And now, back to our regularly scheduled existential crisis

April 15, 2011

Yesterday, the sunniest day in the history of history, I slept from 8 a.m. to 3 p.m. I’ve decided that I should not work nights. This might be problematic down the road.

To compensate for the missed daylight, I decided to walk to the hospital. I have a vitamin D deficiency, I reasoned. Also, I got a new phone. That’s another important thing. I talked with my friend Liz while I walked. She is one of my Gurus. For example, yesterday our conversation began, “Hello?” “Hey there!” “Hi honey. So, how’s your heart doing today?” For about 40 minutes I walked in the sunshine, surrounded by blooming cherry trees, chatting with a friend about the state of our souls and how it relates to the world around us.   I’m sure you see where this is going. I felt inspired for the first time in weeks, and I was half an hour late for work.

Within an hour of arriving to the hospital, I found myself ruminating over the loss of so much daylight. I felt resentful of the week of vampiric hours. Eventually, I came back to the old internal conflict: I feel critical of my training, but equally dedicated to the work. And, I worry that the rigor of med school is dulling my sensitivity. I am becoming too adapted to my routine to appreciate the significance my job has on my patients.

There were two C sections. One was a transverse breech (the baby was lying horizontally, and we could not flip her around). The second was was a woman who had had a C section before. We tried to do a VBAC (vaginal birth after C-section), but she had an abruptio placenta (the placenta detached from the wall of the uterus before the baby was delivered). I drew blood on two patients: an 18-year-old, pregnant with her second child, and a woman who only spoke Mandarin.

At 1 a.m. a 20-year-old post-partum woman threw up. Her blood pressure was extremely elevated. We went to her room on the third floor with the Sono machine. I helped clean the sheets and change her gown, then ran back downstairs to get labetolol to lower her blood pressure. We made eye contact while my chief did her sonogram, but she looked sick and didn’t talk. I took the sonogram machine back to the first floor with the printouts in my breast pocket. They would be given to the chief when the patient was moved to our ward for observation.

At 2 a.m. I had a minute to check my email. The program coordinator emailed us an article to read for next week’s meeting. I groaned, printed it out, read about half of it before i realized it was too close to home to read at 2:30 in the morning. I ran to the bathroom and burst into tears.  Here is an excerpt, about as far as I got before I had to stop.

Editor’s note: This Perspective article about the effect of the clinical clerkships on the professional development of medical students was written from the alternating perspectives of a teacher and long-time clinician, Katharine Treadway, and a third-year medical student, Neal Chatterjee, who is now an intern in internal medicine.

Neal Chatterjee: There’s nothing particularly natural about the hospital — ever-lit hallways, the cacophony of overhead pages, near-constant beeps and buzzes, the stale smell of hospital linens. This unnaturalness was strikingly apparent to me when I arrived as a third-year medical student — freshly shaven, nervous, absorbent — for the first day of my surgical clerkship.

As I joined my team, my resident was describing a recent patient: “He arrived with a little twinge of abdominal pain . . . and he left with a CABG, cecectomy, and two chest tubes!” This remark was apparently funny, as I surmised from the ensuing laughter. And the resident sharing the anecdote — slouched in his chair, legs crossed and coffee in hand — seemed oddly . . . comfortable.

As the year — known at Harvard Medical School as the Principal Clinical Experience — proceeded, the blare of announcements dulled to a low roar, the beeps and buzzes seemed increasingly distant, and the stale smell of hospital linens became all too familiar. Occasionally, however, there were moments that evoked a twinge of my old discomfort, some inchoate sense that what had just transpired mattered more deeply than I recognized at the time. These moments were often lost amidst morning vital signs, our next admission, or the differential diagnosis for chest pain.

At the end of the year, we were asked to reflect, in writing, on our first year in the hospital. What eventually filled my computer screen had nothing to do with vital signs or chest pain.

I began to write, “I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips. I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident. I have delivered a baby. Alone. I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night. I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

In a 2005 commencement address, the writer David Foster Wallace told the story of two young fish swimming along.1 An older fish swimming by greets them, “Morning, boys. How’s the water?” As the young fish swim on, one looks at the other and says, “What the hell is water?”

The third year of medical school is like being thrown head first into water. Although the impact is jarring, eventually the experience becomes natural. We become comfortable — legs-crossed, slouched-in-a-chair, coffee-in-hand kind of comfortable. Occasional moments, however, remind us that we are immersed in water. If we focus on them closely, we see that our lives are filled with these moments. The challenge is to collect them in a meaningful way — to spend time with them, wrestle with them, allow the discomfort they generate to sit inside us.

The article goes on to describe a decline in compassion among medical students, the sharpest drop of which occurs in the 3rd year. Schools have responded by instituting classes about empathy. But, it seems that you don’t have to teach students how to care. You have to teach them how to deal with their feelings.

At about 3 a.m, the chief called my cell phone. She needed to see the sonogram print outs. I had almost forgotten I had them. I washed my face, and went back to the floor.

The rest of the night was slow. I went to lay down in the call room, and fell asleep for two hours. Rest: my achilles heel. When I woke up, I rushed to triage, embarrassed – perhaps even mortified – that I had missed a huge part of the night. I snapped at my teammate for calling me sleeping beauty. I profusely apologized to my chief. I checked on my patients. They were fine. Then, I wondered if I am cut out for a job where falling asleep from 3 to 5 is something to be ashamed of.

By dawn, I apologized to my teammate for snapping. I asked if she’d gotten the email about the article. She hadn’t. I told her what it was about, and we started to talk. For the next hour we walked home through the odd combination of 7 a.m, cherry blossoms in the inner city, and people on their way to work.

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One Response to “And now, back to our regularly scheduled existential crisis”

  1. ACN Says:

    Wow. Roz, I think I need more of you in my life. Also, if you end up being a OBGYN, sign me up. 🙂

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