After three months of excruciating hours, ailing patients that had been stuck in the hospital for weeks, and intimidating attendings who peppered us with questions out of the blue, the transition to outpatient has been smoother, calmer, and, well… Boring.
Rather than rounding on patients with appendicitis, sepsis, or aspiration pneumonia as I had during my time in the hospital, I am now doing medication reconciliation, hand holding, and counseling – So. Much. Counseling. While I’d always loved talking to patients, I find myself constantly having to redirect patients to the questions at hand to prevent them from getting sidetracked. Half the time I feel like I am learning how to be a therapist instead of a physician.
This lament is what is running through my mind as I’m sitting in my oversized white coat in my preceptor’s office, glancing absentmindedly at the ever-growing stack of papers on her desk. I’m thankful, yet again, for the surgical mask on my face that hides my occasional subtle yawn when she walks in.
“Helena, I have some bad news to share.” She is looking down at her desk, her shoulders drooping beside her. Even as someone who is training in medicine, I find her words so doctor-ish.
“Okay,” I say, a little distracted. I had been going over my to-do list in my head. Pick up the groceries on the way home, 100 more flash cards, 20 practice questions…
I take a deep breath of the stuffy office air. I have been yearning for the pace of the hospital. I missed constantly seeing patients and scrubbing into surgeries. Lately I’ve found myself agitated at the idea of spending 40 minutes with the same patient. ‘I miss just getting to do medicine all the time’
“Mr. Smith has died.”
A jolt back to reality. “That’s terrible.” I mumble. A reflexive response. But it is not before long that my mind is reeling. Mr. Smith was my panel patient—I had been assigned in my first year to follow him throughout his medical journey. I’d accompanied him to appointments, gotten to know his family, and called him regularly to check in. I was in the room for his diagnosis. I watched as he stared in disbelief upon hearing that he had metastatic lung cancer. “But I’ve quit smoking!” he’d said, “All of my last scans were normal!”
I remember his oncology appointment. I remember how rushed it all felt, and how it was to sit with his daughter in the waiting room. I remember her telling me about her son’s hobbies and her pet’s names and her father’s pride in being the patriarch of their family.
I also remember wiping away tears as I drove to my afternoon clinic. I remember missing questions in all of my other clinics because I was so distracted. I remember missing sleep as I tossed and turned, wondering how much time he might have left.
Most of all I remember feeling angry: at cigarette companies; that I was assigned to such an emotionally heavy case. Angry at myself for not being better at compartmentalizing.
This moment highlights the schism between the fantasy and the reality of being a medical student. In medical school, you inevitably become the recipient of a hefty amount of praise that you’re not entirely sure you deserve. The myth goes that patients look up to you, your friends from high school envy you, and family members gush with pride at reunions, showering you with compliments about your intelligence and dedication. In a lot of ways, you are society’s idea of perfect. You are young, successful, intelligent and hardworking – many of America’s most highly valued ideals wrapped into the two-word title — “medical student”.
Then there’s the other side of being a medical student that only you, your classmates, and your family members will understand: the constant pressure to be perfect. The pressure to make it look easy. The fear that if it’s already this hard, it will only get harder. The assignment you missed because you only got three hours of sleep for the fourth night in a row. The messy, run-down apartment with dishes that have been in the sink for God knows how long. The feeling of never having it together and never being good enough. It all serves as a constant, sobering reminder: you are anything but perfect.
As we progress through our career grappling with these personal demons, the human aspect of medicine often fades into the background. But today in my preceptor’s office, it calls me back. The first day I met Mr. Smith was perhaps the worst day of his life. I was sitting in the same seat in my preceptor’s office six months ago when she had looked up at me and said, “We have a patient coming in today, and his last CT showed metastatic cancer. We don’t know the origin of the cancer right now, but the prognosis doesn’t look good. I am referring him to oncology.”
I tensed up as I pictured myself in the room watching her give the news. I hated the thought of it, watching for the sake of learning, without having to endure the pain of lived experience. I tried to rationalize with myself. ‘Relax,’ Deep Breath. ‘You’re only a student. You’re just here to learn.’
At the time, my preceptor and I walked into the patient room together and greeted him with smiles and brightly asked him how his day was going. This time it felt wrong. There was a sucker punch coming and only we knew it.
Shortly after the niceties, my preceptor sat down at the patient level, took a breath, and said with compassion and efficiency, “We’re reviewed the results of your CT. I’m so sorry, but it looks like you have cancer. At this point we don’t know where the cancer started from, but it seems to have metastasized.”
A pause. “Okay” the Mr. Smith responds. His face remained hardened and strong, though there was no one with him for him to be strong for. He waited for us to say more.
“I’ll be referring you to an oncologist,” my preceptor continued. “It’s really important that you go to that appointment as soon as possible. I want to make sure that you aren’t delayed in treatment if that’s what you choose to do.”
I watched as his face changed from blank, to angry, to confused. My preceptor didn’t realize that the news has not yet landed.
“I don’t understand,” he responded. “I quit smoking and I had a full CT less than a year ago! And there was nothing there! Nothing!”
As I watched the scene unfold, I felt a sense of dread wash over me as if I was a small animal backed into a corner. I wanted to leave the room as fast as possible. ‘I shouldn’t be here, I shouldn’t be here.’ I kept thinking. ‘This is private. I shouldn’t just stand here and watch.’
But despite this anxiety, face-to-face with true vulnerability, I was honored to be a witness to medicine at its most human level. I stood quietly as the patriarch in front of me slowly appeared smaller, more honest, and more fragile. True imperfection. In a way, it was beautiful. Pure.
A few weeks after Mr. Smith’s diagnosis, his daughter and I sat together during his first oncology appointment. She told me her husband had recently left her and she was caring for her father and her son on her own. When they called his name for the appointment, she grabbed my hands in hers, looked at me and pleaded, “Please. None of this medical stuff makes sense to me. You understand it. You can help us.”
At the end of the day, I chose medicine. I continue to choose medicine, in the words of philosopher Emmanuel Levinas, “For others, in spite of myself, from myself.” Even when the diagnosis is beyond our control, even when following patients hurts, I choose this field because this is important work, because it needs to be done, and as I continue to learn over and over, it needs to be done with compassion. I did not change Mr. Smith’s prognosis. I did not prolong his life. But I provided a comfort to a family in struggle. I was a strong hand when someone needed strength. And in doing so, I became a part of his journey, and now he is a part of mine. That alone is a gift.