In which I lean.
My personal theory about time is that memory is not processed as seconds or minutes but as input, interpretation, and decisions. It’s like sheet music. For familiar pieces, my fingers fall into place and before I know it, it’s time to turn the page. But learning a new piece, each measure, each chord takes (for me, a delinquent who surrendered any aptitude for the bass clef in high school) seconds to parse. I first sound out the right hand, then painfully pace through the left. One new line could take me longer to play than a whole page of familiar music. And so a week in another country with unreadable street signs, new foods, and getting lost on public transit takes up more “brain-time” than months of shuttling home-work-class-home-work-eat-home-class-eat-home-church-home.
So the first month in California felt like three months. The first day of residency felt like a week; the first week of residency felt like two. But then week after week, month after month time began to slip by like sand through my fingers. Suddenly I’m at a quarter of a quarter done with residency. Sometimes this thought comes edged with panic. If this is how little my practice has improved thus far, how will I ever get to the level that I see second years practicing at?
Clinical acumen nonwithstanding, my prayer habits have fluctuated through residency. The night before my first ever shift as a resident, I was so nervous. I had my bag packed with all the things I’d need. I brought maybe five different snacks, an extra mask, a face shield, and some reference cards (none of them were used on shift). I prayed the days preceding. I prayed on the drive there. But as I got more shifts under my belt, I found myself praying less. Sometimes I listed to emergency medicine podcasts in the car. My ineptitude had not resulted yet in tragedy; there were always watchful eyes catching my slips. But one patient taught me to pray before all of my shifts.
(As always, the details of every case are modified to preserve patient privacy.) I saw a patient with a painful knee after a fall. When I went to see her, she had just been X-rayed and all was well. Long story short, I evaluated her for her fall, but something about her seemed off. She was weak, sweaty, and shaky, and it didn’t seem to be related to the fall, which had happened the day before. Plus, her EKG looked weird, but I’m not great at EKG reading. After a long discussion with my attending, I ordered an extensive workup and was waiting on the results when a nurse called the team to the room — the patient’s heart had stopped. I’ve been trained on the protocol for resuscitation before year after year. I’ve been in plenty of simulations of cases like this, and in the ICU I had participated in a few codes. But this time I could do nothing more than rush to the room and then stay out of everyone’s way. My role in the code: hand out gloves. My junior resident intubated; my senior resident supervised; the techs did compressions; the pharmacist and nurses handled medications; the attending gave orders; the scribe entered everything that was shouted out and kept time. I handed out gloves and prayed.
The patient lived. She had a fatal electrolyte imbalance, the kind of potassium overdose that is induced by lethal injections for capital punishment. She was resuscitated successfully, the imbalance was righted, and as far as I know she left the hospital after a few days in the ICU.
The days and weeks afterward, I replayed that scene forwards and backwards in my head. I identified areas of improvement and ordered materials to work on my EKG reading. But I also was forced to conclude, as my attending was on the case with me, that some things are only visible through hindsight. And fools though we are, no amount of medical knowledge, experience, or skill is foolproof. So now I pray before shift.
This patient reminded me of a haunting conversation I had before the start of residency. I was eating dinner at a welcome event for an undergraduate Christian club and chatting with the students sitting next to me, two black women who were sisters. They asked what I did; I said I was about to start training as an emergency medicine doctor. I hate to admit it, but I kind of enjoy the reaction I get when I say it. Usually people say some form of, “Whoa, that’s intense.” Some say, “does that mean you do surgery?” (No, those are other people.) Often students who are premed start a barrage of questions. So when these two women gasped and looked at each other, I was a little embarrassed but also used to it. I wasn’t ready for the conversation that came next. “So, you work in the emergency room?” “And you finished med school?” “In medical school, is that where they teach you how to kill someone?” The atmosphere was weirdly tense for an outdoor barbecue. I was bewildered. “Kill someone? What do you mean?” “You know, like lethal injections. You know how much potassium you need to give to kill someone?” “No, we don’t learn about lethal injections. We do have to learn what potassium levels are dangerous so that we know when and how to treat people.” “So with what you learned, you can test how much potassium someone has and know how much more to give them to kill them?”
At this point, I was so confused. “In medical school we have to learn what abnormal and fatal medical processes are so that we can identify and treat them. I guess that kind of knowledge in the wrong hands could be used in truly horrible ways.” The two women looked at each other knowingly, somewhat satisfied. “That’s a very nice way of putting it,” the first woman said. In my tentative questions that followed, I discovered that their mother had been treated at some emergency department somewhere and though there were signs that she had high potassium (hyperkalemia), they gave her medications that increased her potassium even more, and she almost died. No wonder my career evoked imagery of fatal injections for them. “I’m so sorry that that happened to your mother. I can’t even imagine what you all went through. That shouldn’t have happened,” I said. My heart was beating fast with words left unsaid. I wanted to defend medicine, or to somehow vindicate myself as not-one-of-the-bad-guys. Were they really accusing me, or was I imagining it? And am I not complicit in the bloody history of medicine that to this day carves out higher death tolls for black women across the board? The younger sister said, “I’ve never talked to a doctor outside of a hospital before.” She didn’t remark on whether it was a good or bad experience. The barbecue continued. It was a beautiful cloudless day. I got into other conversations and didn’t talk much to those two sisters again.
I asked a friend her thoughts about the conversation, and my almost fight-or-flight response to defend medicine, to excuse those doctors who probably were doing their best but had a terrible unforeseen complication. But I also knew I had to acknowledge their experience, and that they had good reasons for mistrusting a field that has systemically abused and marginalized their bodies and stories. My friend replied, “You know how they say, ‘what police do to black men, doctors do to black women.’” I actually didn’t know that phrase, but I nodded along. It tracked.
Now months later, my patient with the high potassium was a black woman, too. Even with good intentions, I can’t pretend systemic racism and unconscious bias did not play a part in my evaluation, either.
It’s not just one case of unconscious bias, either. I was taught in medical school, both by books and question banks and with real patient encounters that women are more likely to come to the emergency department for somatic symptoms caused by anxiety. I remember a woman who saw spots in her vision in her right eye, then felt hot and tingly from her head to her right arm, and weakness to both her legs causing her to fall. Diagnosis: anxiety. A young woman had a racing heartbeat and a burning sensation in both elbows. Anxiety. An elderly woman who was briefly confused and then watched her home blood pressure cuff tell her that her blood pressure was rising and rising and rising — (after extensive workup to exclude other causes of disease) anxiety. Of course, there are men too. A young tall man with sharp chest pain, anxiety. A middle-aged man who watched his Apple watch track his heart rate all the way up to 180 and called an ambulance, anxiety.
In each of these cases, we performed a workup of varying thoroughness to exclude “can’t-miss diagnoses”, like the life-threatening ones of heart attack, rupture of various organs, stroke, blood clots. Once those were ruled out and no other explanation remained, we would presume anxiety. After all, there is a strong mind-body connection between emotions and sensation. Stress can flood a body with adrenaline or give a vasovagal signal — that woozy feeling before you faint. Hyperventilation can temporarily tank the concentration of calcium in the blood, causing muscle cramps, numbness, tingling, and weakness. And thus far I may have anecdotally seen more women with anxiety-related symptoms than men. Or am I seeing what I want to see?
Two different patients in residency came in with strange somatic complaints that I couldn’t narrow down to anything physical. One woman came in for pain in one side of her face, sort of near her sinus. I did a full physical exam, tapping everywhere near it. She said there was swelling, but I honestly couldn’t see the asymmetry. I thought, maybe it was anxiety. She had a history of it. My attending came and with a gloved hand felt the inside of her cheek, where she had a possible abscess. A second woman came in with sudden pain to one wrist, and when I did her physical exam, every possible movement seemed to hurt it. None of the pain medications had helped. It didn’t localize to any specific muscle or tendon, and her affected wrist didn’t look any bigger or redder than the other one. I told my attending, maybe it’s a soft tissue injury? Or maybe anxiety? My attending saw her and came back telling me to tap it, or insert a needle to take out joint fluid. He suspected a septic joint, a serious joint infection, a can’t-miss diagnosis. (disclaimer: it was gout, not an emergency but still, I should have thought of that.)
I don’t know if I know more medicine now than I did at the beginning of residency, but I’m learning much more about myself as a weak steward of other people’s lives. I’m starting to recognize my well-worn negative tendencies and logical fallacies, and learning to keep them in check. I’m unlearning my old, bad habits of doubting a patient’s reported pain, of assuming things are less serious instead of assuming the worst, of anchoring on a diagnosis before all the possibilities are considered. And I’m leaning on the Lord to cover the rest. I can only pray that it will be enough.