Elizabeth Brunn

One of the biggest challenges medical students face is finding their voice: with their medical team, with the hospital staff, with patients, and with their chosen specialty.

As a medical student, you want to be proactive, to advocate for the patient, and to learn the best management techniques. But ‘proactive’ for one physician can easily be ‘annoying’ for another physician. Likewise, what can be viewed as ‘lack of initiative’ by one physician is ‘eager to learn’ by another.

During my third-year rotations, I became hyper-aware of my body language, tone, level of voice, where I am expected to sit in the conference room, what computers I can touch to write a note on, and so forth. The social construct of the hospital is exhausting for medical students, especially when we feel so low on the totem pole. I know my personality didn’t change on a day-to-day basis, but how it was interpreted and critiqued by my professors did. It almost made medicine and treatment the easy part.

Beyond the medical team, students struggle to find the right voice for each patient. Voicing a concern to one patient can be misinterpreted as being judgmental to another; enthusiasm can be viewed as naivety.

Some patients distrust students the moment we enter the room in our short white coats and student-colored scrubs, as if to warn the patient with a giant siren blaring, “student approaching!” I once had a patient tell me to leave the room faster than I could hold out my hand to introduce myself. Other patients love the extra set of hands to help, a voice to advocate for them, and ears to listen and make sure nothing is missed.

On my obstetrics rotation, one patient told me she hoped her future baby was a girl so she could name her after me. It was on this rotation that I truly felt I found my voice.

So, on this journey through medical school, how did I learn to normalize myself so all patients trusted that I am here for them? How did I find my voice that is true to myself, to my patients and to my supervisors? Most importantly, how did I learn to hang up my judgments when I put on my white coat every morning?

There is no right answer to these questions. For me, I found that the only way to find my voice is by knowing my patients. And the best way to know my patients is to approach them without judgment, and to not be afraid to ask them anything. Patients can sense when you’re uncomfortable asking a question, and they’ll only reflect your body language, which will lead you to a dead-end.

But hanging up my emotions, my reactions and my beliefs as soon as I put on my white coat in the morning is easier said than done. I’ve been blessed to see some doctors place their emotions and opinions to the side beautifully, and other physicians fail miserably.

One clinic that I worked at during my obstetrics rotation had a far higher rate of teenage pregnancies. Understanding my opinions about teenage pregnancy but not wanting my body language or questions to reflect judgment, I asked my attending how he is able to phrase specific social questions like ‘marital status’ or ‘do you do drugs’ in a nonjudgmental way to his patients.

His response was: “Elizabeth, there is no such thing as a nonjudgmental question. You are a white, blonde female. You cannot change your demographics just like you cannot change that you will be judged. It’s inevitable. These patients can go to any doctor they’d like in Northeast Washington, D.C. But instead they choose to get on trains, buses, or foot to come to me in Northwest Washington, D.C. And for that I am overwhelmingly honored. It doesn’t matter how late they come to the appointments, I always see them.”

And honestly, this is the truest and most humbling advice I have been given. I think these patients travel long distances for this doctor because they know he is an excellent physician who will not judge them and, ergo, provides excellent care. Sure he has his own judgments, but there is a difference between personal opinion and medical opinion. In order to believe in patient-centered medical care, personal views must be left at the door when you put on your white coat. Someone will always be pre-judgmental of my personality. But I think as long as I continue to be appreciative of my patients’ time, respectful of their goals, and patient along the journey, everything else will fall into place.

in-Training
in-Training - the online magazine for medical students

Erin Baumgartner

I had experienced codes before. Prior to entering medical school, I had worked as an emergency room scribe, charting patient encounters as they unfolded. I considered myself familiar with a code’s whirlwind of action, always one step away from the true pandemonium. After all, I had stood on its borders, plucking shouted orders and silent actions from the maelstrom, weaving them into a coherent, documented clinical picture. Naïve, and all too eager to count at least one thing as somewhat familiar, I did not consider myself a novice. Of course, that assumption was proven wrong.

I had already been on my surgery rotation for four weeks, having just switched from general surgery to the trauma service. The day of the code, the pagers went off in the middle of grand rounds. Room nine of the emergency department was a confused impression of scrubs, blue gloves, bleeping machines and blood. My fellow medical student and I were shuffled like hot potatoes from one corner of the room to another, before finally being banished to hold the elevator so that we could quickly transport the patient to the surgical floor. It was not until I was scrubbing in that I realized that my hands were shaking. They had never shaken before. The barely contained chaos seemed to have followed us from the ED to the operating room. I remember a constant revolving door of people going in and out of the room, and what seemed like half of the trauma surgery attendings showing up at one point or another. They barely had time to open and begin shoving in packing before the patient’s pulse cut out.

I had expected to be relegated to the typical medical student roles of hand and hold, but suddenly the attending turned to me and said, “be ready to step up when she gets tired,” indicating one of the surgical nurses standing on a step-stool at the head of the bed, doing chest compressions. Everything took on a surreal quality after that, both blurred and sharp-edged at the same time. I tried desperately to recall everything from my basic life support training I had barely a month ago. And then, it was too late; the time for recall had past. The nurse was stepping down, and I was stepping up. Chest compressions are not all that difficult to do on a mannequin lying on the hard ground, but unfortunately, I had found that it was infinitely more difficult to do standing on the tips of my toes on top of a rickety step-stool. At one point, I could feel the stool beginning to slide out from under me. Luckily, someone’s foot shot out to hold it steady, and I sank back into the mindless, repetitive movements of chest compressions: push hard, push fast!

The whole thing only took thirty minutes from start to finish, from the door of the ED, to the operating table, but it felt like an eternity nonetheless. Once the time of death had been called, it was as though someone had pulled a plug: the room instantly became silent and empty. However, the ache in my wrists stayed with me for days afterwards, and ultimately, it reminded me of the lesson that medical school has taught me over and over: seeing is very different from doing.

in-Training
in-Training - the online magazine for medical students

Nicole Perkes

Once upon a time, in a rural hospital far, far away, a med student began her clerkship.

At the University of British Columbia, the Integrated Community Clerkship (ICC) provides an opportunity to spend the first clinical year of medical school in a hospital in rural British Columbia rather than a large academic center. The intent is to provide hands-on education and to encourage physicians to one day return to serve a rural community.

Applying to the ICC was a no-brainer for me. Medical education in the big city felt strange right from the start. Our preceptors didn’t know their students and in a class of around 288, I really knew only a few of my own colleagues. It made sense to retreat to a smaller town, to get to know the community around me, and to be treated like a human being. The longitudinal aspect of it was just something that came along with the decision to train rurally.

What is longitudinal education?

The industry seems to use the terms “integration” and “longitudinal” nearly interchangeably. The definitions have become one of those tortuous academic arguments that the literature is fighting to pin down. My longitudinal experience meant that I spent every day in a different specialty and continued to rotate through each specialty for the whole twelve months of third year. We had a smattering of relatively small exams throughout the year in preparation for one final cumulative multiple-choice exam — a test of endurance and sheer will, with a hint of medical knowledge.

In contrast to a traditional rotational program, I also spent a half-day every week in family practice and since our community’s general practitioners follow their patients in the hospital, I spent roughly another two hours every day rounding on our in-patients. I doubt this is a part of every “longitudinal” program, but it was certainly a focus of ours.

So, what was my experience of it?

In the beginning, every day was a chaotic frenzy to locate the right department, find a clean pair of scrubs and explain to a preceptor that I was late because the previous preceptor was quizzing me on some differential or another. All this was done while simultaneously guzzling cold coffee, switching my brain from one specialty to the next, and making first impression after exhausting first impression. I couldn’t find the ophthalmoscopes, I didn’t know how to dictate, and every question I asked or decision I made was dripping with confusion and self-doubt. This lasted three months. At least.

Winter exams came and went. Christmas break was spent on my parents’ couch with a flu followed by a URI, followed by a viral gastro and another URI.

The turning point came just as they said it would. Sometime in spring, a phenomenon common to all the ghosts of ICC past transpired. I forgot to be nervous. I walked, blind and yet confident, into any emergency room without fear of making a mistake. Well at least if I made a mistake, I knew I could identify and correct it before presenting to my attending. I was focusing my histories, nailing my exam findings, and ordering the right investigations to lock in my diagnoses.

By the time our last cumulative national board exam was written in July, I was beaten down, sleep-deprived and thirty pounds heavier than when I started. Strangers had stopped telling me that I look young for my age.

And, yes, as I hear it, this is fairly identical to the experience of my colleagues in the traditional rotational system. But there was something different — I saw the light! Not just the light at the end of the third-year tunnel, but at the end of fourth year, too! By writing that exam, I proved to myself that I was retaining my knowledge. I would be able to study for and write my qualifying exams in another year with grace and precision.

Longitudinal learning works. I didn’t ever binge and purge for exams. I didn’t engulf myself in one specialty to the exclusion of all others. Instead, I integrated surgery and medicine. I incorporated my psychiatry experiences into my emergency department skill set. I learned anaesthesia procedures that I took to obstetrics and internal. My time in radiology directly correlated to pediatrics, urology, ENT and nearly every specialty. Unbeknownst to me, I had started to become a self-motivated, well-rounded, compassionate physician.

Is it just me?

As fourth year begins, the ICC students have returned to their home sites to share stories, and our tales of woe and tearful triumph are eerily alike. We all played the underdog protagonist, who struggled with confidence and identity in the beginning, navigating spooky forests and conquering dragons on a journey of self-discovery and ultimate victory. Indeed, this story has a happy ending. Alas, it is only the first part in an epic lifelong series of tales sure to entertain!

Back to the longitudinal learning thing … Would I do it again?

In chance hallway and cafeteria reunions with classmates, I am without fail asked about my longitudinal experience and how it compares. My now well-rehearsed response includes knowing eyes, a joyful smile and vigorous nodding, but none of the details. For the sake of modesty, I don’t list the number of babies I delivered, or the uncountable surgeries for which I was primary assist, or all the medical patients I managed on my own from admission to discharge. I don’t mention the sincere thank-you’s from so many patients and their families, or the overwhelming compliments from nurses on my growth and development over the year, or the confidence that has grown from gaping nothingness, or the pride I now take in every aspect of my work. I keep it to myself, I think, because words cannot describe, because the great adventure cannot be summarized, and because my experience continues to humble me.

Whenever I am asked about my experience, I get to look back, to remind myself of where I came from, what I endured along the way and how far I still have to go. Longitudinal learning mirrors the true nature of medicine, preparing us to be insatiable lifelong learners. After my year of integrated clerkship, I am eager to turn the next corner, accept my next challenge and face the next storm with the understanding that I will become a better doctor and a better person for it.

So, would I do it again? Bring it on!

in-Training
in-Training - the online magazine for medical students

Lindsey McDaniel

On a Saturday morning at one of our local safety net clinics, where third-year medical students see patients independently and then present to the supervising attending, a man in his 60s arrived to talk about some lab results he had received and what they meant. This man, Mr. S, had many medical problems, including hypertension, COPD, chronic kidney disease and newly diagnosed diabetes. He came to the office that day wanting to know why he had several abnormal values on his most recent lab work.  Mr. S clearly wanted to take care of his own health as best he could, but like many patients he had very low health literacy. Confounding this situation was the advice of his neighbor, a chemist, who informed him he needed several more tests done, further confusing Mr. S.

“Why am I anemic? What does it mean that I have high parathyroid hormone? My neighbor told me that y’all need to do these tests here,” he told me, pointing to the hand-written words ‘transferrin’ and ‘thyroid panel’ on his lab results sheet. Since this was the first time I had encountered this patient, his lab results were a bit of a conundrum to me at first as well. When I looked at his whole picture and the other medical conditions he had while presenting to my attending, his lab results made more sense.  Mr. S had chronic kidney disease, which easily explains both of the abnormal results; his kidneys weren’t secreting enough erythropoietin to stimulate sufficient red cell growth, and they also weren’t reabsorbing enough calcium and activating enough vitamin D to satisfy the sensitive parathyroid glands.

Explaining this to a man with low health literacy was simultaneously simple and challenging.

“Your kidneys aren’t working as well as we would like, so we want you to see a nephrologist, a kidney specialist, who can help you manage that better,” my attending explained when we saw the patient together. Mr. S accepted that, but when I went back to give him his paperwork, he had a little more to say when I asked him if he was satisfied with the answers we had given him. He thought he understood our explanation well enough, but he wondered what could he have done to have prevented this. He felt neglected by the specialists he had seen in the past, both because of his uninsured status and because he hadn’t understood their explanation of his condition well. He was concerned that he would be written off again. This time, the only care I could provide was to listen and reassure.

Overall, I  sent Mr. S home feeling like our healthcare team hadn’t helped him all that much. He was a very pleasant, talkative gentleman who clearly wanted to have a voice in his own care. He seemed satisfied for now, but I wasn’t. I had listened to his concerns and tried to translate the medicalese I have been learning for the past two and a half years into something he could understand. But I didn’t feel like I had done a very good job. I realized then how important it is to find a way to help people of all educational levels understand enough to be an active player in their own healthcare, and how difficult it can be to find the right words for each patient. I hope that the more I talk with patients, the better I will become at doing this.

So many people, myself included, say that we want to go to medical school to help people. One of the hardest realizations to make is that we can’t always help people in the grand ways we once pictured. Sometimes all we can do is listen and make sure that the patient feels heard and respected. Sometimes we have a medical intervention that will improve that person’s life to some degree. Sometimes we have a medication that will make it worse for a while in hopes of making it better in the long term. Sometimes we see well people and try to help them stay well. The important thing is that we never lose the desire to help and to keep trying to help in the face of encounters that feel futile or patients who can’t always help themselves.

in-Training
in-Training - the online magazine for medical students

Dacia Russell

I will admit to being an “OR avoider” — albeit, one who is certainly in awe of the stylized pageantry of sterile armor adornment. In the operating room, safe spaces are demarcated by mere inches. Rest your hand beyond the thresholds monitored by the scrub techs and you are deemed a threat to a clean procedure. Gesturing in ways that are otherwise socially advantageous gives new territory to harmful bacteria that threaten favorable outcomes.

As third-year medical students, an indelible grooming in patient safety seeds in the instruction we receive on behaviors that adhere to evidence-based guidelines for minimizing surgical complications. This education undeniably evolves with our understanding of the science and systems that underline medical practice. For me, a specific OR experience remarkably transformed and accelerated my education in patient safety. Witnessing and participating in the unfolding of a medical error made me rethink the resources necessary and available for safe medical decision-making.

Our case was a laparoscopic inguinal hernia repair. Nothing in the team’s preoperative routine diverged from the customs designed to optimize surgical results. We reviewed the patient’s chart to confirm that the proper procedure with the right location would be performed for the correct person. Surgical sites were marked. Consent was reiterated and lingering questions were answered. Once in the OR, a time-out ensued. Sterile drapes were positioned. We began, seemingly without event.

Shallow anatomical planes defined the workspace. To reach from abdomen to groin, small incisions were made, into which even smaller trocars were placed. Technical success required delicate coordination between surgeon, equipment and fascia. The torn tissue arose in view prompting the scrub tech to offer a needle for the repair. A few millimeters of steeply curved medical technology, the needle seemed an odd match for the exacting straightness of the trocar. The surgeon reflexively shared this sentiment. “This needle won’t fit.” But with a curious reversal of opinion bolstered by an unobserved expression of logic, the needle was advanced. And it complied with stiff walls of the trocar. But did it emerge unchanged? Dissatisfied with the progress after several turns of the needle, the surgeon pulled back on the anchoring suture. Only its frayed end returned. The needle was lost in the patient.

The pivot from progress to error in our case was the consequence of multiple factors. We were time pressured. Several complex cases were scheduled after our case, and regiment loomed large in the stated objectives of the team. We were performance pressured. The surgeon had only completed a few inguinal hernia repairs laparoscopically. Moreover, the relative newness of the procedure certainly extended to me as well as the assisting senior resident who was a relative novice with these procedures. We were decision pressured. We had delayed seeking assistance at key junctures. Thus, procedural unfamiliarity and uncertainty stood in the stead of seasoned guidance that might have reformed aberrant decisions.

These challenges are certainly not novel. But our preparation and impulses could most favorably be described as inadequate. Reflecting on our situation and reviewing patient safety literature, several mechanisms stand out as potential safety measures. For one, tethering individual accountability to a bias for inquiry transforms any moment of participation into a platform for turnaround. Practically, this means that we promptly ask questions and seek expertise as uncertainty seeds. Culturally, this demands that we work to dismantle norms that concentrate authority in any one person or in any one paradigm. Secondly, investing in ritualized protocols and appropriate interruptions that include equipment checklists and intraoperative time-outs are powerful add-ons to reduce risk. These practices help eliminate unneeded patient risks and work to protect the patient. Lastly, empowering healthcare teams with viable resources to manage workflow represents a formidable stake in protecting patients. Such resources can be articulated from multiple perspectives. That is, institutions can establish workload management policies, practitioners can advocate for optimal staffing, and even national authorities can weigh in with analysis of protocols that address safety in workflow.

Ultimately, our case withstood the sheer of its pathology. A senior surgeon was called for guidance. Multiple rounds of imaging were completed. The consensus of data gathered and expertise elicited settled on making an open abdominal incision. Subsequently, the needle was recovered. The attending surgeon and senior partner openly discussed their intention to fully disclose the error to the patient and patient’s family. Unfortunately, I was not able to see the patient in recovery and gauge his reaction to the phalanx of staples meandering on his abdomen. Nor was I privy to the disclosure between surgeon and patient where the events of the surgery were recounted. My hope is that all was ultimately well.

The lessons from this case have motivated me to strike new commitments to patient safety.  I was encouraged by the culture of safety and disclosure that flanked our case. This culture has been nurtured through years of patient safety scholarship and grooming leaders who are open and willing to learn from their organization’s mistakes. Yet, there were deficiencies in our approach that reveal avenues for sustained improvement.  As I contemplate integrating technology with the norms of medical practice, I am thus driven to advocate for a framework where questions are viewed as assets, pooled expertise is the default for tackling uncertainty and professional accountability includes the authority to command resources to optimize safety.

in-Training
in-Training - the online magazine for medical students

Sasha Yakhkind

Article by Rishi Kumar, MD | “Doctor’s Orders” curated by editor Sasha Yakhkind

Congratulations! You’ve made it to the clinical portion of medical school. Now you’ll work alongside interns, residents, attendings, pharmacists, social workers, and a myriad of other health care workers to provide quality care for your patients. As a resident, I’ve seen medical and PA students struggle with feelings of anxiety, incompetence and disorganization. They are excellent with patients, but often have difficulty with team dynamics and understanding their roles as clinical students.

Here are some tips for success modeled after Covey’s “The Seven Habits of Highly Effective People.”

1. Embrace Change: Clinical medicine is very different from what you learned in the basic sciences. Your lecture hours have turned into work hours. Your predictable schedule has much more fluid and riddled with fatigue. You will be seeing patients in clinic, suturing lacerations in the emergency department, holding retractors in the operating room, and somehow finding time to go home and study for your shelf exam. The quicker you adapt to change, the better!
2. Be Friendly, Be Patient: Stress is multifactorial for the clinical student. Exams, evaluations, extracurriculars, busy work days and burnout are all very real. Despite this reality, every person you encounter deserves your respect and kind demeanor. Patience is intrinsically linked to keeping calm when you’re stressed. Waiting for a critical lab result? Patient disposition issues? Didn’t get your choice of vacation or days off? Making the most of a bad situation is what will define you — be comfortable with things being out of your control.
3. Know Your Limits: No one expects you to be adept at every procedure or an expert in every field right off the bat. At the same time, residents don’t know your background experience with various tasks. If you don’t know something, ask … and learn for the next time. Often times when one student learns something, the information disseminates among the others on the team. No greater way to learn than from a colleague.
4. Balance: Your hours will be more unpredictable, but it’s important to find activities to do in your free time. Going out for dinner, watching a movie, hitting the gym, playing sports, and pursuing other hobbies were all things I did as a med student. Find what makes you happy and a way to incorporate that into your schedule. There’s plenty of time for medicine … so relax!
5. Team Before Individual: Your team dynamic will determine how happy you will be over the course of the rotation. Residents try to set aside time to “pre-round” on your patients, review concepts, and offer critique, but sometimes we just need your help with follow-ups, paperwork, or making phone calls. Be the helping hand! You succeed and fail as a cohesive team — if one person is happy, everyone will be happy. By the same token, never try to “one-up” a co-student or resident. It makes you look pompous, and no one likes a showoff or know-it-all. A lot of the feedback from attendings is driven by input from the residents (not to mention your dean’s letter comments). Make yourself stand out by putting the team first.
6. Be Honest: It’s sad this even made the list. Often times honesty comes into question when students are embarrassed to admit an oversight; however, we’re in a field where false information can have serious repercussions on another human’s life. Admit all mistakes or shortcomings and move on! In the end, lying is one of the worst things you can do. Also, if you’re uncomfortable about a certain patient or something happened, like a needlestick injury, you’re doing more harm by not telling someone on the team.
7. Have Fun: Despite all the hard work, the most important tip I can share is having fun. You’re practicing medicine, a field rooted in the noble art of caring for others. You will learn the deepest secrets of your patients. You’ll see patients nearly escape the grasp of death, and from time-to-time, some who pass away. You’ll see healthy people present for routine physicals. You’ll watch trauma patients roll in with a chest compression device running. Think about it: how many other people get to see this?

My years as a clinical student were memorable beyond description. To this day, I reflect back on the excitement (and fear) I had as an MS3 and how much more knowledgeable I seemed as an MS4. This maturation is something all medical students will go through before beginning residency. Hopefully the aforementioned tips have provided you all with a glimpse of some important considerations all clinical students should contemplate.

Dr. Rishi Kumar, MD graduated from Baylor College of Medicine in 2013 and is currently an anesthesiology resident at Baylor College of Medicine seeking to improve anesthetic care by employing the latest techniques in perioperative management. He is a lover of medical education, sports, gaming, investing, programming and absolutely everything tech. Drop him a line at his blog, rk.md.

in-Training
in-Training - the online magazine for medical students

Jimmy Xu

A mere five weeks into my third year of medical school, I met a patient who would leave an indelible mark. Jose was a Hispanic man that teetered between overweight and obese; I am a tall, medium-build Chinese-American who was thin in high school.  He struggled with depression during 40 odd years of life; my biggest worry growing up was excelling on the competitive piano circuit.  He spoke of a family rife with discord and unhappiness; my family is intact and supportive.  He dropped out of college; I want to stay in school forever.  He ate rice and tortillas; I ate rice and tofu. We were different but for a moment, our lives intersected.

During my first week on the psychiatric consult service, my attending directed, “Interview the 45-year-old man here for alcohol detox on the fourth floor.”  When I walked into the room, he was somnolent, confused and tremulous from his alcohol withdrawal.  He viewed me with suspicion and annoyance, as I was another medical minion sent to disturb his rest. Seeing his pain, I placed another pillow behind his head and tilted the bed so he could sit up.  He was having trouble opening his eyes so I shut off the light and then I sat next to him. We made small talk about the World Cup and Latin-American soccer players.  He told me about his disappointment in Neymar’s injury.  I told him about attending my first soccer game in Argentina that ended in a riot.  Gradually he began to view me with less suspicion and began sharing his story.

I held my breath as he described his physically abusive and absent relationship with his father, and all of a sudden the petty disagreements I had with my own seemed insignificant.  He whispered about the uncle who sexually assaulted him.  He cried about his first sweetheart who he married, who then left him when she could not handle his drinking.  He proclaimed with pride about achieving junior status in college and lamented that he has not one friend to talk to.  I realized that the abuse he suffered, constant worry about money and his fragmentary education set him up for failure; I could easily have been the one in that bed and he wearing the short white coat.

Although our physical appearances and social standing differed, we were both second-generation immigrants whose families moved to America. However, whereas I was lucky to be afforded all the privileges and luxuries in life that fast track one towards success, he was not. My parents arrived with medical degrees and instilled in me an ethos of grit and hard work. His parents arrived with that same work ethic but without education and access to the doors that it can open. Whereas my father held a stethoscope and penlight during his 16-hour days, his father held a hammer and tape measure.

My patient told me he wanted help, that he wanted to get better, but I know that the odds are poor.  Even for those with world-class levels of care and social support, addiction is one of the hardest afflictions for people to overcome. For those not so blessed with financial and social resources, addiction can truly be a difficult ordeal. Two weeks later, a counselor called and said that Jose has been attending AA meetings and is 15 days sober. I can only hope that our time together brought him some solace during his stay because I am grateful for everything he taught me.

Author’s note: Patient-specific information has been changed to protect the patient’s identity.

in-Training
in-Training - the online magazine for medical students

Katharine Caldwell

In the rest of the house, the noise of the party is deafening: the clink of glasses, the sizzle of burgers on the grill, the excited cries of relatives reunited after long absences. But in the bright light of the kitchen, Mark is talking to me without sound. He presses his right hand over his left then moves up its length, separating his thumb from the rest of his fingers as he goes replicating the open and shut motions of a jaw. “This is the sign for cancer,” he says.

“Ooh, creepy,” I cringe. “I didn’t know ASL was so morbid.”

“Exactly,” Mark agrees, punctuating this with open hands. Mark is an American Sign Language interpreter and, even when not working, a little bit of gesticulation is to be expected when he speaks. “So that’s why her son got mad at me.”

Mark has been explaining to me how he had been translating for a client at her doctor’s appointment and had been given the unfortunate task of delivering the news that this woman had cancer. When he’d done this, using the sign for cancer that he had just demonstrated to me, the woman’s son had become very agitated and snapped at him.

“I don’t think I would have liked the picture of something eating my mother either, to be perfectly honest. So what did you do? Spell it out?” I ask. I’m certainly showing my ignorance of ASL here, but I’m genuinely curious.

“I used a couple of other signs for the same idea.” He says and his fingers unconsciously form them in the space between us. I’m not sure he realizes he’s done it, and they flash by so quickly I’m not able to gather what they mimic.

“The metaphor of it is so different from English. Much more graphic. I guess the nature of a visual language, but I’d just never thought about it.”

“It makes translating very…” he pauses, searching for the word. He finally settles on “strange,” but doesn’t seem quite content with it, and he quickly revises it to “challenging.”

“You have to think about a thousand different things. I’m always having to think about what’s being said and how that translates into sign, but also the way it was said and how to convey that. Sometimes I have to think about the setting — some of the ASL gestures are just more graphic and might not be appropriate in certain settings. I dance around a lot of things to fit the tone of the conversation.”

“Like saying ‘passed away’ instead of ‘died?’”

“Exactly. I just end up changing a lot of the words so I keep the intention and the meaning of the speaker because I can’t always hold 100 percent to the words. Not everything translates.”

I laugh. I tell Mark that is a feeling I am very familiar with. Although I’m sure that translating from one spoken language to another is nothing like the challenge presented by translating a spoken language to a signed one, I am familiar with the feeling of confusion at exactly how to translate the untranslatable. I tell Mark the danger of ever letting anyone at a hospital know that you speak another language. As a medical student, the second a doctor I’m working with notices me speaking with a patient in Spanish, I quickly find that I’m being grabbed and asked to translate in every situation that arises — many beyond my level.

I’m constantly turning people down when they ask me to translate. I don’t have the skill to communicate the results of the MRI with this patient because I’m not sure how to say “adrenal gland” or “not concerning for malignancy.” I don’t have the comfort level to ask a patient very detailed questions about his or her medical history, where one error — one transposed word — could change a treatment plan.

But often times I do step up and try to help physicians communicate with Spanish-speaking patients. I often work as a stop-gap measure until a translator arrives in emergency situations, or I step in when I realize an attending is going to do that thing where you just speak very slow English to a non-English speaking person in hopes that they’ll somehow be able to understand just by decreasing the velocity of the words thrown at them. I hate when people do that. I don’t speak Chinese. I will not speak Chinese no matter how slowly you speak it to me. I can’t learn the language in the pauses between your words.

When I do step in and translate, or even when I step in to have a primary bilingual encounter with a patient, I always do so with a disclaimer to the patient that my Spanish isn’t perfect, but I’m going to try and if they ever are confused by what I’m saying or feel I’m misunderstanding them, they should stop me and we will wait for the translator. I often repeat back to patients what I think they’ve said to me to ensure I’ve gotten the right message.

I am a very cautious translator.

What always fascinates me is how quickly I find myself editing what’s said. I find myself unable to grab for the exact translated word in Spanish, so I walk around what was said in English using two or four or six words to get there. Sometimes words are traded out for synonyms. Idioms are lost. It’s what I can do. This is likely most often a failing of my own language skills, but sometimes the result of an idea or phrasing that simply does not exist in one language or the other.

I try to be as faithful as possible to the intention of what was said, even when the words themselves don’t always seem to come out identical.

But no matter how much double checking I do, how simple the encounter, serving as the translator, the go-between, always makes me nervous.

How much did I lose?

How much slipped past me unsaid?

Did I fail to really express the doctor’s concern? Did that really come across as a joke?

Did I fail to communicate the patient’s fear, their anxiety?

Was I wrong to have switched out the patient’s choice of “tube” for the more medical “drain” when she was speaking?

How much is lost on my lips?

All of medicine is a translation game because medicine itself speaks a language that often bears little resemblance to English, with most of its being composed of a bastardized Latin or Greek. Half of its thoughts are shortened into acronyms or nicknames, and a portion of its terms are archaic references to things long since forgotten. We spin together sentences full of lab values and statistics and the names of tests that we don’t even know what all the letters stand for anymore.

How can you expect someone who speaks a traditional American-idiom to follow a conversation filled with words like “hyperplastic,” “myeloma” and “choledocholithiasis?” Three years into my medical training and sometimes the details, the nuances of these conversations, slip past me. I should keep a list of the strange abbreviations or words I’ve looked up. Surgery seems especially bad at this, just squishing together all the words we want to say into one big mess and adding a suffix (pancreatoduodenectomy, esophagogastroduodenoscopy, choledochojejunosotmy).

Sometimes, I’ve wondered if doctors use this language to keep themselves at arm’s distance from the patient when things are uncertain or terrifying. Is medical jargon some sort of clinical coat that we wear, not only to distance ourselves from the reality of suffering all around us, but also to evade the painful realities of medicine?

Certainly medicine is an imperfect and unpredictable science. Perhaps we use medical jargon to hedge our bets. We’ve all seen ninety-year-olds come back from multi-organ failure while nine-year-olds die on the table with nothing more than acute appendicitis. We’ve seen poly-trauma victims recover completely normal function and simple fractures lead to lifetimes of disability and pain. We’ve seen non-treatable, 90 percent dead-in-a-year cancers turn to no evidence of disease, while 99 percent survival at five years end up in the one percent. We’ve seen the amazing turnarounds, the long shot winners, and the miracles. But we’ve also seen the nasty shocks, the one in a million, and the impossible heartbreaks.

We say “the CT was concerning for distant metastasis” instead of “your cancer will kill you before Christmas.” We say “the speed of resuscitation was inadequate and it appears your loved one no longer has higher cortical functioning” instead of “your husband bled out too quickly. We couldn’t stop it, and now he’s dead. His body just doesn’t know that his brain isn’t functioning anymore.”

Do we simply talk this way because the cool, clinical language of science is the one we have grown so accustomed to speaking that we forget many people are not as fluent as we are? We forget that many people have barely enough competency to know when to nod along.

Do we say these things because we’re hoping that what we know to be true is wrong? We’re hoping for the miracles, knowing they won’t come, but not wanting to take that hope away from those people who still believe in them.

Do we say these things because if we dared to say “will be dead,” “will not recover” or “permanent pain” it might burn us to sit so close to the fire of day-to-day suffering?

Or do we simply say it because we have not been taught the ability to translate our medical language into English? We are not certified translators; we are human beings with some bilingual proficiency trying to step around the sentences, and trying to hold onto the concepts and feelings. And sometimes we fail.

It’s probably, on any given day, any or all of these things.

Eddy used to listen to Jimi Hendrix or the Grateful Dead. He’s probably got Jefferson Airplane vinyls hidden in the dusty corner of some closet in his house. Now, even well past his bell-bottom pants and flowered shirts, he still retains some of that same vibe. I might walk in one morning and have him hand me a flower and tell me about how nuclear disarmament is the most important political issue. After free love, of course.

Eddy was admitted to the hospital for emergency surgery and it was during that emergency that he was first told he had end-stage cancer. Up until that point he’d been feeling fine, maybe a little bit more tired than usual, but his wife had been sick recently and it was probably because of that.

I remember the first time I saw him in the emergency department. He was wearing the same look as a student who thought he had sat down in his English class only to find himself in Japanese 201. He looked so overwhelmed, lost, and very small in that bed. He was thin, certainly the result of the all those years of cancer left festering deep inside his body unknown to him. But the smallness was greater than that, as though the cancer had eaten away more than just tissue, but part of his substance.

I think of Mark in the kitchen moving his hand up his arm.

Eddy’s ribs poked through his chest, his sternum dipped slightly. Hands, chest, face: pale. That his H/H (blood numbers — there I am, speaking medicine) would show severe anemia was a surprise to no one. Every time I see him, I feel helpless. One of my attendings on surgery likes to say “a chance to cut, a chance to cure.”

Here there is only a chance to cut.

Over the course of the next couple of days, Eddy underwent a very long series of surgeries. After one of many, we go see him on rounds.

My resident flicks the light on without warning, without introduction. No “hello,” no “good morning,” just bright lights and “Surgery team here.” He does the quick incision checks required: incisions clean, dry, intact, wound edge non-erythematous without drainage.

Just as we’re about to step out, my resident drops that someone will be coming by today to take him for the CT.

“What CT?” Eddy asks. He’s slightly slow to speak. My resident had almost made it to the door by the time the question leaves his lips.

“To see if the cancer has any more sites in your liver.”

“But I thought you took that one out when you did the surgery.”

“No, we just biopsied one of them. We’re not going to remove them.” My resident says and then he hits the door.

I can see it on Eddy’s face. He has more questions. He hasn’t understood even though it’s been said to him half a dozen times in strange, clinical sentences. The fact that his cancer has metastasized to his liver means he’s stage four, it means he’s going to die, it means there’s not much more to do now, maybe some palliative treatment, but no chance of cure anymore. I know I’ve heard a dozen different people in a dozen different white coats tell him these things, but it was all in these unclear, roundabout ways.

I should say something, I should call my resident back. But he’s already on the phone to the operating room; first case is already asleep in the room. He’s gone. He’s already half scrubbed.

But I say nothing.

Stupid.

“What would you do?” Eddy asks me the next time I go by to see him, this time alone. “Why should I even bother? This has been hard enough on my wife figuring out that I have cancer. If she knew that it was in my liver too I think it would kill her. I don’t think she could handle it. Would you have the CT? I don’t know if I want to know. Does that make sense?” I’m not sure he’s talking to me or just to himself or to the universe, but then he looks at me with his eyes large in their hollow sockets and waits for an answer.

And oh God, I wish that he hadn’t asked. I don’t know what I’m supposed to say. Should I tell him what I know about the numbers and the survival rates? Should I tell him that no matter what the CT shows, he’s not going to ever get to be a cancer survivor? Should I do what everyone else has done and dodge the question with more numbers, more big words, so as to not have to be the one to hand him the finality of his diagnosis? Should I escape the conversation with an answer that he will be unable to translate?

I start to. I start to give him the same information he’s been handed a dozen times, but the words die in my mouth. That’s not what he needs.

Should I just tell him the truth — that if it were me, I’d check myself out of the hospital right now, fly to the Caribbean and spend the last six months of my life on the beach?

That’s not what he needs either. This isn’t about me. He just needs a translator. Someone to translate his emotions into a medical response that the doctors will understand. He needs someone to translate his “I need time to think about this” into medical speak.

“You don’t have to have it done if you don’t want to,” I say, finally. “It’s okay if you need to think about what you want. It’s okay if you tell them that. They will understand. They were just trying to expedite things for you by having it done now, but they can always do it outpatient after you get discharged.”

He says nothing for a long time. He looks up at the ceiling above him, a ceiling he must have been staring at for the last several days. I’m sure he is incredibly familiar with the place where the ceiling meets the lights, the place the paint is cracked. He’s memorized the details of it all but this time I think he’s looking for the answers. I don’t think he’ll find them.

“Thank you.” He says at last and turns back to look at me. It’s a soft, genuine “thank you.” One that curls up the corners of his lips as it leaves them behind.

I’m certain I’ve said the wrong things, just as I do in Spanish. I’m certain I’ve failed to communicate appropriately what I mean to say, but I hope that he’s heard the intention in there somewhere and that it’s a comfort to him for me to speak the same language he speaks in lieu of the medicine he’s heard too often.

Medicine permeates our speech. Being a doctor is much like being bilingual in a country that speaks predominantly a language that is different than the one you speak at home. You go to work and speak Medicine. You text it to your colleagues. You converse in it while you wait in line for coffee. You write it. You dictate in it. Then you come home, switch back to normal English, and your partner stops you halfway through a sentence because you’ve lost him or her down the rabbit hole of shortened words. You send an email to your mother with “s/p” and “2/2” found in the body and she thinks they’re typos.

We speak Medicine and we do it so easily, so quickly, and so completely that we fail to recognize that someone else might have trouble understanding the tangled idiom of our sentences.

What I’m learning in the third year of medical school is that as doctors we have to wear a very large number of coats. Sometimes we’re healers, sometimes counselors, sometimes teachers and sometimes translators. And sometimes we’re especially bad at wearing that last coat enough. I don’t know whether we just have to learn by experience, or this is something that we should be teaching our doctors to do.

I don’t know if it’s something I’ll ever be good at it, or if I will always feel like I do when I try to translate to and from Spanish: like there’s a chance I’m missing something, like there’s a chance something is being left on my lips.

I do know that I must always strive to ensure the meaning is heard and the intention understood even when the words themselves are clumsy. Because Mark is right: not everything translates.

in-Training
in-Training - the online magazine for medical students

Jimmy Yan

“He always does this, it’s unbelievable!”

My preceptor’s voice was unmistakable. We had just finished our first case and I had momentarily left to get some coffee.

“This is getting unacceptable, someone needs to bring this up to the board!”

I had never seen him so worked up after having worked with him over the course of the week. Whatever this issue was, it clearly had been festering for while. From the sounds of it, the person in question has had a habit of this particular behavior.

“I agree, he keeps getting away with it and figures someone else will be there to pick up the slack,” said another anesthesiologist.

“It’s a typical surgeon’s mentality, they all just want to operate and then not deal with patients afterwards,” chimed in a nurse who was on her break.

“Whoa, I operate and see my patients plenty,” said one of the orthopedic surgeons. “Don’t lump us all into the same group here.”

It was getting a bit uncomfortable in the staff room, especially for a visiting medical student who had only been here for a week.

“I think I’ll go check on our next patient,” my voice rasped. This was a bit of a lie as I knew the next patient was not in the pre-op room; I just needed a parachute and, in turn, I hurried out.

As the day continued, I heard more and more snippets of what was happening. Putting all the parts together, it seemed like the commotion was about a particular surgeon who allegedly went ahead and booked a patient for an operation at the end of the day, even calling to tell that patient to come down to the hospital without informing anyone else ahead of time. People were frustrated with having to work longer, rescheduling other cases on the trauma list and just the blatant disregard for process.

At the end of the day the surgery did occur but the surgeon in question did have a reason for his actions: his patient was riddled with widespread metastatic colon cancer. The patient and his family had different views on how to move forward on treatment, with the family wishing for palliation while the patient was still hoping for a cure. Finally, this surgeon agreed to conduct an exploratory laparotomy on the patient to see if there was any portion he could possibly resect or at least definitively ascertain the prognosis. Unfortunately, there was nothing to be done because the abdomen was riddled with tumor. Following the operation, the surgeon phoned in the family and stayed near the patient’s bay until the patient and the family was ready to hear the news.

This experience reinforced the notion to me that there’s always more than one side of an experience in medicine. It’s easy to craft and follow stories that have clear “heroes” and “villains” but when does reality ever exist in such distinct dichotomies? All too often, easy short cuts are applied in the hospital setting which lead to labeling people, for example the “cold” surgeon or the “whiny” patient. One of the most important reasons to further explore the narratives in medicine is that doing so breaks past initial labels and allows us to better understand patients, how their experiences have shaped them and where they see themselves in our care.

A Fly on the Ward

The clerkship experience can be the definition of tumultuous. As we’re suddenly tossed into the wards, it’s easy to become caught up in the shuffle as we move through our service rotation. These posts try to take a step back and become “a fly on the wall” observing and reflecting on the overall movement through clerkships.

in-Training
in-Training - the online magazine for medical students

David Louis

The first day of my medicine rotation, I proudly put on my white coat and stuffed its pockets with my stethoscope, reflex hammer, otoscope and a few pocket-sized books to help get me through the day. The stress and anxiety of taking Step 1 was over. I was going to treat patients! Heal the sick. Comfort those in mourning. I was finally where I wanted to be: in the hospital.

When I arrived, weighed down by the multitude of objects in my white coat, I was greeted by, “go down to the ICU and see T.E., a 40-year-old woman in septic shock and respiratory failure secondary to an abdominal surgery.” With that single sentence I was brought back to reality, and the realization set in: maybe I was not as prepared as I had thought.

As I walked into her ICU suite, prepared to attain as much information as I could from her, I discovered to my dismay that she was intubated and on a ventilator. The standard third-year history and physical I had memorized was going to need some tweaking.

Over the next coming week, we had formed a bond. I spent time with her and her family, pointing at posters showing the letters of the alphabet, or pictures of nouns and verbs, in an attempt to construct the sentences. On some visits I would spend close to an hour in her room, attempting to form her sentences, letter-by-letter, word-by-word.

By midweek, I had formed a routine of rounding on my patients, with T.E being the last. On that Thursday, I walked by her room on my way to the computer station. To my surprise, she had been extubated — taken off the ventilator! I stopped in my tracks, turned to her and her family, and threw up my arms yelling, “You can talk!”

In retrospect, this story represents the reason why I have chosen a career in medicine. No amount of studying a disease process or treatment modalities would have prepared me for this experience. I have found that most physicians who are able create a tight-knit bond with their patients all express the same trait: vulnerability.

Ask yourself: do I allow myself to lay my emotions, fears and thoughts out on the table when interacting with my patients? Do they know I’m terrified right now? What if I make a mistake, make the wrong diagnosis or prescribe the wrong medicine? Medical students and physicians early in their careers are exceptionally vulnerable. We are still learning how to take a history and physical and form a treatment plan. Something as simple as starting IV fluids has the potential to either seriously harm or help a patient. And we know this. This is the reason why we overthink our treatment plan, or begin stuttering when an attending asks us what our plan is. I believe that by showing our vulnerability and acceptance of failure will allow physicians of all ages to improve their practice of medicine.

Vulnerability does not simply apply to tangible medicine either. My experience with T.E was successful only because I walked into her room eager to face a new experience and content with the risk of failure. It is what most medical students face day-after-day. Unfortunately, we do not always realize it. I am writing this short essay to bright to light the power and value of vulnerability and the positive impact it can have on your life and the life of your patients. Do not fear failure. Accept the knowledge that you will fail and be willing to learn from the experience. But I will add a disclaimer: do not make the same mistake twice.

In this regard, there is no career like medicine. We have the capacity to form such meaningful relationships with those in need. Information that not even their closest friends or family members know about, is shared with us. Clearly, patients allow themselves to be vulnerable. Let us create a movement in which physicians reciprocate that feeling. All too often I seen the physician-patient relationship as one sided. It is time for that to change. And it can change! Letter-by-letter, word-by-word, we have the power to display our vulnerability and improve patient care. I certainly would not have realized this if it were not for T.E.

in-Training
in-Training - the online magazine for medical students

Nita Chen

She was a petite, otherwise well-appearing woman, apprehensively sitting at the edge of the examination table. Hoping to mask my nervousness about this first, intimate patient encounter, I inquired about the reason for her visit. She told me that she was here to discuss a hysterectomy. She shakily explained her two-year history of heavy, painful menstrual bleeding. She hoped that the hysterectomy would be her saving grace. The insistence on this procedure made me suspicious of stirring waters beneath calm surfaces, so I probed further.

The patient recounted embarrassing obstacles that developed due to her constant, painful menstrual bleeding. I mentally began to form and shift around possible differentials. Yet as the conversation turned to the traumatic experience of her most recent delivery, another category of diagnoses quickly bubbled to the forefront of my mind. Her answers to my questions about abnormal bleeding were tagged onto self-berating tangents where she recounted her perceived failures. Her life centered on the happiness of her family, but it was clear that this was also the root of her mood disturbances. She explained frustrations associated with her recent pregnancy, familial responsibilities and inability to truly be herself. These circumferential rants made it clear to me that her chief complaint was simply the grounding granule upon which all her deeper-seated problems crystallized. The descriptions of anhedonia, erratic behaviors, sleep disturbances and seemingly endless complaints rung the alarm bells for postpartum depression.

After I felt I had a decent handle on the most significant stressors in her life — the strained spousal relationship, the medically handicapped father that required constant care, the chaotic management of multiple children and pets that ran amok in her house without proper spousal support and the current obstacles in obtaining the appropriate special needs requirements for her youngest — I decided to assess the patient’s insight on her condition. Despite her strong expressions of overwhelming frustration and self-directed hatred, she remained solely fixated on her medical presentation. She seemed profoundly confused when I observed that she must be overwhelmed with her responsibilities. Instead, she saw these symptomatic developments as consequence of her personal failures, rather than the culmination of expectations and responsibilities. She seemed baffled by the idea that all the stresses she described at length could result in medical and psychological ailments. After all, she had been dealing with these problems forever; it just wasn’t a big deal.

She had so many things to be grateful and happy for. She didn’t have a right to feel overwhelmed and depressed.

When she mentioned that she did not have time for therapy because of her son’s never-ending special needs sessions, I tried to point out that personal health often takes a backseat for working mothers. I felt a hint of achievement as I sensed a glimmer of realization in a brief moment of pensive quiet.

When a brief pause gave way, I ushered myself out to update and discuss the patient with my attending. I was slightly taken aback at his surprise when I expressed concern that the patient may be suffering from postpartum depression. He listened attentively as I explained her repeated expressions of self-directed frustrations and her seemingly narrow-minded perception of what the hysterectomy would accomplish. In the brief time my attending and I discussed the possibility of two chief complaints, abnormal uterine bleeding and postpartum depression, I felt a strange sense of accomplishment and humbled acceptance. This warm feeling continued to grow when we decided to start her on an antidepressant and delay the hysterectomy.

At the same time, however, a flicker of uncomfortable disturbance hummed in the back of my mind at the dissonance in the current practice of medicine. The prioritization of medical symptomatology over psychosocial factors may appear benign in the acute setting, but its impact on our patients’ well-being may be more severe than we realize. As trained problem solvers, it is natural that we expect patients presenting to an obstetric clinic to have a major obstetrics complaint, not realizing that other underlying pathology may have precipitated this potentially secondary complaint. Especially from the perspectives of overworked and extremely busy attendings, it is easy to fixate on the most obvious symptoms within their expertise.

Throughout the preclinical years, medical curricula and standardized patients emphasize the importance of “getting to know your patients.” From my short experiences on the wards, I have realized that while this is a true and beautiful sentiment, the reality of rushed twenty-minute appointments create a barrier to hearing each patient’s life story. The reality of medicine prevents us from seeing the intricacies that may be crucial context for each patient. I took more than twenty minutes to interview this patient, but I discovered vital information. I was able to establish rapport, trust and engagement. In exchange, I missed the other two patients that were swept in and out of the office. As a student, I have to question how to best balance the realities of medicine with appropriate and humane care to our patients. Perhaps, we as third year medical students, can serve as the bridge between our patients and our supervisors. We can make use of our time in the ever-bustling wards to really get to know patients. In these prolonged encounters that our supervisors do not have the luxury of experiencing, we can parse out the psychosocial context that surrounds each clinical encounter. In doing so, we may serve as an important contributor to the team. Too often, I have felt that my lack of knowledge and experience are obstacles to being useful, but this interaction showed me that as students, we might have hidden clinical skills of our own. If we learn how to brandish these effectively during our medical education, we can play an active, vital role in the living organism of medicine.

in-Training
in-Training - the online magazine for medical students

Omar Aldaas

The beginning of third year clerkships is an exciting time for medical students. The first step of my licensing exam was finally behind me and I could now focus on applying that knowledge into a clinical context. I had heard many stories about the third year of medical school. Perhaps, what stood out most were the reflections shared with me when people witnessed death for the first time. From full codes to hospice patients, something about death seemed to draw out the most intense emotions and thoughts, which could change lives forever. Although I would always try to do the best for my patients, I knew it was inevitable that I would come across death. I wondered what profound thoughts and reflections I would have when I experienced it for the first time. It wasn’t too long before I was called to do CPR in the emergency department — and I found it did not play out as I expected.

I was walking by a patient room when a nurse saw me and asked if I wanted to “practice” CPR on a patient. It caught me off guard but I quickly learned to be confident and take opportunities like this because it may not present itself again. Before I knew it, I was applying compressions and it wasn’t long after that the doctor called the time of death. Before I even had a chance to remove my gloves, the doctor pulled me to the side to discuss differentials with me. I didn’t have time to process what happened — I was just shuffling from room to room the rest of my shift talking to other patients. Later, to my surprise, I wasn’t troubled by thoughts of the patient who had died in front of me — what concerned me was this lack thereof. Why did I not have the intense emotions and reflections that everyone has after witnessing something like that? Was I so jaded by the stresses of medical school that something like death could not even shake me?

I was plagued with these thoughts for months until I began my community-based education at the fire station. During this week, I had an experience that will stick with me for the rest of my life. The fire station was called because a man was attempting to commit suicide by jumping off a parking structure. I was not mentally prepared for what I saw when we got there. The man was seated on the edge, his legs still resting on top of the railing. His friends and coworkers were at the bottom, begging him not to do it. They told us about how he has three young kids, and a wife who needed him. I had run multiple codes during previous emergency department shifts, but it was never as chaotic as what I saw that day. People were screaming, crying and panicking. Security tried to get the situation under control, but it was like trying to put out a fire with glasses of water.

The man eventually swung his legs over the edge and at that moment, I lost my composure and began to cry a little. No one noticed because of how hectic it was, but that moment really got to me.  This man was about to end his life. He was in so much pain, that he saw death as the only option. How would his coworkers, friends, wife and kids be affected? It wasn’t like the death I saw in the emergency department. This time, I had the context of the man’s life, and I saw some of the people directly affected by it in front of me. I wanted to go catch him but I knew I couldn’t. Fortunately, an officer tackled him as he was thrusting forward, saving his life. When I went up with the paramedics to see him, his face was as white as a ghost. He wasn’t even able to move once the adrenaline left his system. I noticed he wrote notes on his arms to his wife and kids.

This man was a moment away from death, and now I was looking at him, safe, in good hands. I was overwhelmed with different emotions. I was happy to see he was alive, but sad that he was in so much pain that he was in this situation in the first place. I found out about how he was having trouble at work and that his wife was sick in the hospital. My heart ached for him.

I still think back to these experiences. I wasn’t jaded the first time I did CPR because I lacked context. A person had died in front of me, but I knew nothing about him. I reduced him to a medical problem. Unfortunately, I noticed that many of the staff did the same thing; but, I know it is not out of bad intentions. Sometimes it is easier to just think of the dead body as a medical problem than a human being. You need to move on quickly to your next patient, and I understand that. But after this experience, I promised myself I would never do that.

That man I did CPR on also had a story. Although I did not know about it, he deserved the same dignity as anyone else. I used to think of death as the conclusion to someone’s legacy. I now know that it is so much more than that. It isn’t just an end, but also a beginning. It is the beginning of a new chapter in so many people’s lives. The lives of the loved ones of someone who passed are forever changed. That alone deserves empathy and compassion. I’ve learned to give each human being the level of respect and dignity they deserve.

After my time at the fire station, I ended up doing CPR on another patient. This time I asked the resident if I could go with her to speak with the family. I will never underestimate the value of a life again. As a physician, I’ll always provide the best care possible for my patients, through life and death.

Image credit: Photograph by Stannate, used with permission under Creative Commons.

in-Training
in-Training - the online magazine for medical students

Jeff Hassebrock

Friday afternoon psychiatry didactic sessions are a holy time among medical students. A golden weekend rapidly approaches and the afternoon, typically spent trudging through paperwork, is instead spent listening to residents talk with minimal effort, on behalf of the students, required to listen. At the end of a frantic third year of rotating, sometimes it’s nice to just set the busy work down and take it all in. Granted, I’ll actually have to learn the info at some point before the test, but for one afternoon, it’s nice to be passive.

Now, this particular rotation was coming to an end and true to psychiatry’s form, our resident wanted us to reflect on our experiences. The prompt was simple, “What kind of doctor do you want to be?” It’s odd how little I’ve thought about that question over the last three years. I seem to recall a period of life, not too far removed, where that was all I thought about. Then, after acceptance into medical school, that question somehow became of little importance due to the enormous task of going through the formidable mountain of school that stood between me and “doctor-ness.” My time was much better spent figuring out what I needed to know for that day so I could learn what I needed to know for the next day. Things sort of go on this way and eventually I wake up in a hot conference room on the fifth floor of Central Tower thinking about what led me to medicine in the first place.

“What kind of doctor do you want to be?” That question carries a lot more weight hearing it the second time around. I actually had the chance to see plenty of doctors beyond the few I idealized while shadowing oh-so-long ago. By this point, I’ve seen things that made me cry and had moments that made me cringe. I started to find it a lot easier to think about the type of doctor I didn’t want to be, but then I thought about Drs. Ratcliff, Green, Oliver and Sheffield. The longer I sat in that conference room, the more I realized I knew exactly what type of doctor I wanted to be because I’d seen them over the past year.

I want to be a good doctor, and here’s what that looks like:

• Sheffield is patient — a good doctor is patient. He sits when he talks, listens intently and is genuine interested in the care for the individual across from him.
• Green is kind — a good doctor is kind. Compassion is something that he’s cultivated and empathy is something he exudes. Again, it has to come honestly, out of a true care for the patient.
• Chen is effective — a good doctor is effective. She knows what she can and can’t do. She focuses on fixing the problems that need to be fixed immediately, and orders the rest into a list to tackle one-by-one with the patient.
• Deblieck is humble — a good doctor is humble and educates as much as he treats, not out of a sense of superiority, but out of a sense of leveling the playing field for the patient. He knows that patient understanding can be both therapeutic and empowering.
• Ratcliff is confident — a good doctor is confident. He reassures patients when needed and moves decisively to appropriate treatments. His hands move with the steady swiftness one earns through experience and they themselves are reassuring. He is efficient with everyone’s time, out of respect, and earns all the trust he receives.
• Oliver communicates — a good doctor communicates. She speaks at or below the level of the patient. She includes loved ones when appropriate, and follows through on her promises and commitments. Patients trust that she has their best interests at heart after they see that she is honest with them. She sets beneficent boundaries for her patients and her life.

These are good doctors, and they are who I want to be … all of them.

My father had a saying growing up that I repeat like a mantra when I need to connect with someone, “Don’t tell me. Show me.” This is what all of these doctors I’ve listed have in common. They show us what it means to connect to our patients, to care for them as people and ultimately to help them. Sitting here during my psych didactic reflection, this is the only answer I have to what makes a good doctor, showing people you are willing to connect.

In March of 2017, I hope to be matching into an orthopedics residency. Much to the chagrin of my internal medicine and psychiatry colleagues, I fell in love with the structure more than the physiology of the human body. Perhaps I’ll never be able to parse out the difference between mood disorder with psychotic features and schizoaffective disorder, and I’m sure that at some point I’ll forget which medicines confer mortality benefits in congestive heart failure; however, I’ll be immeasurably better equipped to connect with my patients because I spent time in this small psychiatry conference room pondering the question that led me to medicine in the first place, “What kind of doctor do you want to be?”

in-Training
in-Training - the online magazine for medical students

Wesley Thomas

“Great, six weeks of crazy people!”

This is the sort of attitude with which I went into my psychiatry rotation. Couple this with the fact that while most schools only have four required weeks of psychiatry, my school has six weeks. Of course, I would have more free time compared to other rotations — it is called “psycation” for a reason — but at what cost? Mental illness was something that made me uncomfortable. I didn’t feel like I could empathize with the patients.

To make matters worse, everything I had heard from the media made me believe that all I would see during my rotation would be homeless people who overdosed on meth and borderline patients with suicidal ideations. These were all people who somehow did this sort of thing to themselves, right? Wouldn’t these people just end up in psychiatric wards again and again? Are we not just medicating these people and then letting them out into the wild?

I sat in the room with my first patient, running through my list of questions like any other data-gathering third-year medical student would do. “Do you have any suicidal or homicidal ideations?” Of course she used illicit drugs, right? “Do you ever hear things or see things that other people don’t?” “Do you have any history of psychiatric illnesses in your family?” But then I got to one question that threw me off: “Do you have any history of physical or sexual abuse?”

A single tear ran down my patient’s face. I politely tried to probe. It seemed like the right thing to do. “Can we talk about what happened?” The patient began to sob, saying, “Do we really have to?” The patient then detailed to me how she had been abused as a child over and over again, first by her father, then by her uncle and then by her neighbor. She described how it caused her to never be able to trust others in relationships. The abuses she had experienced controlled her life and led her to her current situation: she just needed a way to escape the pain. I called my attending into the room. What else was I supposed to do? As I continued my rotation, similar stories played out again and again in the patients I interviewed. In one way or another, abuse had played a major role in defining the course of my patients’ lives, leaving wounds that were all too raw and real.

Yes, there were in fact multiple people strung out on meth during my psychiatry rotation, and yes, there were in fact a good deal of borderline patients with suicidal ideations. But, what I came to realize was that these were people who did not necessarily wish this upon themselves. These were people who were broken and needed a way out. They used substances and put themselves in compromising situations just to be able to deal with their pain and feel a sense of worth. The ones meant to be there for them were the very ones who caused their pain. These patients were simply crying out for help in their time of need.

Further, there is a biochemical and genetic component to mental illness. But the association of abuse with mental illness is undeniable. Studies have shown a four-fold increase in the rate of mental illness in those who have been abused. Abuse has been associated with higher rates of childhood mental disorders, anxiety disorders, personality disorders and major affective disorders. It can send a person spiraling through a vicious cycle of guilt, anger, depression and hopelessness, forever impacting the course of their lives and the decisions that they make.

Three million reports of child abuse occur in the United States every year. This works out to about one report of child abuse every ten seconds. Worse, this doesn’t even take into account the thousands of cases of abuse that go unreported. The sheer number of cases of abuse should make us pause: abuse is much more common than we think. My advice to fellow student doctors is to never write off your patients dealing with mental illness or substance abuse. The problem may be more than just a lack of willingness to change or a problem with compliance with medications.

As future health care providers, we must always take time to understand our patients. Don’t just be a data-gatherer. Be willing to ask the tough questions that no one else wants to ask. Patients put a great deal of trust in their physicians. In fact, a physician may be the only person with whom a victim of abuse may be able or willing to talk. We, as future physicians have an opportunity to stop generations of abuse with each patient that we meet. It is our duty. Don’t make assumptions about your patients based on what you have seen or heard. Each patient is worth the extra effort. It may be awkward to ask difficult questions at first, but it could make a world of difference to that patient. Always remember that each patient is unique, and each patient has their own story.

in-Training
in-Training - the online magazine for medical students

Alex Slaby

Patients don’t always have to let us into their rooms. This week I had one of those moments where I had to take a step back and appreciate some of the unique life experiences that patients have allowed me to share with them. As medical students, I think we don’t give enough acknowledgement or praise to the vulnerable individuals that allow flocks of medical students to bumble around their bedside. But our perceived ineptness is the last thing on the patient’s mind; a friendly face that is willing to listen to their story is just as important. Let’s not stress that we may not know the answer to every one of their questions, rather let’s make sure we do our best that they get the care they deserve.

When I entered the room of a woman in her 2nd trimester with vaginal bleeding and an incompetent cervix I had no idea what to expect. I was on my third day of my OB/GYN rotation and just a few hours earlier I had gotten to witness the beginning of life in a room across the hall. After reporting to my attending and a few imaging tests later it became clear that this patient’s baby was not going to survive. Even worse were the overwhelming emotions that cut through the room when we informed the patient that, due to complications, she would have to deliver her baby now.

After minutes that seemed like hours, there I stood. Crammed in a small room full of nurses, doctors, and other students I watched as a single mother cradled her tiny, underdeveloped and dying child. It is an image that will forever remain in my memory.

Powerful experiences like these should not be taken for granted. I can’t even begin to imagine the fear, distress and pain that this woman was going through — and yet she allowed a budding doctor to be involved and to learn from it. Patients like this admirable woman are gracing us with an opportunity to understand firsthand about diseases and pathologies we’ve only ever read about. Their willingness to let us learn extends beyond allowing us to partake in personal moments — they also let us next to their bedsides at the most inopportune times. A patient may have just seen the hospitalist and consulting specialist, the nurse just took vitals, and the phlebotomist finished drawing blood. Needless to say, right as I’m about to percuss the abdomen the dietary aide walks in with the patient’s long awaited lunch. Over 90 percent of the time the response I get is something along the lines of “Don’t worry, I’ll get it when you’re finished.” I think situations like this speak volumes to how patients perceive us. They treat us with respect and dignity; in their eyes we are a part of the medical team even though we ourselves feel sub-par in comparison to residents and doctors that are teaching us. Let’s give them the same recognition.

This is why, as often as possible, I like to take advantage of being a third-year medical student. We aren’t necessarily bound by time constraints and have the opportunity to spend a few extra minutes with a patient. Getting to know a patient’s interests, hobbies, friends and family goes a long way in trying to make someone feel a bit more comfortable in their new (and scary) hospital setting. Stop by a patient’s room before your lunch break. Give a quick wave to that person you saw at the ER that morning. Smile at the psych patient you interviewed a few days earlier. Too often, unfortunately, many of the patients I’ve encountered either have family that have passed away or aren’t able to make it into the hospital.  The extra 5 minutes we spend with them might give them a chance to unload their worries and maybe even help them forget they’re in the hospital, isolated from their loved ones. It’s the little things like this that make the difference — treating the patient like an actual person rather than a textbook case is not only good medicine, but shows your appreciation.

So I urge everyone to take a step back and think about some of the personal situations patients have allowed you to take part in. I think too often as students we can get caught up in a sea of jaded healthcare workers, OSCE’s and question banks — taking for granted how much a “real-live” patient can help us learn. They teach us so much; let’s do all we can for them. Someday we may be the people changing their lives, but right now they are the ones shaping ours.

in-Training
in-Training - the online magazine for medical students

Asma Akhtar

Less than 24 hours and one psychiatric consult: the time it took me to question my books, to question all given facts and statistics, to question the obvious.

The boy was our sixth patient of the day. He walked into our room and immediately diverted his eyes when I introduced myself as the medical student. He sat with his legs turned away from my attending and me, his eyes fixated on the cellphone in his mother’s lap. He nodded and shook his head to our conversations. His speech — though he barely talked at all — was slow and careful. His fingers twitched incessantly.

My attending suggested he had autism, and offered diagnostic tests so the boy could be started on the right medications. He also recommended considering special learning classes for the patient at school. The boy’s mother dropped a blunt no. “I was like him when I was young,” her thick Arabic accent echoed through the walls. “But look at me now, I am fine. He is just shy.”

Shy. Being shy is not talking, but wanting to. Being shy is needing the extra push; it is realizing the world is a tunnel with a light at the end … something to reach for. The young boy, however, couldn’t get to that light. He was not shy. He was distant and disconnected and detached. The world as we saw it was not the way he imagined it. New people were strangers, another species who didn’t understand, who couldn’t understand. To him the world was spinning colors, a kaleidoscope of different.

The mother, however, refused to entertain our suggestions about diagnostic testing or social therapy. So, we proceeded with the interview. We asked the boy how he was doing. If he was sleeping well. Eating okay. We received nods. If we were lucky, maybe a rapid eye glance towards the ticking clock above our heads. Nothing more.

The mother requested to speak with us in private and had her child sit outside for a while. As the nurse took the boy away, the mother started crying. “How can he have autism?” she said. “What did I do wrong?”

As my attending consoled her, I couldn’t understand why the mother was so upset. Her child was healthy and alive. He could walk, talk and eat. He didn’t have a life threatening malignancy. His blood counts were normal. I handed her a Kleenex as she finally agreed to sign the paperwork for the diagnostic tests and therapy. I was still confused, I still didn’t get it. Why was this woman so miserable?

It wasn’t until the mother left the room and I talked to my attending that I finally understood the significance and impact of the mental illness. This kid — with an IQ most likely lower than average — would not be able to get a decent job. His social isolation would prevent him from forming long-term relationships. His mother was upset for this very reason. Her son’s possibilities and opportunities — his whole life — took a whole new turn and it took hard words from my physician to finally grasp the concept, severity and danger of mental illness.

This is not only true for autism, but for post-traumatic stress disorder, bipolar disorder, anxiety, depression and all other mental illnesses. Although these diseases do not necessarily have physical manifestations, they are so robust as to completely change our every day life. The way we talk, interact, see the world, the way we live: that all changes.

As physicians, it is our responsibility to understand these serious implications and to help these patients live as fully as possible. A patient is not just his or her numbers — their vitals or their lab values. A patient is not just an MRI reading or a CT scan finding. Every individual has a mind, and we must take into account mental health when treating these patients because if left untreated, they can have dire consequences. More importantly as people — as humans of society — we must not stigmatize these illnesses.

Our books tell us the most common causes of human death are cardiovascular disease and carcinomas. Magazines, research articles, media, friends, family and physicians target these illnesses because that’s what the statistics tell us to do. However, it took me less than 24 hours and one psychiatric consult to realize that we have failed. We are missing the hidden pieces — the mental illnesses that creep into our lives and infiltrate our society: these are the silent killers, that are just as (if not more) deadly.

in-Training
in-Training - the online magazine for medical students

Parsa Salehi

A Silver Bullet
The tiny guns held by my little action figures
still remind me of that god forsaken trigger.

A Silver Bullet
The man came to do an evil deed;
yet, I was the one who was in need.

A Silver Bullet
The money is all that he wanted;
yet, to this day I am still haunted.

A Silver Bullet
But, no! The banker did not give him any.
NO, not even a small, single penny.

A Silver Bullet
The man became furious,
and I became curious?

A Silver Bullet
I would save us — take away his gun.
Then we could all be safe! And run.

A Silver Bullet
I ran at him ready to kill.
The man was shocked by this thrill.

A Silver Bullet
With hesitation the trigger was pulled…
NO, he was not a man to be fooled.

A Silver Bullet
The blast was tranquil, but o’ so loud —
Not a single breath came from the crowd.

A Silver Bullet
My life flashes!
The plane I was supposed to be on crashes…
And burns to ashes.

A Silver Bullet
But my body was fine?
Once more I could dine.

A Silver Bullet
But if the silver bullet had shattered my head,
why did she lay there peaceful, beautiful, and dead?

A Red Bullet

This story was written based on a patient I had the privilege to work with during my psychiatry clerkship rotation. The patient had been present during a bank robbery. In the heat of the moment, he decided to challenge the robber and attempt to disarm him. In the chaos, the robber fired his weapon. The patient described that the moment he heard the gunshot, he thought he was the victim. His life flashed before his eyes. In reality, the bullet had missed him. Sadly, it had struck an innocent bystander, who passed away from the injury. The experience changed the entire trajectory of this patient’s life. He ended up developing post-traumatic stress disorder and has struggled with flashbacks, anxiety and depression since the incident. Fortunately, at the time of our meeting, he had been making much progress in therapy and responding to medications.

My interaction with this patient was a very meaningful one, and inspired me to write this poem. This patient’s story also reminded me to be grateful and enjoy everyday, as at any unexpected moment one’s life can change entirely.

in-Training
in-Training - the online magazine for medical students

Ajay Koti

Goes by fast.

Over the course of third year, I came to favor several select phrases to guide me through patient encounters. When patients commented on my perpetually and pathologically icy hands: cold hands, warm heart. For otoscopic examinations of children: looking for elephants.

Goes by fast is used for the question, “How far along are you?” which is asked frequently of pregnant women and medical students. It is a common inquiry, perhaps second only to “When is the real doctor coming?” which I have asked myself more than once.

“How far along are you?” Third year. “How many more years?” Just one.

Goes by fast.

Time — both its passage and its seeming scarcity — was a recurring source of anxiety throughout the year. Long days began and ended outside the confines of sunlight. They rolled into one another, indistinguishable; work punctuated by weekends and holidays, blizzards and heat waves, and Republican primary debates. These markers served as reminders that Time was still sailing forth, and that I was — for better or worse — its captive passenger. Third year would begin and end, and then so too would fourth year, and then with it medical school, and then onto the next chapter. The churning waves of Time with their relentless forward inertia would be the only constant.

Despite its omnipresence, Time seemed to be in reliably short supply throughout the year. I keenly felt its absence: less time to cook and clean. Less time to exercise; less time to date. Less time to read and to write. And it frequently seemed that my peers had a command of Time that escaped me. They finished novels, ran half-marathons and published papers all while possessing a medical knowledge superior to my own. The only indulgence Time afforded me was enough to follow the aforementioned Republican primaries — a gift that I would have gladly gone without.

Alas, this was a fiction, a self-delusion. Time was not as out of reach as I pretended. There was enough for family and friends. Enough for the occasional (and not-so-occasional) Netflix diversions. Enough, generally speaking, for a decent night’s sleep. The truth is that there was less productive time, whether from a failure of time management or a deficiency of discipline or some combination thereof. What time I had was dedicated to the least physically, mentally and emotionally taxing tasks I could conceive. All others would be swiftly eliminated from my schedule.

The first on the chopping block was consistent bed-making, that most jaw-droppingly inane, tedious and loathsome of household chores.

More slowly abandoned was writing, and this I regret deeply. The clinical year meant that I ostensibly had more to write about, but I spent less and less time putting the stories to paper. A daily ritual became a weekly ritual, which ultimately became a monthly ritual. My notebook remained atop my desk to brazenly remind me of my neglect. It evoked shame and guilt that surpassed that of my parents (Hi Mom). In an act of self-preservation, I banished it to my bookshelf, wedging it between a copy of Inferno, Brown not Dante, and Crime and Punishment. It was a temporary exile, I promised myself. It would soon be lifted when I had more time.

As the frequency of the entries dropped off, so too did their length. Pages accustomed to long vignettes were now populated by short paragraphs and one-liners in increasingly imperceptible scrawl.

An elderly gentleman, previously a force of nature, lay trembling in bed, his face freckled with rapidly multiplying beads of sweat.

A 54-year-old female schoolteacher with a newly diagnosed tumor of the small bowel.

69 y.o. F w/chronic pancreatitis 2/2 longstanding EtOH abuse.

85 YO ♀ PMHx CHF, HTN, DM2, CAD s/p CABG, COPD on 2LNC presenting w/SBO. 

I told myself that these were merely placeholders. That I would go back and fill in the details. Later. When I had more time.

But these weren’t people — they were diagnoses. These weren’t narratives — they were board questions.

Part of the allure of a journal is its ability to capture Time, that elusive companion, within its pages. My motivation in keeping one was to document my advancement in medical school as Time pressed on. A vignette from first year would seem feeble and naïve compared to an essay written in second year, which, in turn, would most certainly contain newly realized truths. And so on and so forth. I imagined myself forty years on dismissing the entire journal as rubbish, having achieved a deeper, more sophisticated level of understanding buttressed by a lifetime of caring for the sick.

But as the essays became one-liners, as the people became reduced to their diagnoses and as the faces and names swirled into one giant amorphous pool, it became clear that I was not documenting my progress, but rather my regression.

Studies have suggested that medical students lose empathy in the clinical years. I was aware of this phenomenon — we all were. But I foolishly thought that awareness would be sufficient protection. Maybe this was the explanation: I had experienced a loss of empathy. Time was wearing down my humanism, and after only one year. What would be left of me after another year? Another ten? Another forty?

However, these losses must be weighed against incontrovertible gains. I may have been more empathetic a year ago, but I was also infinitely more ignorant. Hypertension in a child once screamed “pheochromocytoma!” But now, it means that the blood pressure cuff was probably just too small. I have gained knowledge. I have gained skills. I have gained confidence. I have gained weight.

So, how then can I restore humanism to my experience? How might I insulate it from the erosive effects of time? I don’t pretend to have the answers. But I presume that my drop-off in writing hasn’t been particularly helpful. That might be a good place to start.

To my journal — I promise never to banish you to the bookshelf again.

I can’t say the same for Dostoevsky.

in-Training
in-Training - the online magazine for medical students

Matthew Trifan

In my third year of medical school, I was taking care of an elderly patient who had been in and out of the hospital multiple times in one month. Upon his third admission, my exasperated attending threw up his hands and said, “Who am I, Sisyphus?” I understood how he felt. Like the mythological Greek king rolling his boulder up the hill — only to have it roll back down again, ad infinitum — no matter what we did to manage this patient, he always returned to the hospital sicker than before. We were fighting a losing battle. This poor man suffered from diabetes, kidney disease and heart failure, the kind of chronic problems that brought many patients back into the hospital again and again. Treating him didn’t just seem futile; it felt absolutely hopeless. Death would inevitably win, just as it did with all our patients.

That, I thought, was the true Sisyphean effort. Not the endless cycle of treating the sick, but the madness of treating patients at all. No matter what we did, they would all die. The boulder would inevitably roll back down the hill. And we would have to all start over again, picking up new patients and straining against the weight of that stone. There was no end in sight, no completion to our task — nothing but a long string of failures.

So, why do it? Why practice a craft that can never achieve its true purpose? I suppose we must ask the larger question: why do anything in life, knowing that we will someday die?

For me, the answer lies in the philosophy of Albert Camus. The French-Algerian thinker argued that all of life is a struggle to reconcile what we innately desire and what we fully know to be true. At its heart, this is a fundamental conflict between life as we want it — governed by order, meaning, and hope — and life as we know it — governed by chaos, death, and chance. In Medicine, this means that we view Death as both an unacceptable defeat and an unavoidable truth. We want to believe that we can prolong life indefinitely, but we know that every patient will inevitably die. We want to believe that we have ultimate control over Death, but we know this is laughably untrue. Camus calls this internal conflict “the Absurd,” a paradox that can never be resolved. We encounter the Absurd as we simultaneously search for meaning in life and realize that life is inherently meaningless. We cannot help ourselves; Camus explains that it is in our nature to search for deeper meaning to life. However, because no such truth exists, our quest is, simply put, absurd.

But take heart. Camus is quick to point out that a “futile” struggle need not be a hopeless one, nor one unworthy of our time. Quite the opposite, he argues that the greater the futility of our struggle, the greater our chance of achieving true happiness in life. If we can learn to embrace the futility of our daily lives, we can learn to embrace the futility of Life itself. If we can become conscious of the paradox we are trapped in, we can choose to transcend it and be happy in spite of it.

In this spirit, Camus beckons us to embrace the struggle of “the Absurd” and do everything in our power to rebel against simple solutions. He bids us to reject escaping the Absurd through suicide, religion, love or legacy. None of these allow us to live our life to the fullest, because they inevitably quell our curiosity, along with our thirst for deeper purpose. Rather, Camus asks us to fight to keep our minds sharp and open, suspended on the heart-pounding precipice of that unbridgeable chasm. We must remain hungry for purpose, for answers. It is only through our awareness of the Absurd — of that irresolvable struggle between what we want and what we know — that we can obtain lasting happiness.

Let me explain further by returning to our tragic hero, Sisyphus. In his seminal essay, “The Myth of Sisyphus,” Camus describes the ancient Greek as the “Absurd hero,” condemned to a fate that mirrors the very struggle of Absurdism itself. “His scorn of the gods, his hatred of death and his passion for life,” Camus writes, “won him that unspeakable penalty in which the whole being is exerted toward accomplishing nothing.” The author acknowledges how horribly Sisyphus’s fate must strike us, noting that, “[The gods had] thought with some reason that there is no more dreadful punishment than futile and hopeless labor.” Camus adds to this a vivid description of the hero’s suffering, “…[seeing] the face screwed up, the cheek tight against the stone, and the shoulder bracing the clay-covered mass…” We can feel his pain in our bones. Thus, when Sisyphus finally reaches the peak of his struggle, cresting that mighty hill, our hearts plummet as the boulder goes barreling back downwards. Sisyphus is hopeless, eternally doomed to the bleakest of fates.

And yet, there is a silver lining. At that very moment, when the rock rushes back down the hill, something awakens in Sisyphus. He pauses. He reflects. He awakens. “It is during that return, that pause, that Sisyphus interests me,” writes Camus. “That hour like a breathing-space, which returns as surely as his suffering, that is the hour of consciousness.” Indeed, that is the moment in which his act of rebellion occurs. That is when Sisyphus awakens to the Absurd and chooses to claim his fate as his own.

“If this myth is tragic, that is because its hero is conscious,” Camus states. “The workman of today works everyday in his life at the same tasks, and his fate is no less absurd. But it is tragic only at the rare moments when it becomes conscious.”

In Medicine, we are deeply conscious of our own endless plight, of our Sisyphean struggle, against immutable Fate. We are sharply reminded again and again that we are fighting a losing battle. In the wake of each patient death, we awaken to the Absurd. We become aware of our struggle, of our place within it. Then, like Sisyphus, we must choose whether we will surrender to the futility of our fate — or rise above it.

Our struggle is not in the task of treating patients, as my attending believed. To heal is merely an act of labor, with our muscles well-trained to push the boulder onwards. Rather, our struggle is in that final moment, when we must let go and watch life slip through our fingers. That is the hour of consciousness. That is the moment when we awaken to our own mortality and see the world with absolute clarity. That is when we return down the hill with hearts filled with resolve — knowing once more that life is precious, that we will certainly die, and that we are happy nonetheless. It is the joy of knowing that our fate is our own.

I find it fitting that Camus should end his essay with Sisyphus at the foot of the mountain, facing his task once more. As physicians, we, too, must end our days at the foot of the mountain, preparing to carry the next soul up the hill. Now more than ever, we must ensure that our burden never eases. We must feel death’s defeat every time it comes, and we must feel it as if it were our own. In those precious moments, we awaken to the Absurd. We experience our hour of consciousness, when we are free to choose joy in spite of death. We find something to live for — our countless triumphs over our endless struggle.

Camus gives us a simply and powerful message of hope. To practice medicine, we must imagine Sisyphus happy.

in-Training
in-Training - the online magazine for medical students

Brian Walker

Nothing is quite as strange as the first day of your surgery clerkship. It isn’t just the shock of seeing a living human intentionally cut-open or the unforgettable smell of cautery for the first time — even just getting into the operating room can be an obstacle. Prior to this rotation I had no idea it was even possible to operate a sink using my feet. In my first attempt to scrub-in I managed to scald both arms from the elbow down and splashed so much water on myself that I looked completely incontinent. Finally, drenched in water, I approached the O.R., praying that I wouldn’t bump my arms into anything and render myself non-sterile, a surgical tech noticed me out of the corner of his eye and nonchalantly said, “You forgot your mask.” Smiling stupidly as only a medical student on the first day of clerkships can, I dejectedly went back to grab a mask and start round two with the sink.

After getting a mask on and autoclaving my arms in the sink again, I snuck into the O.R. hoping that I hadn’t forgotten anything else in the process. While waiting to gown-up, I studiously observed as the anesthesiologist intubated the patient and the scrub nurse made last-minute preparations to the instrument tray. During my observation I found something very peculiar in the choice of surgical attire: the physicians were the only ones with skull caps while everyone else wore bouffants. I was wearing a bouffant because it was the closest option as I franticly rushed to the O.R. that morning. I had no idea why anyone who had a choice would pick a bouffant over a skull cap since the bouffant was clearly ridiculous looking — or so I thought.

As it turns out, my curiosity over the choice of headdress wasn’t unfounded. Just this past August, the American College of Surgeons (ACS) released a statement on surgical attire that included a specific endorsement of the skull cap, stating that the skull cap is “symbolic” of the surgical profession. The Association of Perioperative Registered Nurses (AORN) took issue with the ACS’s opinion, citing the potential increased risk for infection using skull caps, since it normally leaves some hair uncovered. They stated that wearing a particular head covering based on its symbolism is not evidence-based and should not be a basis for a nationwide practice recommendation. Apparently I was not the only person who had wondered about the difference between skull caps and bouffants.

Exploring a little further I was a bit astounded that two of the biggest health care worker advocacy groups in the U.S. were bickering over paper hats. While I can understand the argument for changing headdress if it were to decrease post-op infection rates, it turns out that data on the subject is sparse and mixed. What intrigues me even more than a discussion on post-op infection rates is that the ACS chose to use “symbolism” as the reason for the skull cap’s continued use. They could have chosen to argue any number of other reasons like functionality or aesthetics, but instead argued its symbolic value. This led me to wonder if a disposable paper hat can realistically act as a symbol to convey the expertise, authority and prestige of the surgical profession.

Medical culture is one of the world’s oldest professions and as such has rich symbolism in the images, clothing and words associated with it. Staples of medical symbolism include the rod of Asclepius or the Hippocratic Oath which are still in use thousands of years after their creation. Each year in the medical world we have ‘white-coat ceremonies’ where students receive a physical white mantle which is used to designate their place in the medical hierarchy to everyone around them. This symbolic clothing continues after graduation as you transfer from a short white coat to the long white coat, representing your advancement in knowledge, expertise and authority. Words and titles are likewise heavily symbolic in medicine. The term “doctor” has become so symbolic of the skills and expertise of a physician that it’s application to other professions has been hotly debated among MDs, DOs, NDs and PhDs for years. The debate continues into our day as NPs, PAs and other health care workers assume roles once occupied solely by physicians.

Not all of these symbols are inherently bad. After all, it is pretty important to delineate the trainee from the attending, the physical therapist from the nurse, and the ophthalmologist from the cardiologist and we do this through symbolic clothing and titles. So is the ACS really unwarranted in their use of skull caps to the same end? If the ACS’s reasoning is flawed, then so might be many symbols of the medical hierarchy and without at least some symbolism confusion may result. However, it could also be argued that some symbols are unnecessary and only work to segregate what should be a cohesive team of health care workers. Being a novice in medicine I don’t pretend to have the answer to this question but I have had experiences that help me live with them.

One such experience occurred during that same surgery rotation. Contrary to my previous experience in surgery, this time I had managed to put on all my PPE correctly, not scald my hands and be in the O.R. early enough to witness the entire surgery from start to finish. For the team around me this was an unglamorous, uncomplicated, routine bowel resection, but to me it was something different. I was amazed at how the surgeon expertly manipulated the anatomy to achieve her goal. I was equally impressed at how the anesthesiologist maintained the patient safely between inadequate and over sedation no matter what was going on in the case. The circulator’s and scrub nurse’s coordination of so many moving parts was the epitome of precision. As I tore off my gown and gloves at the end of the case and helped transition the patient back to their bed, I was struck with how perfectly everyone had performed.

Reflecting on this experience I noticed how important authority and position actually were to the function of that O.R. but that it had nothing to do with a person’s headwear. Everyone in that room had a very specific authority, expertise and role. If the anesthesiologist told the surgeon to stop because of a rapid drop in blood pressure, the surgeon stopped. If the surgeon asked for an instrument, the scrub nurse swiftly provided it. If the scrub nurse found that a needle was missing, everyone stopped until it was accounted for. I noticed that with everyone’s specific authority and expertise also came a mutual respect for other’s authority and responsibilities. I imagine that if anyone had become too fixated on their own authority or importance the O.R. would have ceased to function as smoothly as I observed and, in the end, the patient would have been the one dealing with the repercussions.

This isn’t to say that I have never seen a dysfunctional O.R. or that they don’t exist. We have all seen dysfunctional O.R.s and this is exactly why this particular experience struck me. For the best outcomes, we do need authority, power and expertise as physicians. Moreover it is important that others recognize that at appropriate times. Yet, even more importantly, that same authority and recognition should be afforded to our team. In the end, it has nothing to do with bouffants, skull caps, white coats or how many letters are written behind our name. It depends on the individual and how they wield their own authority and expertise while respecting the same in others. Our unique challenge as the next generation of physicians is to define the capabilities and boundaries of this authority and then employ it wisely for the benefit of our team and patients.

in-Training
in-Training - the online magazine for medical students