The Soul of a Doctor Page 15

  But I had survived and I was ready for my exit interview, where I would get feedback on what I had done well and what I needed to work on. I remember looking forward to some honest assessment of my clinical skills and some suggestions on how to improve. This had been my first clinical rotation and I was eager for feedback, which I knew I would need in order to become the kind of doctor I someday hoped to be.

  But the only feedback I got from my senior resident that day consisted of a firm handshake, a stern look in the eyes, and a surgical comment: “Strong work, Dr. Bethune,” he said. Then, as his pager went off, he released my hand, turned, and rushed off down the main hall in the busy ED, angrily glaring at his pager and muttering under his breath, “Fuck! Here comes more goddamned beats.”

  Had I just completed my exit interview? “Strong work?” What the hell did that mean?! What was I supposed to do with that? Was I so absolutely horrible, such a complete and total disaster clinically, that he didn’t even know where to begin and was trying to be kind by patting me on the head and patronizing me with this cheesy one-liner instead of the real feedback I needed? Or had I just done everything, everything, for the past three weeks so perfectly that he really had no feedback for me? Perhaps he was just too busy, too tired, too overworked, to notice what I had or hadn’t done for the past three weeks? Perhaps he just didn’t care.

  Since that first rotation, I’ve gotten to work with many more residents, and I’ve become more proactive in seeking out feedback about my clinical work. Every once in a while, someone is really able to give good critical and constructive comments. But even so, far too often, the only feedback I get is, “You’re doing fine,” or “Don’t worry about it,” or, the worst, “Strong work.”

  In grade school, high school, college, and even the first two years of med school, I knew I was doing well because I got the questions right. I didn’t really need feedback. But now, on the wards, although I’m working my butt off, trying to be there for my patients during the day and fighting the constant uphill battle of trying to motivate myself to read medical texts during the evenings, how do I really know how well I’m doing? How do I know if I’m learning the things I need to know in order to be a doctor and practice medicine? How can I know unless someone who knows what they’re talking about takes the time to give me feedback?

  But then doesn’t this raise the question, who really “knows what they’re talking about”? The tired, stressed-out, overworked resident who says, “Be a team player: help out with scut, get me lunch from the cafeteria, and otherwise stay the hell out of my way”? The godlike attending, whom I’ve supposedly been working with for the past month but who in reality has addressed me directly only once and probably doesn’t even know my name, much less what I’m able to do clinically? Maybe the fourth-year med student, then? Or the intern—someone who’s a year or two more experienced than I am, but who’s probably still insecure in that role and concerned that I might make him or her look bad if I’m too strong? I don’t know who I can really trust to give me honest feedback about how I’m doing.

  So I suppose I’ve come back to square one, then. If I do my best, work hard, and try to master the things I think will be useful to me in practicing medicine, then—as I did in high school, college, and the first two years of med school—I’ll be able to look myself in the mirror and say, sincerely, “Strong work.” On some basic level, of course, I’ll have to listen to people with more experience and read books in order to figure out what kinds of things will be useful to know in order to practice medicine; but at the end of the day, I have to listen above all else to that internal voice that pushes me to strive to be better—and that sometimes says it’s OK to relax. I have to trust my own instincts, learn not to second-guess myself or doubt that I can be good at this whole medicine thing. Getting good feedback from others is important, but I’m realizing that regardless of the feedback I do or don’t get, and regardless of who’s giving it, I can’t afford to sit around waiting for someone else to tell me how I’m doing. I think my education will be a better one—and ultimately my patients will be better served—if I simply remember to do what I’ve always done.

  The other day I got a fortune in a fortune cookie that I keep in my wallet to remind me of what to do when I want feedback: “Rely on your own good judgment to lead you to success.” That simple statement will guide me to being able someday to do truly “strong work” for my patients.

  I Would Do It All Again

  Gloria Chiang

  I REMEMBER THE FIRST time I got to do a whole case in the OR on my own—a simple excision of a lipoma. I remember the excitement of feeling my own hand guiding the scalpel blade through the patient’s skin, using the Bovie to separate the fascia, and tying off the arteries as I had become accustomed to seeing it done.

  I remember being amazed by the first vessel that spouted defiantly at me and boldly colored all of our masks and gowns crimson.

  I remember agonizing about a subcuticular stitch I had thrown hours earlier in the OR that just did not look as pretty as I had wanted.

  I remember leaving the hospital at ten o’clock on a noncall night, knowing that I had six hours to sleep, eat, shower, and prepare progress notes for the next morning.

  I remember spending my birthday on call, coaxing a patient to drink GoLytely in preparation for his surgery, revisiting a little old lady every hour to see if she was urinating enough with each fluid bolus, and checking a computer every five minutes to see if our patient had finally gone down to get his abdominal CT.

  I remember the shocking phone call from a friend who had stuck himself with a needle in the ED and had to start on a protease inhibitor.

  I remember my favorite emergency-room chief complaint thus far: “My body is hot.”

  And here is what I’ve learned: I’ve learned that I can handle hundred-hour work weeks without caffeine, contrary to what everyone has told me.

  I’ve learned that people in medicine and surgery really do sit on opposite sides of the cafeteria at the nine o’clock meal.

  I’ve learned that how someone perceives you is often directly correlated with his mood rather than your actual performance. I remember hiding in a bathroom for two hours waiting for a particular attending’s shift to end after he had verbally chastised me, only to have him smile at me two days later and tell me that I was doing a great job.

  I’ve learned about the hierarchy that is general surgery. On my first day on wards, I unknowingly sat at the large table in the conference room. A shocked PA student whispered to me that students never sit at the table, but I stayed put, in silent rebellion against that hierarchy.

  I’ve learned to never complain. I remember taking care of a drunk, homeless man who had maggots coming out of his disintegrating rectum, filling the whole ED with the smell of rotting flesh. When I called my brother the next day, he told me that he had spent his call night wading through bowls of diarrhea with a tongue depressor, looking for a tiny packet of heroin that his patient had swallowed.

  I’ve learned to begin trusting my own clinical judgment. I remember the first time I disagreed with my residents’ and attending’s diagnosis of appendicitis. After the negative appendicitis protocol CT, I felt the seed of confidence growing within me when the trauma senior announced to the reading room, “She’s young, but she’s smart.”

  I had thought that I would find relief at having survived to the end of my surgery rotation. Instead I can’t believe that it’s actually over. And I would do it all again.

  Growing Up

  Vesna Ivančić

  CHAPTER ONE: PARENTS

  “Attitude, Veka, is the only thing that’s important,” he said.

  Because they were on the speakerphone again, I could hear my mother emptying the dishwasher in the background. She can never do just one thing at a time. The tinkling sound was the silverware; I mentally opened the second drawer from the window that faces the patio. The clanging was the pots being placed in that drawer under the stove
, to the left of the fridge. The wheels on the dish rack rolled lightly, jumping and catching the rails; it must already be empty. I heard her bare feet approaching on the warm wood floor and closed my eyes. I love home in California.

  “I know, Daddy. I’m trying to have a good attitude about it,” I said, realizing he had pinpointed my problem precisely, as usual.

  My relationship with my father is the strongest proof of genetics short of Drosophila and Mendel’s peas. We are so alike that he is the only foreign antigen unfailingly tolerated by my immune system. Even when we disagree, the elegance of his logic brings into focus a perspective I needed to have “reset,” rather than to react defensively toward. After all, my father is a software engineer whose special talent is to find “bugs” in people’s thinking and “reboot” programs. In the end, I am always forced to laugh at myself when he succeeds in reminding me that the big picture still exists. I once asked him how he does it—how he knows the inner workings of my brain so well. He smiled mysteriously and said, “Ti si ja, Vekica” (You are me). That is the amazing thing about genetics.

  But I am my mom too and was relying on that part of me to be in full swing the next morning when I started my pediatrics rotation. I wish I could be more like my mother, but unfortunately the patient, forgiving, supermom half of me is harder to resurrect. Besides, I was still mourning the end of my surgical clerkship. I could not believe the T would rumble past the Charles/Massachusetts General Hospital stop tomorrow, and I would stay seated, crossing the river to Cambridge. It had been a long time since my babysitting days, and the thought of critically ill children being entrusted, begrudgingly, to me, under the unforgiving eyes of their protectors, was terrifying.

  “Just go there and do the best you can, srecica,” Supermom said encouragingly. “We love you no matter what, and we’re always with you.”

  She had begun saying that “we’re always with you” line more often lately, since my uncle had died, I think. I hated it because they obviously were not here with me, and the allusion to being with me in spirit made me think of death—their death. I cannot imagine ever living life without my parents, but I guess it becomes possible in the same imperceptible way that things become impossible—things like believing one can grow up to be a fairy princess who flies and reads people’s minds. I do not remember when, or why exactly, I stopped believing that. Now it seems like a simple acceptance of the way the world is. So much of growing up happens subtly.

  CHAPTER TWO: CHILDREN

  I arrived at Cambridge Hospital an hour early, which, if I had still been on a surgical service, would have been an hour late. We were evenly matched on that Monday morning in October: four students and only four full inpatient beds. I have not seen such ratios since. Before beginning our orientation, we rounded on a toddler with pneumonia, another with reactive airways disease, a boy with viral meningitis, and a teenager with cellulitis from a mosquito bite. We washed our hands so many times that it seemed we spent the better part of the hour in line for the sink.

  Sometime about midmorning, the attending arrived holding two purple-streaked glass slides and, like the Pied Piper, led the entire troop of residents and students down six floors to the laboratory. The kid with cellulitis was not getting better—even on intravenous antibiotics—and early that morning, he had developed an ominous rash. The slides we were whisked downstairs to ogle were samples of his blood, smeared on the glass and stained and fixed, transforming a little red drop of blood into pink and purple swirls of art. The pathologist expertly clicked the slides into place, all the while looking through the eyepiece for just one or two platelets. Finding none, she settled on the immature white blood cells and proclaimed they were arrested in development—unable to grow up properly. “Still, I’d have to see a blast to make a definitive diagnosis,” she told our attending. I looked up from the multiheaded microscope and raised my eyebrows at the student sitting across from me. We had only met that morning, but the look we exchanged revealed we were thinking the very same thing—where else had we heard the word “blast”? And yet no one mentioned leukemia all day. How could you say it in the same sentence as “mosquito bite”? I clung to the closest uncertainty —she still hadn’t seen a blast, right?

  The attending sighed and apologized for interrupting our orientation, promising she would return after she talked to the family and arranged for a bone marrow biopsy at Mass General. “Things like this don’t happen around here very often,” she assured us as we stood, filling the heavy room with the scraping of chairs and rustling of papers.

  One student was quick to retort that he did not mind such an auspicious start; it was “cool.” The Pied Piper stopped in her tracks, the rest of us heaping up behind her like dominoes. “It’s not cool at all,” her icy voice warned us. “I’ve known this boy since he was two years old, and now he could die.”

  All heads bowed to the floor as we tried desperately to avoid eye contact with the beet red student whose shame we shared, despite knowing he had not meant it that way. Of course there was no time to explain. It was just like a movie. We plodded back upstairs for the scripted juxtaposition—a bunch of young, healthy people in white coats, sitting around a table discussing patient history write-ups and call schedules as the attending goes to tell a mother that her baby might die.

  CHAPTER THREE: HOSPITALS

  The biopsy was scheduled for the very next day. I arrived on Ellison 18, one of the pediatric floors at Mass General. He was waiting in the doorway, leaning on the frame, one hand resting on his intravenous stand. Suddenly I was not at all sure if he was the same kid I had seen yesterday. After all, I had only met him one time, and he had looked much bigger propped up in bed. I introduced myself again and claimed to bring greetings from everyone at Cambridge Hospital. I do not know what on earth made me say that. “I bring greetings from the kingdom across the river.” Who says “greetings” these days? I retreated to safer territory and asked him how he was doing. “A’ight,” he said, reminding me he was, above all, a cool fourteen-year-old kid. The kind I was nervous talking to even when they were my peers exactly a decade ago.

  “Have they done that biopsy thing yet?” I asked, my best attempt at nonchalance.

  “Nah, they’re late. It was ’posed to be twenny minutes ago.”

  “All right if I go with you?”

  “Uh-huh.”

  “So how’re you doing?” When I heard the words aloud, I knew I had just asked that question. What now? Fortunately he had a different answer this time.

  “Okay. They said I’ll be here for weeks. They think I have leukemia or somethin’.”

  “That sounds pretty scary.”

  He looked right at me, shrugged in that “whatever” kind of way, and then excused himself to use the restroom. I figured he had had enough of me and feared making a difficult situation worse by hanging around with my inexperienced, clumsy self. Bringing greetings? My God, I could not be trusted. So as he maneuvered the intravenous stand into the bathroom, I whispered good-bye and headed for the elevators.

  With my heart hammering its way out of my quivering scrub shirt and into my throbbing fingertips, I felt just as if I were on the Esplanade for an afternoon jog. What surprised me most was the realization that I felt so relieved as I walked away. That realization led immediately to guilt. What was I running from? Being uncomfortable? Facing death? Providing answers? Providing hope? Weren’t these the very things I had come to medical school to learn how to do? The window next to the elevators faced the helicopter landing pad, and I remember leaning against it wondering what to do next. What I was doing—running to class—felt wrong. Going back scared me even more. Maybe this was all wrong. Maybe I could still become a pilot or, better yet, an astronaut? One of those minutes that disguises itself as eternity passed, and I watched my sneakers, in postcall slow motion, heading back to Ellison 18, to my patient.

  Miraculously he was still in the bathroom. Maybe he would not even realize I had almost fled. I walked in and intr
oduced myself to his parents. They smiled and thanked me for coming, in warm and welcoming Spanglish. Minutes later, the oncologist called and we headed, processionally, down to the pediatric intensive care unit. The nurse went first, wheeling him toward the same elevators I had just rejected. I followed, continually disentangling various cords and lines, and his father led his crying mother behind me. My thoughts flashed back to my cousin’s funeral last year, his friends carrying the coffin, followed by my large family, each person carrying a white rose, the parents holding each other and crying, just as this boy’s mother was doing right now. Whose horrible idea was it to walk this way? The kid commanded his father not to embarrass him by joining in the crying. I just stood there, smiling at the mom helplessly.

  When the procedure was over, I handed the tubes of bone marrow and blood to the oncologist and took the elevator back upstairs to tell his parents it was done. Only his mother was in the room, and she cried as soon as I walked in. I knelt on the floor next to her and held her hand, apologizing for being seduced by French in school instead of learning some essential Spanish. “French is harder, I think, no?” she said, and smiled at me. What is it about harder that always seemed better to me? Right then, it just seemed useless—beautiful but useless. I felt guilty about everything. “Can I get you anything?” I asked, knowing I did not have what she needed.

  She shook her head no. Her husband had just gone down to the cafeteria.

  I told her that she needed to sleep, and eat, and ask for help. She nodded. Who was I, trying to be a mom to someone who truly was one?

  I looked out at the Charles River and finally understood what people mean when they say something looks a million worlds away. The Charles was a holodeck image projected on the wall. Its grass and trees and waves and ships and bridges and cars were so unreal and so beautifully useless. As I stood up, I noticed my hand had been lying on her soft arm, my thumb moving back and forth across it, smoothing it, the way my mom had soothed me so many times before. Perhaps it was that familiar motion that triggered my memory, or maybe just the silver ring, like my mother’s, that I was once again wearing after three months of a jewelry-free surgery rotation. Supermom had passed on something after all: I have my mother’s hands. Hers are darker, and the veins stand out a little more than mine, but not much. We have the same big knuckles, the same long fingers.