The things I wish I had known about clerkships before third year began are the same as the things I wish I had known about life, but which I’m grateful to have learned the long way.
And those things mostly amount to this:
Life is about people.I wish there were a less patronizing, less Hallmark way to utter the simplest truth I know, but I’m not sure there is.
Many of us have been fortunate enough to live lives untouched by abandonment, disappointment and loss, experiences that all have a way of sharpening our appreciation for the supporting cast of characters that comprise our existence. And so, these lessons often have to be learned vicariously.
Throughout third year, we have the opportunity to peer into our patients’ lives through the cracks created by disease. An unexpected diagnosis takes the experience of being alive, turns it upside down and shakes it forcefully, leaving victims riddled with a mixture of uncertainty and hope. The glimpses we catch of this tumultuous experience can be as large or small as we allow them to be, and I challenge you to shed as much light into these spaces as possible.
Mr. L was an 85-year-old man who was in good health until a pulmonary embolism threw him off kilter just before Christmas. The relatively minor insult to his lung function unmasked an underlying restrictive lung disease, likely related to an occupational exposure he’d had during the 1980s. One month and two hospital admissions later, he was in our unit, satting at 88% on a combination of 100% O2 via nasal cannula and Heliox. Each time he would sit up for my physical exam, I would listen for changes in his Velcro-like breath sounds while watching his oxygen saturation drop to the low 60% range.
It was hard for Mr. L’s family to comprehend how his functional status could have declined so precipitously. As a third year student with an eagerness to fix anything I could, I did my best to learn Mr. L’s life story and answer his family’s questions when possible using my limited repertoire of medical knowledge.
After one such occasion, I sensed annoyance from my team when I announced, during morning report, that I’d had a conversation with a patient’s family about the nature of his restrictive lung disease. My chief hinted at me that, oftentimes, “less is more” when it came to dealing with family members. After all, the pulmonary team had decided that Mr. L’s DNR/DNI status obviated the typical workup for restrictive lung disease – a lung biopsy – because in the process of searching for an answer, we might unintentionally end his life. Empiric treatment for suspected restrictive lung disease heavy-hitting pharmacotherapy was out of the question without biopsy evidence of disease, a confusing reality that left me feeling a bit like Alice in Wonderland. So, instead, we were doing nothing, and his poor prognosis seemed to negate the need to explain the pathophysiology to his family.
I am a people pleaser by nature, so I tried to cope with the difficulty of getting to know someone’s family so well while fighting back my instincts to share everything I knew and risk “confusing” the family and/or upsetting my team. Meanwhile, my patient’s respiratory status continued to decline.
After multiple rounds of conversations, he was exhausted and ready to give up the fight. When I left the hospital late one Friday night, two weeks into Mr. L’s care, I had the feeling he wouldn’t make it through the following day, when I was scheduled to be off work. And so, on a Saturday afternoon, I sat at home in front of my computer, refreshing his medical record and watching as notes were dropped by medical ethics, palliative care, and, finally, by the nursing staff, all of which were justifying orders for high-doses of morphine.
I turned on a Regina Spektor song that begins, “No one laughs at God in a hospital…” and hit repeat. I cried because he was going to die and I cried because I wanted to be there for it and I cried because I felt selfish for wanting to be there. Was I some sort of medical masochist for becoming so involved? Should I have established more rigid emotional boundaries?
I wish I would have known that it’s okay to cry.The next morning I awoke early to head to the hospital, and was shamefully relieved to see his name on the nurse’s station monitor. When his daughter saw me, she ran down the hall. We cried and hugged and I knew that this was why I went into medicine, even if it hurt. He slipped away later that morning, and I sobbed throughout the entire death exam, an experience that is visceral even when you haven’t taken the time to know the names of a man’s children and grandchildren and where he liked to practice his golf swing.
In the process of caring for Mr. L, I became so busy and emotionally involved that I forgot how badly I wanted to honor the medicine clerkship. And yet, nobody had to tell me I’d done a good job, because I knew in my weary heart that I couldn’t have done anything more, and the gratification that comes from being externally validated fell by the wayside.
Life is not about things.
Life is not about places.
Life is not about grades, or about how many peer-reviewed articles you can memorize before your case presentation, or about demonstrating your superiority to your colleagues, or about having all the answers.
Life is about people.
And, so, third year is about people too. It’s about listening to them and learning their stories, explaining to them what you know to the best of your ability, and figuring out what it means to take care of those whose conditions you cannot fix.
From my position standing on the other side of medical school, I wish for you to know that doing the simple things well is often what’s most impressive of all. Maybe that’s because so many healthcare workers skip what’s “simple” in lieu of what we perceive to be more complicated and therefore worthy endeavors. But I think that’s a mistake. As far as diagnostic and therapeutic interventions, what you can accomplish as a third year medical student means very little. But your power within the emotional life of the patient often overwhelms that of the attending, and sometimes, that means everything.