched, an ice-cold neck, the scrambling feet up the switchbacks, the heat of forms in Berlin, the taste of sweat, warm, as it drips down your face and breaks its weary salts upon your lips and…

My eyes were full of tears.

I did not believe in God.

I do not believe in God.

I bowed my head and beneath the golden light began to pray.

"LOL"

I’ve always joked that Irish Catholics respond to tragedy with laughter.

Maybe it’s some quirk in my upbringing.  But I often follow up anything serious I say, be it a rough day at work, or a reference to something difficult that I experienced in the past, with a “hahaha.”  Friends who text me frequently can attest to this.

In mundane matters, the response can be perfectly appropriate.  Yet, for serious matters, like those considering pain, loss, mortality, it can seem inappropriate.  Maybe it is inappropriate.  I’ve always been unclear on this.

The other day, while speaking to my psychiatry attending about the patients we had met with that morning, we came onto the topic of laughter.  About one of our patients who kept laughing intermittently between heavy, silent tears.  He would always go on a monologue when he did this, saying he laughed because it was the only way he could accept that he was going to die, that he was going to die soon.  He had end-stage lung cancer.

Afterward, my psychiatry attending and I discussed whether this coping mechanism was appropriate or not.  This eventually devolved into a discussion about our favorite comedy shows.  We had a five-minute aside about the humor of South Park.  About whether certain topics should not be joked about - like current events, issues about race, death.  For some reason, I found myself asking him if he’d ever read Reinhold Niebuhr, seeing that my attending is an Ole grad like myself.  He had not.

I mentioned an essay that had struck a chord with me in college, titled “Humor and Faith.” In it, Niebuhr talks at one point about how both “humor and faith are expressions of the human spirit, of its capacity to stand outside of life, and itself, and view the whole scene (p. 49).”  Yet, he continues, the problem with viewing the whole scene are all the inconsistencies contained there.  The incongruities of reality that conflict with our narrative.  For instance, to reference a Louis C.K. stand-up bit, we complain about waiting 30-minutes for an airplane, yet afterward we FLY THROUGH THE AIR, LIKE A BIRD.  The disconnect between our complaints and the fact that we are flying, which from this new perspective is miraculous, causes us to laugh.  Yet inconsistencies exist in other ways: I am alive now yet one day I will die.  How can this be?

We as humans do not usually laugh about this.  Though maybe I would.  As I’ve said, it’s a habit of mine.

Niebuhr continues with the conclusion that faith is an appropriate response, as faith can reconcile the “incongruities of existence which threaten the very meaning of life (p. 50).”  Yet faith has other effects.  For instance, the fact it nearly drove me to suicide in college over the issue of my sexuality.  It is funny - people often ask me why I continue to defend religion, even though it nearly destroyed much of my adolescence.  My response: “Because it was a beautiful enough vision that I was willing to sacrifice everything, even my entire identity, to make it true.”  Even in the absence of faith, I still strive to find that beauty.  Maybe that is why I write.

Maybe it’s why I laugh.

I’m reminded of a passage in Elie Weisel’s work, ‘Night,’ documenting his experiences in the Holocaust.  In a class in college, we discussed the issue of theodicy in his work - theodicy being a theological query into why evil exists in the world.  Most of us came to the conclusion that he no longer believed in God.  Yet there is a scene where a man plays fiddle deep into the night, and the tears it provoked in the Jews as they were corralled in a tiny barracks.  When they awoke, he was frozen.  Dead.  It has a strange tragic beauty, and this beauty always felt to me as if Weisel were asking a question.  Is this God, he seems to ask?  These moments of humanity, of complete vulnerable, mortal beauty, in the face of so much suffering?

A few days ago, I attended a speech appointment for a patient of mine with ALS, or amyotrophic lateral sclerosis, more commonly known as Lou Gehrig’s disease.  The disease represents one of the more aggressive motor neuron diseases, usually beginning as weakness in a hand or foot, and spreading to the muscles that allow us to swallow and breath.  Most patients die in 3-5 years after the presentation of their first symptom.

At the current appointment, they’re recording his voice.  For when he can no longer speak and be understood.  Phrases such as “I’m hungry” and “I love you.”  Later, he will be able to speak these phrases so people can hear him in his own voice.  At the end of the appointment, the speech pathologist checks the audio file and notes, “You’ve got about 316 phrases right now.  Is that enough for you?  Or is there more you would like to be able to say?”

A life.  An entire life.  In 316 pre-recorded phrases.  I feel something but I bury it, opening up my cell phone e-mail inbox.

Afterward, the speech pathologist goes over a few learning points.  “We try to keep things that he would actually say.”  He points to a few off-color ones, such as “Fuck you” and “Nice ass.”  Then he plays one of laughter.  He nods vigorously.  “These are the most important recordings,” he states emphatically.  “If you cannot speak, you at least should be able to laugh if something is funny.  Studies have shown it builds a greater relationship between the patient and future providers.”

He plays the track.  We hear laughter.  2.12 seconds of it.  We shake hands and I leave the room.

Later, I’m driving home, one of those chilly nights where the heater from your car blazes your fingers while you feet grow cold.  An episode of ‘This American Life’ emanates from my phone in the coffee cup slot.  They’re talking about time machines and the many reasons people would use them.  About half of people will change history (usually, killing Adolf Hitler) and the other half will change some part of their past (not get in the subway because that guy will vomit on you).

One woman comes on toward the end and says, “I would change the last conversation I had with my husband before he died.”  She describes that it was over tupperware, on the phone.  That she hadn’t ordered it and her husband asked her why.  Because, she noted, the ordering catalogue was on his truck dashboard.  And he was driving on the other end of the phone, and looked, and saw the catalogue right in front of him.

“And then we laughed about it,” she chuckles dryly.  A few moments of silence.  You can hear the static of the microphone.

Then she continues, more somber, “At least we laughed.”

5 Things Every Pre-Med (And You) Should Know About Networking

1.  You’re completely irrelevant.

“Whaaaaaa?!” you’re saying.  Back off.  I’m a pre-med student!  I work hard!

Yeah, I work 80+ hours a week minimum, have an inbox with more messages than Amy Schumer has jokes about STI’s, and somehow manage to date (poorly), have a social life (alcohol alone), and occasionally call my mother (she’ll refute this).

So when you want to network with me and feel like I don’t have time for you, you’re probably right.

So why do we mentor?  Why do I have a number of students I’ve met for coffee or a phone call over the years?  It’s because it makes me feel good.  Because it turns out it feels nice to give advice and share your knowledge.  To feel like my knowledge might matter to someone.

When I’m at a networking event for pre-meds, you should realize that I’ve volunteered my time to waste my time.  I’m not getting paid to be there.  So don’t be intimidated to approach me.  THAT’S LITERALLY THE ONLY REASON I’M THERE.  With the exception of the occasional free beer or cheesecake slice.

Two pieces of advice come out of this: 1) know why I’m helping you.  It’s not for a one-time hour-long coffee.  It’s for that one-in-every-ten mentees who will contact me consistently, once every three months, to give a succinct, three-sentence update on their life.  Someone who thought my advice mattered and that I might want to stay in touch with them.  There is almost no way that me helping you will benefit my career, except in the most tangential of ways.  But I do want to help you.  See me as a person who wants to be a part of your career, not a stepping-stone on the journey.

2) If you can offer anything, like time to work on a project with me, or collaboration on an essay, let me know right away.  I love nothing more than working with other professionals or students, and if you can actually do something to make yourself relevant in a real way, do not keep it in your back pocket.  I want to see your talents if you want to contribute.  But BE SPECIFIC.  Don’t say I’d like to work on “anything you could let me do.”  Tell me EXACTLY what you want to do, why you want to do it, and why I’m the best person to help you out.

2.  Do your research.

That girl who sent me an email that one time?  I don’t remember her name.  In fact, I never even bothered replying to it.  It’s not like I didn’t care about whether she got into medical school or not.  It was just kind of was like laundry – something I sort of thought about doing until I wasn’t thinking about it anymore.  And her message got buried somewhere between inbox message 26,001 and 26,003.

What I do remember is that message that started with a name.  “I talked to so-and-so who mentioned your name as an (expert, thought leader, mentor).  I noticed you did (x, y, or z).  That’s incredible and I’m highly interested in talking about your work in that area!”

If you use that literal format in a message, you’ll sound stupid, but the general gist remains.  I was FLATTERED.  Someone had taken the time to learn about me and had found this information because my NAME IS FLOATING AROUND IN THE ELITE ETHER.  Obviously this is a complete and total non-fact, but that’s the way this email will make me feel.  It shows someone took the time.

And if someone takes the time, it behooves me to do the same for him or her.

DO YOUR RESEARCH.

When you see a networking event and a list of highbrow, hoity-toity names, look them up.  Prioritize 1-3 people.  KNOW THEIR FACE.  Know what they study, what they do, where they went to school, what they’re passionate about in healthcare.  Don’t come across like a stalker.  Don’t reference their childhood address.  But show that you know who they are, that you know why they matter, and make them realize why they matter to you.

Because they DO matter to you if you’re talking to them.  Tell them why.  Make them know they’re a priority to you.

Be a good person, and again – DO YOUR RESEARCH.

3. Don’t apologize and don’t ask permission, unless you want to look like a child.

My least favorite phrase in an email?  “Thank you for your time and get back to me as soon as you can.”  Or “I’m sorry for taking up your time but…”  Or “I’d love to meet with you when your schedule frees up.”

Yes, it sounds polite.

This email is considered RUDE in the professional world, because it’s an email that doesn’t tell me what I need to do.

Every time I receive an email I use the following heuristic:

1)   Is the email long?  If yes, I probably won’t read it unless it seems critically important.

2)   Is this something I can postpone?

It’s the latter question that raises the issue.  When you say “get back to me as soon as you can” or “I appreciate your time” it implies to me that this doesn’t need to be dealt with right away.  And if I don’t respond that day…  I’m unlikely to respond a week later when I’m equally as busy.

Ending an email as I often do with “please shoot me two or three times you would be free to meet and I’ll adjust my schedule accordingly” I usually will get a response that day.  It’s an easy end to the email.  It gets to the point, which in healthcare is POLITE.  I don’t want you to tell me I’m nice or that you appreciate my time.  Just tell me what you want from me and I’ll do it so I can delete another email from my inbox.

4.  Medical applications are an art, not a Mad Lib.

You know that guy in your class?  The one who goes to all the school parties, has a million hobbies, and got that completely average MCAT score?

Well, he’s surrounded by all those popular faces in school for a reason – he’s fun.  He’s energetic.  He’s interesting to talk to.  He’s not brilliant, but he’s not stupid.  I would want to work with him.  I’d like to break up the monotony of dealing with thirty patients in twenty minutes by talking with him on my lunch break.

This is no excuse for doing poor school work for that sake of a social life.  If you’re credentials don’t meet some rudimentary cut-off, you won’t make the initial cut that will grant you an interview.  But after that?  I don’t really care that you got a 4.0 and the guy behind you only had a 3.59.  Because he competed at DIII nationals and enjoys backpacking Glacier every summer – and that’s what I’m going to talk to him about for at least ten minutes of his interview.

Yeah, it’s cool that you volunteered at ________ making ________ number of people feel ______, but so did everyone.  It’s like a Mad Lib every medical student on earth could fill out ad nauseum.  Yes, you should be able to fill in the blanks.  But unless it’s saving a third world country, to be honest, I probably don’t care.  And if you say it made you “feel good” or that you were “humbled” and “transformed” I’ll probably reject you out of spite.

You don’t prove you’re a good person by having a series of good things you do on a resume.  It’s by being unique.  It’s by making people happy to be around you.

If the volunteerism section of your CV has twelve bullet points, but there are only three people you consistently eat with over your lunch break, I suggest you reprioritize over the next two months.

5. My training is to spot bullshit.  Don’t do it.

This could be reworded as “be authentic.”  Don’t tell me you care about people.  Tell me about that time you sent your best friend a care package in Oregon because her mom had passed away.  Don’t tell me you enjoy basic science research.  Tell me that you hate it but love writing essays about the patients you’ve met.  Don’t tell me you want to do medicine because it’s a chance to work hard at something worthwhile for other people.  Tell me you do it because it’s the only job on earth that could get you out of bed in the morning – even though you’ll mumble profanities the entire time you cook your eggs.

BE AUTHENTIC.

My job is to know that the drug-seeker in the ER poured water into his urine sample rather than peeing.  My job is to know that the sexual history I just received doesn’t sound quite accurate.  My job is to know that even though all the labs look right… something is seriously wrong with this patient and I need to figure it out now.  I’ll go back to the room and do the physical from head-to-toe again.

My job is to spot bullshit from a mile away.

DON’T DO IT.

If you’re a total mess, and confused about why you want to be a doctor, and unsure if you can afford it, and worried about having friends, or having a husband or wife down the line, it’s ok to say that.  No one expects you to have the answers.  Having a poster-cut-out answer implies you’re obsessed with your image.  And an image has no correlation with reality.

I want to know who you are.

I want you to be vulnerable.

That for me is the purpose of healthcare – or maybe just the purpose of any human art.  Maybe just human life in general.  Seeing the world as fallible.  Seeing the world as messy.  Seeing all the different tones of moral grey and still choosing one, and choosing it because it’s beautiful and maybe you just want to, maybe you just happen to think a life in healthcare would be good for you, and that’s all that matters.  Choosing an illusion and believing it so wholeheartedly that it becomes real and the world is swept away in your vision.

Live authentically.  Live uniquely.  Live messily, sin boldly, and make the world more beautiful in it’s wake.

After all, you’re completely irrelevant anyway.

The Burden of Ambiguity

I knock on the door, walk in, smile and survey the room. It’s a pediatric visit. Both parents are seated; the child, a 7-year-old boy, lies in his mother’s lap. I have already perused the chart and saw the red flags: A series of recent ER visits. A strange series of lab tests—Lyme titers, surveys for Kawasaki disease, a Monospot—all with negative results. Seemingly random imaging tests.

I begin by taking a history, which evokes only a series of non sequiturs and logical perambulations. The timeline is difficult to construct. I find myself at times unable to understand even what the chief complaint is—the current presentation (fever, an old scalp abrasion, a sore throat) or this strange notion of chronicity. It’s as if all the random minor illnesses common in childhood were part of a larger syndrome that threatens to kill their child at any possible moment.

The mother hands me a folder containing printouts from all their visits since birth. It has the breadth and haphazardness of a cold-case file. I read a few of them—benign finding by an ophthalmologist, the seemingly bemused meditations of an ER doc. As much as I want to leave the room feeling reassured the child is perfectly fine, I sit at my desk, staring at a spot on the wall, running through my rather short medical student’s repository of knowledge.

That evening, still puzzled by the case, I peruse UpToDate for more than two hours, searching terms such as “recurrent fevers” and “Bell’s palsy.” With a patient like this, you are faced with one of two possibilities: “paranoid parents” or “Am I missing something?” As medical students, we hear both of these phrases used in practice. In fact, I heard a doctor call this boy’s parents “nice people, but a bit … you know …” the day of their visit, and two days later describe the time he nearly missed a serious diagnosis in a history that seemed perfectly benign.

I keep returning to the room. I check the boy’s skin. I check his eyes. I complete the physical exam to the best of my ability. I read some more. I repeat the tests looking for new findings. I ask the parents for more history. And still, nothing. I can’t even feel confident that the findings they report at home have actually happened. It’s clear that the kid has a minor illness today, but might it be related to something larger?

The word “diagnosis” embodies this internal tension. The etymological roots dia (meaning “apart”) and gignoskein (meaning “to learn”) suggest that we can pry apart our patients’ histories and physicals to truly “know” the nature of their disease and give it a label. A label has power. (Why else create ones such as “idiopathic?”) It gives certainty even to things that seem—if not implicitly, at least by current standards—grey.

As I walk the family out of the exam room, I fumble awkwardly to give them the semblance of an answer. To “know” whether this is pattern or coincidence. To prognosticate so they know what to expect. But there is no certainty here. I am left grasping and say things I’ve heard more practiced physicians often say: “We’ll let you know when we get the lab results back.” “I’ll keep researching to see what else I can learn.” “It may be nothing at all. Let’s see how things play out.”

In private, I wonder: Would I join a chorus I have heard so many others fall back on? “They’re crazy.” “He’s probably healthy.” “I think they’re just making all of this up.” No one likes a cold-case file. We would all much rather have a label for our patients or their families.

To be honest, I don’t know which I would have chosen for this young man and his parents. I think of his case often. It remains unresolved. I find something truly unsatisfactory about that.

Dreaded diagnosis? I dread finding no diagnosis at all.

***As published in the August 2015 issue of Minnesota Medicine***

Why Putting Your Hand in Orifices Makes You A Better Doctor

“You feel them now?!?!”

She literally grabbed my hand by the wrist and pushed it up, well…

I’m not sure it’s really appropriate to say, to be honest.  Let’s just say the ‘them’ she was referring to were her ovaries.  For those who are confused, during a sensitive female exam you can press upwards from the ‘exam portion’ and downward from the abdomen and actually palpate the ovaries, especially in younger, thinner individuals.

The ‘patient’ in question was a volunteer, paid for her time, tasked with teaching first-year medical students too scared to lift a breast a sensitive female exam.  These are students who struggle listening to the heart in a buxom female patient.  Who stare at a child with an ear infection with a mixture of fear and loathing.  Who pray every medical experience they have can just feel like shadowing as they sit in the back of the room and check social media outlets on their phone.  Teaching the sensitive exam is no small task.  I’m pretty sure I downplayed my own nervousness by mumbling something about my hands having an “essential tremor.”

Yeah, I was just a big wuss.

To be honest, I’m not sure the outside world really understands this part of medical education.  They see these socially-inept nerds who ruined their college science classes – adding an element of stochasticism to what should have been smooth bell curves and asking shitty questions no one cared about to their professor for five minutes after the class let out because they were going to become an “orthopedic surgeon.” [What an asshole.]  Then they see these smooth-talking, sometimes callous, sometimes chipper, white-coated interns breezing through hospital wards, assuming they’re doctors, not really understanding how little you really know after your first four years.

Some element of the change comes from learning the sensitive exam.  For some reason, I think of a talk one of NPR’s leadership, Jason DeRose, gave at St. Olaf College many years ago.  He told us that the job of the journalist, or maybe not the job, but the essential function, of the journalist, was to enter into ‘unearned intimacy’ with the lives of the reported.  It requires learning and then disseminating knowledge about individuals in as unbiased a way as possible, trying to determine the facts both because of, and in spite of, their personal stories.

What else am I doing when I ask a patient if they’re sexually active?  [“I ask these questions to all of my patients.”]  Multiple partners, or just one?  [“Your wife sounds like a real keeper.”] Female or male? [“No, I didn’t mean to imply anything.  It’s a routine question.”] Any history of illicit drug use?  [“You wish you did because of your wife?  Funny joke, sir”].

But why should we care?  Because sometimes you diagnosis that monogamous, elderly male in my office with full-blown AIDS.  Because sometimes you find out the ‘drug-seeking’ woman in the ER is giving her boyfriend the pills because she’s homeless and without the trade he wouldn’t give her a place to stay.  Because sometimes that young woman will tell you about the time she was raped, and that’s the reason she doesn’t want you in the room during the sensitive part of the exam.

In this career, you learn to be surprised by nothing.

And sometimes you learn the best way to care is to go into the one place it hurts the most, and ask the questions and do the things no one else will.

In a much more benign way, doing the ‘sensitive stuff’ well  - i.e. making patients feel like sharing it is normal and doesn’t matter - is just good medicine.  In fact, the other day, I was in the ER.  Scrotal cyst.  Turned out to be some folliculitis, likely secondary to a new soap product he reacted poorly towards.  The small nodule had already been drained – I didn’t have to do any procedure.  Yet, some clever questioning and a more thorough exam made me decide we should test him for syphilis.  To be honest, it will probably come back negative.

But then again, maybe it won’t.

What struck me afterward was how easy it was.  How easily I could do the exam in two minutes with gloved hands.  Ask those questions.  Probe deeper about his partners and his sexual practices.  I felt like a natural.

Which brings me to my final anecdote.    This one, a counterpoint to the woman and her ovaries.  The male sensitive exam.  In the first room I entered, an elderly male volunteer sat in his hospital gown.  The exam went without a hitch.  Scrotal and penile exams are a breeze, especially for a male student like myself.  Then, in the second room, a younger male patient.  I realize I’m near the end in a long line of medical students that have examined him.  He’s tired and frankly, not paid that much.  I doubt he wants another drawn out, hesitant prostate exam.  So in front of three of my colleagues also in the room, I lube up a finger, go in, palpate, and exit in a matter of seconds.

Which would have been fine, except…

“That was amazing!  That was the fastest prostate exam I’ve ever had!  You’re like Dr. ____, a real professional.  You should be a urologist.  I barely even felt that!  Are you sure you did the whole thing?  WOOOOOWWWWW!”

And a smartass classmate smirks at me and says, in a voice loud enough that everyone in the room can hear it, “You should add that information to your dating profile, Patrick.”

The man turns ashen.  Looks to the ground.  The room is silent.  I take off my gloves and wash my hands with soap.  I mumble something as we leave the room about “having a good afternoon.”

‘Unearned intimacy?’

Perhaps.

Maybe I’d just make a better urologist than an OB/GYN.

Normal S1, S2

I wake up and head to the hospital.

 

First patient of the day - COPD, CHF, a typical slew of diagnoses.  We chat about his medications, symptoms that just won’t go away.  I ask him about smoking and drinking, the usual.  Ask where he lives, who he lives with.  His face grows somber.  “I’m alone,” he says.  “Ever since my wife died six year ago.”

 

“That must have been difficult for you,” I say.  We pause a moment.

 

I ask him about allergies to medications.

 

The next patient visit goes well until I mention his Hepatitis C.  How his recent medication has effectively cured him.  He stares at me, face reddening, eyes beginning to furrow.  “How do you know I have that?" he asks in a rage.  I tell him I read his medical chart to prepare for the visit.

 

He doesn’t want a med student perusing his medical history.  He tells me his medical problems are between him and his primary doctor.  I tell him it’s within his rights to choose who he wants as a provider, same way a female can refuse a male doctor for the sensitive female exam.  He tells me to get out.

 

I leave the room and my attending finishes the visit.

 

I get paged down to the ER.  One of my patients has just come in.  I run down the hallway and sprint down the stairs.  When I enter his room in the ER, I ask what brings him in, giving the illusion I’m not breathing hard.

 

“This,” he says, lifting up his jeans and revealing…  A scab.  Not broken open.  Not inflamed.  Uninfected.  Probably healing there for at least a week and a half.

 

So I chat with him and his wife about their recent vacation to northern Minnesota, about the new medication he has started.  No side effects.  I secretly congratulate myself on my medical student success.  I tell him not to use the ER for this in the future.  “You have my card,” I tell him.  “Just have a nurse page me and I can swing by and tell you if it’s urgent.” He laughs and we shake hands.

 

His wife grabs me as we’re leaving the room.  “You’re his favorite reason to visit the hospital,” she whispers to me.  She squeezes my arm softly.  I grab some instant disinfectant and walk outside.

 

Since I’m already in the ER, I talk to one of the docs and he gives me a new patient.  An older male with new onset chest pain.  His wife sits with him in the corner of the room.  I take a history and physical, relay pertinent findings to the attending physician.  When I return to the room, I ask an innocuous question or two: “How has your week been?” “What are you doing this weekend?”  She mentions church.  I ask which one.

 

She tells me about the church they attend every Sunday.  About their pastor.  About the afternoon two year ago when a voice spoke to her as she drove down the highway.  A voice that wasn't there.  How she panicked that she was having delusions.  That she was becoming a schizophrenic.  That the voice told her to have her husband call his sister.  The estranged one.  The one he hadn't spoken to in twenty-seven years.  To have him call because it was her birthday.

She didn’t know her husband’s sister’s birthday.

 

After an hour of pleading, she got her husband to make the call.  The husband’s sister cried on the other end of the line.  They talked for an hour and twenty minutes.  That Christmas, the whole family got together.  They took a picture, with the Christmas tree in the background.

 

Why me, she asks.  I stand there in the ER room silently, unable to articulate a reply.  Why me, she asks, when I’m ordinary?  Just an ordinary woman.

 

I tell her I don’t know, but I appreciate her entrusting her story to me.  I listen to her husband’s heart again.  Regular rate and rhythm.  Normal S1, S2.  No murmurs, rubs, or gallops.  I leave the room.

 

The rest of the afternoon, I work with my hospitalist team.  Admit a patient in atrial fibrillation, post-surgery.  Medical co-management.  He mainly talks about his girlfriend, thirty years younger.  I ask him about his book, sitting on a bedside table.  It’s a Norwegian mystery.  “Rather depressing and a bit morbid,” he remarks with a chuckle.  “Like all Norwegian fiction.”

 

At 7pm, I walk to my car in the emptying parking lot, only a star or two visible through the city’s haze.  The radio plays the same generic pop hits.  I walk through the white hallways of my apartment, open my unlabeled door, eat a frozen pizza, watch an episode of Netflix.

 

As I lay in bed about to fall asleep, I suddenly hear her words in my head.  “Why me?  An ordinary woman?”  A shudder goes through my body.  I sit up in bed.  Get a drink of water.

 

I go for a walk around the block and stare at the lights of the city, blinking vacantly.  The night is cold.  I tighten my jacket.  A couple walks by holding hands.  I return to my apartment.

 

The next morning I wake up and return to the hospital.

I Am Here

It was Thursday when an ambulance brought my aunt to the hospital. Her breast cancer had metastasized to her femur. It had shattered the bone.

The next day, a Friday, she traded stories and jokes with my parents from her bed. They learned from my uncle that she had three more months to live.

When my sister and I visited her the following morning, she was unconscious. Her breathing was heavy, uneven. An hour later, as I dropped my sister off at a play practice at school, I sobbed over my steering wheel in a corner of the parking lot. Three months... I returned to the hospital.

Within the hour, my aunt passed away.

Afterward, I could only think of the moment I stood in her room early that morning: of her labored breathing, the hum of the air-conditioning. My uncle's words: "Tina, Patrick and Kelly are here. They came to say hello." How I had stood there unable to summon the strength to simply say, "Hi, Aunt Tina, I am here."

I have never forgotten my silence.

***

Our conversations were long and energized. He would ask me about my life, my running, my education, or fuss over whether I was wearing appropriately warm clothing for the weather. In exchange, I would listen to the latest of his medical maladies at the Northfield Retirement Center, sometimes with 'colorful' descriptions of its resident doctors.

So I listened. About his pain meds and physical therapy. About how he could no longer see. About how he could no longer walk. About the back pain that would wake him up at night. About the loneliness that would consume him like a storm. Many times, we would end up laughing about our lives - the taste of the cafeteria food or the latest failures of the college football team. At other times I would try and comfort him as he sobbed; his head would heave and tears would roll, all in utter silence.

I remember one time in particular when he asked me what the year was. He let me do the math for him. "Six years... I've been here six years..." he murmured. "And all I can do is sit here and wait to die."

For once, I did not know what to say.

***

When did I decide to become a doctor? It could have been one of those cliche childhood moments we all reference in retrospect--but I doubt it. After all, I wanted to be a train conductor, courtesy of Thomas the Tank Engine. As my mom will tell you with chagrin--as mothers do--the intricacies of trains were the singular obsession of my grade-school-age life.

Then perhaps it occurred much later, when I stood with two young parents as their wheezing, three-month-old baby tested positive for RSV and was admitted to the hospital for supervision. Or when I placed my stethoscope on a scar and heard the repaired heart of a young boy with Down Syndrome. Or perhaps when a woman heard sounds on her left side for the first time following an aggressive ear surgery. She started to cry. She was thirty-two years old.

In these moments, I knew I wanted a real and palpable role in shaping the form of a patient's care.

Of course, there were the purely academic joys. Perhaps I fell in love with medicine the first time I heard something like 'replacing an eardrum with a piece from the outer ear' described with some esoteric phrase like 'cartilage tympanoplasty.' Then again, maybe it was the moment in which I was first hypnotized by the rhythmic, almost musical cant of the surgeon: "irrigation, please..." "suction..." "suture..." Or perhaps it was merely the nerdy thrill of seeing a dermatome actually mean something outside of that one neuroscience textbook, pg. 487, figure 13.5.

Yet more than anything, there are these memories which have irrevocably changed the course of my life. The day I could not find the voice to say hello to my aunt when I visited her in her hospital room. That winter afternoon when my friend Obert down at the nursing home began to cry. A summer car ride with my friend as she shared her unfulfilled plans for suicide. The next hour of that conversation remains one of the single hardest moments of my life.

Just what do you say when words are inadequate? When people expect you to solve things but you are helpless to change them?

It is not only illness, but isolation that destroys patients. Above all else, to break such silence is why I have chosen to become a doctor. Because beyond the academics and long hours and interminable paperwork, I want to offer my presence. Sometimes I still succumb to this tempting idea that after medical school, illness will somehow bow before my knowledge and grant me exquisite control over the forces of life and death. Medicine, after all, is replete with such metaphors.

But a metaphor is little encouragement for a patient.

While it is true that I may not be able to be my patients' number one confidante nor their go-to moral support system, I do want to be someone worth trusting when all else fails, even when there is not a single thing I can do to cure them. Because ultimately, that is the real side of life, and that is the real role I intend to play as a physician.

Yes, I hope to treat and I hope to cure, but neither encompasses why I fundamentally intend to become a doctor.

I want to be there when no one else is. This time I will not remain silent.