Everything I Learned in Medical School: Besides All the Book Stuff (7 page)

Chapter 16

Keeping a Healthy Distance

As a medical student, it is easy to get attached to patients. Since a student usually only follows two or three patients, we have time to get to know our patients better than anyone else on the team. This allows us time to meet the families, to hear their stories, and to get to know the person behind the diagnosis. Some may say that getting attached to patients is never a good idea, because one can’t allow personal connections and emotions to factor into medical decision-making. Others would argue that this level of involvement is a wonderful thing, and this attachment is part of caring for patients. Coming into medical school, my mindset was more towards the latter. Thoughts of helping others were still fresh in my head. But I came across two patients that pushed me a little more towards the “keep your distance” side of the equation.

The first case happened to be the very first patient I ever took care of as a student. To maintain patient confidentiality, let’s call her DeeDee. She was a child who suffered from gastroschisis, a disease in which you are born with part of your intestines hanging outside of the abdomen through a hole in the abdominal wall. No one is exactly sure how this disease develops. The abdominal wall closes in from both sides when we are developing as fetuses inside the womb. For some reason, the wall does not form completely in children with gastroschisis, and the intestines (and even other organs like the liver) may stick out from the hole. It is no doubt a frightening sight when your child has parts of their intestines hanging out of the body. Luckily, the gut can usually be put back into place slowly over the first few days of life, and the hole in the abdomen can be easily fixed with stitches. Unfortunately, sometimes the gut has a hard time getting blood to parts that are outside of the belly, and therefore, pieces of the intestine die. These pieces have to be cut out, and the living parts reattached. Sadly for DeeDee, she was born with gastroschisis, and much of her bowel had died and had to be removed. She was left with short gut syndrome, a state where you don’t have enough intestine to properly absorb enough nutrition. It’s a devastating illness, because these kids have to receive nutrition directly into their blood stream. To do this, a central line must be placed, which is essentially a tube that is inserted through a large vein (often the subclavian vein, in the upper chest), and pushed through until the tip reaches into the heart. The other end of the tube is outside the body, where the nutrition can be given. Often, these kids don’t live long, due to a combination of malnutrition and infections caused by bacteria entering the blood stream through the very line that keeps them alive.

DeeDee was in the hospital for the entire month I was on the pediatric inpatient rotation. Every morning, at 6AM, I would go into her room, and even though she was only 2, she knew the morning routine. She would roll over and lay on her side so I could listen to her heart and lungs. Later in the day, when I had free time, I would go in her room and play with the variety of toys she had lying around, and try to keep her entertained. Her mother had decided to give her up for adoption, fearing she could not take care of such a sick child. She rarely visited. All day in a crib with no parents around must have been torture, so I knew she enjoyed the time we spent together. Often when the team would walk by her room during rounds, we would hear her saying my name, or at least trying to say my name, hoping to get my attention to have another play session. My team thought it was rather cute, and I grew attached to her. She was, after all, my first patient.

My month of pediatrics came to an end, so I said goodbye to DeeDee. But only a few weeks later, she was transferred to a hospital that was closer to her family members. Well, this hospital happened to be in my hometown, and I soon found myself back home visiting my parents. So, I decided to surprise DeeDee and go visit her in the new hospital. With stuffed animal in hand, I went to the children’s floor, and asked the nurses where I could find her. “She’s right there,” the nurse said, pointing to the corner. There was DeeDee, sitting in a chair next to the nurse’s station, staring up at me. There was some hint of recognition in her eyes, but not exactly what I was expecting. The nurse and she went outside to play on the swings, so I accompanied them. DeeDee didn’t say much to me, just went about her routine. So, after 10 minutes, I decided it was time to go back home, and left her with the stuffed animal. After one month of spending every day seeing her, it only took three weeks, and she had all but forgotten about me. She was only two, and there were obviously many members of the medical staff involved in her care, so it only made sense she didn’t remember everyone. But to me, she was a special patient, maybe because she was my first patient, and maybe because I felt that I made a difference in her hospital stay. It sounds silly, but it did hurt a little when she didn’t recognize me. Perhaps it would be better to not get attached to patients, I told myself.

The second patient encounter was during my final year of medical school, during a pediatric neurology rotation. We were consulted by the general pediatrics team to come evaluate a patient with headache and ataxia (which means difficulty walking and coordinating movement). He was a 9 year old, and it was obvious from the first glance that something was terribly wrong with him. His eyes were constantly moving rapidly from side to side. When he got up to go to the bathroom, his limbs moved in unsteady, jerking motions, and his own legs could barely support his weight. We asked him to touch our finger with his, then touch his nose, a test of coordination. It took him a few seconds to actually get his arm moving, as if he wanted to move it, but it just wouldn’t move. And when it did, it flew out as if it was out of his control. We thought that he had likely developed an infection, and that the immune system had made antibodies to fight off the infection. Unfortunately, sometimes the body makes antibodies that also accidentally attack parts of the human body’s own cells, known as auto-immune disease. For him, his antibodies were also attacking his brain. In essence, his brain was becoming inflamed from the attack of his body’s antibodies. His brain was slowly losing more and more of its function. The attending pediatric neurologist said he had seen cases like this before, and they often get very sick before they get better, but luckily, they do usually get better.

Unfortunately, he kept getting sicker. By day 3, he couldn’t walk at all, and within a week, he had slipped into a coma and had to be placed in the intensive care unit, where a breathing tube was placed to keep him alive. When the brain loses enough of its function, the parts that control breathing can also stop working, resulting in death unless artificial ventilation can be started, as was the case here. For the next three weeks, we would come into his room every day, and check various aspects of neurologic function, such as his reflexes and how his pupils responded to light. We would comment on the small changes that were happening from day to day, with no real progress, despite trying a variety of therapies such as steroids and plasmapheresis (which filters out many of the antibodies floating around in your blood), in hopes that if his body truly were attacking itself, this would get rid of some of the attackers. Progress was slow and on some days, non-existent. The parents were obviously distraught at having a son that was completely normal one minute, and now a step away from dying. Truly every parent’s nightmare.

My month with pediatric neurology came to an end, and still he remained in the intensive care unit. I left, not knowing what would happen with him, but praying for the best. It was once again a case where I had become attached to a patient and a family over the course of the month.

Four months later, as I strolled through the lobby of the hospital on my way home, I saw a familiar face. It was his mother. My brain quickly tried to remember the context of how I knew her. When I realized who she was, the next question was how to go about asking about her son. After all, he may have died, or may be suffering from brain damage, or may still be in the intensive care unit in a coma. I had no idea. Hospital regulations forbade us from looking at patient records other than for those patients who we are directly involved with at the time, so as soon as I had left the pediatric neurology service, I did not look into his files to see what had happened. So, I posed the neutral question, “How is everything going?” Her face lit up, and she said everything was going well. She was just waiting for Cody to get out of the bathroom. They were in the hospital for a follow-up visit. My smile couldn’t be contained.

“So he’s fine?”

“Yes, back to his normal self.”

And just then, out from the bathroom ran a Cody I had never seen before. Healthy, full of energy, and a normal 9 year old.

“Cody, oh my god, it’s so good to see you.” I felt like giving him a big bear hug, but tried to maintain my professional composure. He looked at me for a second, slightly perplexed. And then…

“Do I know you?”

In the one month I had been seeing Cody everyday, he had been in a coma. He had only seen me briefly when he was first admitted to the hospital before he got really sick. So, it came as no surprise that he had no idea who I was. It was awkward feeling so close to a person and caring so much about their well-being, and yet they have no idea who you are.

Both of these encounters left me wondering about the level of emotional investment we as physicians should make in our patients. There is an important balance between caring about patients, and being distant enough to protect your sanity when things go wrong or patients die. But in the end, it seems that the rewards of medicine come from seeing those you care about get better, and that true care can only come when you are invested fully in your patients. Even if the patients forget you (or have no idea who you are), I still think we owe it to them to be emotionally invested in their well-being. And if at some point down the road that means becoming upset with the loss of a patient, that’s okay.

Chapter 17

Awkward Moments

In 1966, an anthropologist named Edward Hall introduced the term proxemics. Proxemics is the study of spatial relationships between humans or other animals as they relate to various social contexts. Simply put, it is the study of personal space. For humans, when we interact with each other, there are social norms for how close you should be to another person, and based on your culture, social status, population density, and many other factors, each of us has some differences in what we consider appropriate. For the average American, it is thought that people begin feeling uncomfortable when someone is within 24 inches on each side, within 27 inches in front, or within about 16 inches behind them, excluding intimate relationships of course. In the doctor’s office, there is a completely different set of social norms, one in which a doctor is allowed to enter the patient’s personal space, and then examine, poke, prod, and listen to a patient’s body. While this deviation from typical social norms is usually not considered the least bit unusual for a patient or experienced doctor, someone entering the medical field sees and feels it all too clear. Every doctor-in-training has to adjust to this newly found permission to enter the personal space of complete strangers. Listening to the heart, examining the abdomen, and looking into ears may seem routine, but for a new medical student, feelings of self-consciousness and inadequacy are the rule rather than the exception. But with practice, one develops a comfort level quickly with the routine exam. Soon the student is deftly moving from one part of the examine to the next with comfort and flow, holding instruments like a stethoscope and tongue depressor with a confident and steady hand. Unfortunately, there are a few areas of the examination that are not routine, and not as easy to develop a comfort with. Most medical schools provide focused learning sessions for these particular physical exam areas. For us, these came during our first and second year. Each particular session pushed the limits of what we were comfortable with, all in an attempt to teach us how to properly examine the human body and get acquainted with invading the most personal parts of a patient’s personal space.

The first session was held by a group of women’s health advocates. They went around and taught students the basics of the breast exam. That’s right, this group would go from school to school and allow students to examine their breasts. We divided into groups of five or six, and unfortunately, I was placed in a group of all females, which only added to my sense of discomfort. The instructor gave us step-by-step instructions on how to position the patient, and how to properly examine the breasts. This involved walking our fingers over every inch of the breast and pressing down with different amounts of pressure to feel for any masses. When it was time to perform the exam, it became obvious that this technique took a painfully, awkwardly long time. As the exam started, thoughts were racing in my mind regarding the best way to stay cool and not appear uncomfortable. Usually when you are this close to a patient and examining them, you talk to them to break the tension. But what do you talk about when you’re examining someone’s breasts? “Lovely weather we’re having.” “How about those Mets?” Perhaps I would just keep my mouth shut. It was a little easier knowing this woman had her breasts examined all the time, and that this was not weird for her in the slightest. This fact made me more confident and less self-conscious. When my turn came, I stayed focused on the task, went about the exam just as they had taught, and kept the conversation to a minimum. Overall, I felt the whole experience went pretty smoothly. But there were plenty of my fellow students who I’m sure were crippled with nervousness during their turn. You can imagine the quiet, academic, shy student who has avoided having to deal with breasts by hiding in books his whole life. Medical school has a few of those. I’d pay good money to see him perform a breast exam.

So, the first of the awkward physical exam sessions was over. But the next would push the limits of uncomfortable encounters even further. Before our OBGYN rotation, we had to learn the female pelvic exam. I wasn’t quite sure how this was going to work. Maybe they had mannequins or detailed anatomic models for us to practice with. We were divided up into small groups once again, and were assigned to one teacher. Ours was a middle-aged woman who spoke very eloquently, and in a straight-forward and didactic fashion, told us all about how to insert the speculum. This tool resembles a duck’s closed bill, is inserted into the vagina, and then opened in order to view the cervix, which lies deep inside. We learned how to do a bimanual exam in which we feel for ovaries from inside the vagina. This was all very scary stuff. At the end of the teaching session, it was time to practice. Still, no mannequin in sight. She instructed us to step outside the room, and come in one at a time, and to pretend as if you were seeing an actual patient from beginning to end. She also said to give her a few minutes while she disrobed! Holy crap, we were going to be doing these pelvic exams on her! It was difficult to believe that someone would be willing to take on such a task. Each of the instructors must have had pretty strong beliefs in women’s health and education to put up with this. I made my way into the room when it was my turn, and fumbled through the exam. I constantly asked her if she was doing okay throughout, both as a way of avoiding awkward silences, and to try to convince both her, and probably myself, that I wasn’t nervous. In the end, the exam went fine, and there was a good deal of learning that came about as a result of the session. But there were still tons of questions floating around in my head regarding these instructors. One can’t help but wonder if they’re married and, if so, what their spouses think of this job. And how much does one get paid to be examined in this way by medical students? I’ll probably never know, but I do wonder.

So, the tough exams were done, or so I thought. They saved the best for last. Rectal exams and the male genitals! Oh yes, there are groups of men who serve as teachers for these exams as well, and yes, we ended up performing the physical exam on them. They were all mostly older men, and our small group of students took turns sticking our fingers where no fingers should go. Our instructor got into three different positions and allowed us to try the exam in all three ways. That was a total of 15 rectal exams! Add this to the penile exam and the testicular exam, where we had to ram our fingers up into the testicles to feel for hernias, and it made for a rough day for the instructor. But once again, people did this, a job I thought no one would sign up for.

Looking back, there is probably no better way to learn these invasive exams than through these teaching sessions. How difficult would it be to perform the exam for the first time on an actual patient? But apart from the examination, I also learned that my previously established social norms for personal space no longer applied. I would have to adapt to this new set of rules. It was the first step in a long road to becoming comfortable with my future role as a doctor.