On sunny evenings.
It’s 9:18 PM in Oxford. Which probably means the dusk is just about fading, because who would have guessed that England is around the same latitude as Canada or Russia? I’m on the flight back home from a research conference, and just before takeoff, I clicked to the end of my internal medicine question bank for the second time. Then I watched as many episodes of Friends and Fresh off the Boat that the plane ration allowed. And then, because limited airplane selections test my dignity, I watched a tongue-in-cheek Rebel Wilson movie that was basically profiting off people who wanted to lampshade but secretly love romantic comedies. (Sigh. Like me.) But finally my procrastination engines ran out, because I found out that the plane didn’t have the real Lilo and Stitch movie (they had an episode from the TV show) and I discovered indeed my dignity did have bounds. So, recourse lost, I write.
Before I do, side note: About five minutes ago, this plane started smelling of vinegar. I think it’s some neighbor’s feet. Don’t feel bad, pungent neighbor. Feet are just like that.
The halfway mark for rotation year is straight ahead. As of this time next week, I’ll be done with half of the year that everyone talks about, “the worst year of med school”. It’s not the long hours of work that make it hard, or constantly being on one’s feet, or having to do the “excellent medical student” dolphin dance every day for evaluations. It’s dragging yourself home and making dinner to satisfy the stomach/tapeworm and eating it while reading through mind-numbing practice questions that end up asking you for some completely irrelevant point of trivia; it’s saying no to invites out to dinner or bible study or weekends or family time at the table or playing with the dog because of fear that you’d sit through it wishing you were sitting at your desk with your eyes glazed over. It’s lying in bed after saying goodnight to housemates and text conversations and flicking through practice questions, feeling your wrist go limp every now and then before surrendering. It’s hesitating before you tell classmates what you really thought about exams, or what your study schedule really is, for fear of making them feel pressured, or for fear that you’d end up being the inadequate one. It’s wasting the odds and ends of hours scrolling down social media, not really caring about what you see, wishing you had the character to be working or the gall to just do something you actually enjoyed instead of wandering the no-man’s-land of partially pleasing non-activity. It’s working day after day with quality people stuck in an over-loaded hospital, and seeing them treat other people less for it: patients, nurses, transporters, administrators, doctors. And thinking, “is this what I have to look forward to?” It’s the reading and rereading of syllabi, grading schema, cryptic but somewhat aggressive emails from course directors, and awkward elevator interactions, trying to palm read my own trajectory. Because now it matters. Clerkship matters. That’s what everyone says.
But does it?
Experience and learning and mistakes, friendships and relationships and family, clinical acumen and empathy and efficiency, they matter. A sub-par performance on a graded exercise, a half-hearted evaluation by someone who has other things to do, a bad first-and-only impression on an administrator, do they matter? They certainly affect the grade. And I can’t help wistfully hoping that the grade would be a good parametrization of reality. But if it isn’t, does it matter?
More scenes from internal medicine, which now I think about sometimes on my primary care rotation.
An undocumented elderly man from Colombia with completely non-functional kidneys and three months of non-stop watery diarrhea. Because of his kidneys, he’s dependent on dialysis in the hospital. Because he’s undocumented, it took him months to get emergency Medicare to cover outpatient dialysis, so he could never leave the hospital. Because his diarrhea kept not fitting any of the known diagnostic criteria for diarrheal syndromes, all the medicine teams had an eye on him, hoping to be the lucky one to land the diagnosis and publish a case report on his rare-bird disease. Because he only spoke Spanish, no one bothered to explain any of these things to him. The medical students on my team and I visited him every morning and kept him abreast of the daily changes. This test is to look for whether your diarrhea is due to this bacteria. We’re giving you magnesium and potassium now because your blood levels are low; diarrhea can do that. Sorry, I know you don’t like the hospital food, but our dietary staff probably won’t be able to get you the green plantains you keep asking about. But yes, I’ll ask today if they can do that. He was always very understanding about our limited Spanish. He always thanked us as we left. And he kept asking when he could go home. Finally, after all the diagnostic options were exhausted, I was put on a team with the only medicine attending who was Hispanic. He spoke to the patient, he spoke to the family, and he pushed all the delayed cogs of the hospital social work system into gear until his dialysis coverage was obtained, an outpatient dialysis center was on board to take him as a patient, the family were all informed of his plans, and the patient was able to fly directly back to Colombia. “But what about that diarrhea? With the malabsorption and his high blood pressure, he could die without all the repletion we’ve been doing.” I asked the doc. “We don’t know what’s causing the diarrhea, and it’s possible we never will. But this man has already lived a very long life for Central America standards. He’s spent 3 months in this hospital not knowing if he was going to die here in a foreign land, away from his family and his home and the food he loves. At least we are allowing him to live the way he clearly wants to live, and be where he wants to be.”
Another undocumented man with a rapidly enlarging mass on his right shoulder blade. His CT scan had been read for hours: it was a benign growth. But because he spoke only Spanish, his resident hadn’t stopped by to see him all day, and it was almost time for the day residents to leave. When I went to draw his blood for routine tests, he asked about the results of the scan, face grim. I hesitated. In that moment, I must have terrified him — he was probably scanning my face to figure out if it was good or bad news. I was actually frantically deciding whether it would be more harm to the patient to have a totally unqualified medical student tell him about his tumor being benign, or to lie and say the scan wasn’t read, or to say the medical team will tell him later (and let him speculate on whether that was good or bad news). For better or worse, and I still don’t know if this was the right thing to do, I told him that the radiologists read his scan, it was probably benign, and that this kind of growth (a elastofibroma) usually doesn’t spread and can be removed by surgeons in a quick procedure. I held out my phone for the interpreter to tell him the news on speaker. He began to silently weep. I asked if he was okay, if he had any more questions. He said, still weeping, “This is good news.” I was holding my phone with one hand, my phlebotomy tubes with the other. I knew I should try to touch his shoulder or something, anything instead of stand there a handsbreadth away. But somehow my arms were alien, and his shoulder was miles away.
Every time I replay that scene in my head, I wish that he could have had a real doctor there to explain his news. He deserved one who really knew, not someone who looked like one speaking with borrowed words. I wish someone had gone to tell him immediately after the scan was read. I wish I could have touched his shoulder while speaking.
One day during afternoon rounds, a man in an isolation room (usually reserved for patients with infectious diseases) was screaming repeatedly at the top of his lungs, “IS ANYONE OUT THERE? CAN ANYONE HEAR ME? SOMEONE, PLEASE HELP. PLEASE!” The nurse assigned to his room was sitting at her computer, pointedly ignoring him. As for our rounds, our attending and residents just spoke more loudly. He continued shouting for the entire hour we were there, and was still doing so when I left for the afternoon.
Another morning, I saw a woman with bedraggled hair sitting bolt upright in her bed, just shrieking wordlessly at the nurse, who was at the door, saying, “Okay, okay!” I didn’t stay long enough to investigate.
After a patient with what must have been a very demanding family (I wasn’t on that service in time to meet them) passed away in the MICU, the attending at morning rounds made a joke about good riddance. And all the residents laughed. Some pulled out their favorite lines that the family said, especially the ones that showcased their ignorance about the patient’s medical care and insistence on illogical treatment choices. I stood there, my first day on the service, unsure whether I was misreading what was going on, unsure whether these residents were still good people. I think they were.
On one service, I was with a resident who would always scoff before seeing female Hispanic patients. “She’s going to be so dramatic and she’s not going to know anything. I hate it when they don’t really know their story.” She would then blitz through the interview, give a cursory exam, and remark to me on the elevator on the way down, “See?” And what could I do but mutely shrug along? But she saw an uninsured homeless woman with a probably a peptic ulcer malingering in a hospital. I saw a woman in the first week after a divorce was finalized, just trying to stay somewhere warm for the weekend the best way she knew how.
I learned on this rotation that it’s easy to learn about what’s right and wrong until you’re there in the situation. I would never make fun of a patient for being obese. But when my whole team does it, and I’m at the rock bottom of the hospital food chain, who am I to do anything but stand there until it’s over? The cognitive dissonance of being a passive participant in these attitudes and behaviors that so utterly are not me, which represent the sad, burnt-out underside of medicine, gnaws at me still. And the nagging thought, “will I ever find myself feeling this way? How do I escape their path, knowing they started out full of good intentions just like me?”
Oxford was a blast of sunshine in all of this (Ironic, all the locals told me I’ve somehow caught the only week not drenched with rain). In addition to the presentations and keynotes of the research conference, I snooped around various colleges and admired the dreamy arches and spires. Practice questions are a lot more enjoyable sitting in a pew of an empty cathedral, when taking a break meant enjoying the light through the stained glass rosettes. In the mornings before the meetings started, I studied for my exams while half-babysitting a nine-month-old with cheeks the size of Mars. One evening, some students from Oxford came over the flat of the family I was staying with, and we had home-cooked food, sang, and hung out. I remembered, “Oh yeah, before med school, I did enjoy seeing the world. I did enjoy meeting new people, especially other believers, and hearing their stories. I did like making faces at babies, and having them make faces back. I did like sitting outside and drinking a mocha and people-watching. I did like randomly ducking into alleyways or used bookstores or florists.” I didn’t realize I had lost track of that me. I don’t want to lose track of her again.
