The Soul of a Doctor Page 16

  How would she feel if I were the child with leukemia, with a fifty-fifty chance of failing chemotherapy, with my best bet being a bone marrow transplant from a sibling, which offered only a 65 percent chance of cure? I headed toward the elevators quickly, suddenly conscious that I was late for class. A fellow student stopped me at the nurses’ desk to ask what I was doing there.

  “Hey, Ves, aren’t you rotating at Cambridge Hospital?” he called out. “How do you know the kid with leukemia?”

  “He doesn’t have it for sure, OK?” I snapped. “That’s why they’re doing the biopsy today.”

  “Oh, is that today? Shoot, I was going to go watch that. Did you get to see it?”

  I felt as if I was on ER, and next Carter would be asking me how many procedures I had done this past month. My stomach twisted as I nodded yes, unwilling to divulge any more. When I found myself waiting, impatiently, for the elevator once again, it was not fear that waited alongside me; it was a battle of emotions I still cannot describe.

  Come on, Vesna, I heard in my head. His mom is right around the corner. Nemoj, Vesna, don’t. But my stomach was already pushing into my back. My breath was coming only in gasps. I hit the elevator button again and again, each time pushing it a little harder. My finger ineffective, I resorted to my sneaker. Guiltily I remembered another student proclaiming recently that he did not want to be the kind of person, “like a surgeon,” who repeatedly punches the elevator button even when it is already lit. At that moment, a surgeon is exactly what I wanted to be, and I wanted this kid to have the kind of cancer we could cut out.

  But I am not a surgeon, not yet anyway. I clamped my hands over my mouth to make sure no one would hear me. Who knows what horrors his parents might conclude if they saw me crying? Never take hope away from your patients. Where had I just read that? Had they seen me, I am sure they would have assumed the worst. Screw the elevator, I thought, and I started running down the eighteen flights of stairs to the lobby; twelve steps … turn to the left … twelve more … one landing … twelve steps … turn to the left … twelve more … that’s two …

  CHAPTER FOUR: GROWING UP

  My parents called me tonight. Even my sister was home from veterinary school for the weekend because her college friend was in town visiting. She said something about vertebral fossae and all the reading she was assigned in Miller’s Anatomy of the Dog. My sister’s friend shouted out that he loved California—“God, it’s so beautiful; I can’t believe you guys grew up here.” At least I had a chance to grow up somewhere, I thought. Then it was my parents’ turn on the phone. My mother picked it up with the familiar, “Bok, srecice,” which means something like “Hi, joysparkle.”

  “Hi, guys,” I managed, defeated.

  “What’s wrong? You don’t have vesnabells in your voice,” my dad proclaimed, disappointed. It was his litmus test for my mood. If I had “the bells,” it meant I was happy, and by the transitive law that always applies to my family, this meant they were happy too.

  I told them about my patient, about his mom, and about leukemia. These are the things they did not know about. Then I told them some things they already knew, but I told them because I needed to say it. I could not stop thinking about the fact that he must have expected he would still play cards with his friends, get soaked in a rainstorm, lick melting ice cream off his fingers, look up at squawking birds, pant triumphantly after having caught a train just as it was pulling out of the station, stop to tie his shoelaces in the middle of the sidewalk, or change the bulb in the fridge when it went out, but that even these banal things he might not experience ever again. He might not ever grow up—all because some stupid white blood cells he never knew he had would not grow up themselves.

  My parents listened for a long time and then reminded me of what I already knew but needed to hear again: nothing is ever guaranteed; no one is entitled to anything in life; today is the only day we ever have; and the only things worth living for, in the end, are love and family. This kid has that, I guess—a family that loves him—and he has today, just as I do, and almost certainly tomorrow and probably the day after that. Beyond that, who knows what any of us have?

  After all, mosquitoes are everywhere. According to an old Croatian saying, if they bite you, it is because you have sweet blood. I rarely got bitten as a kid, and wished my blood were not so bitter. Today I would prefer it if my blood stayed exactly as it is. Bitter or not, I need it to keep right on maturing, even when the rest of me is struggling to keep up.

  Epilogue

  A GROUP OF MEDICAL STUDENTS and I were walking through the recovery room of a children’s hospital, where nurses and doctors care for patients waking from anesthesia. Even though I didn’t work there, I was proud to be able to show the students this part of medicine, all of which is central to the miracle of modern pediatric surgery: the layout of the unit, the equipment that monitors patients and sometimes breathes for them, and the highly trained nurses. I could even spot an opportunity, as we saw an anesthesiologist suctioning secretions from the airway of a child who moaned, to illustrate with real people what the students were learning in lectures about assisted ventilation and the pharmacology of anesthetic gases.

  The students’ reactions pulled me back. They knew that secretions had to be suctioned, but they couldn’t get over the doctor’s calmness as he inserted a catheter and applied suction. How could someone calmly suction secretions from the airway of a crying child? Here was real patient care, so much more immediate than an exercise in physiology, but they couldn’t imagine themselves doing what the doctor was doing. The doctors who intubated—even more, those who cut and sutured—had to be different from them. “Do you have to stop being affected by that to be a doctor?” one asked. “How can I do what doctors do and still be the person I am?”

  My attention shifted from physiology to what the students were going through. They reminded me that becoming a physician requires you to do things you’ve never done before—not just suctioning a crying child, but talking to people about private matters, sticking needles into people, or putting your hand into someone’s body. Many first-year students, while realizing a long-held ambition in becoming a physician, feel an unexpected rupture in their sense of who they are. Talking to colleagues, I learned that these discontinuities are soon forgotten; by the end of the third year, medical students have to be reminded, and even then are sometimes skeptical, that they ever felt what these students were feeling.

  Over the next few years, I listened again and again as students became physicians. From encounters like the one in the recovery room, several lessons emerged. First, there is much in the training of physicians (and of other health care professionals) that is emotionally jarring, even if soon forgotten. Second, acknowledging those reactions is key to understanding how physicians develop, to humanizing medical education, and to graduating physicians who will listen to how their patients are feeling. Third, students’ reactions point to challenges for all health care professionals. For instance, as in the recovery room, how do we provide emotional support while also doing a procedure that causes distress or pain? How do we maintain that balance?

  IN RECENT YEARS, the kinds of physicians our medical students become has engaged an audience far beyond medical educators. As a society, we are examining what we expect of our doctors. Gradually we are getting the message in the Institute of Medicine’s report To Err Is Human that the care we provide to the sick in America falls far short of what it should be. We can do much more to reduce deaths and injuries and to improve quality. We are ready to do more. But what kinds of physicians will lead in improving medical care? How do physicians acquire the knowledge, skills, and attitudes needed to help an ailing system, not just individual patients?

  The essays in this volume provide some answers. They illustrate how students, as they move from lecture halls to hospital wards, become physicians. They describe what it feels like to undergo (and to seek) those changes. They make us think about the conditions that fac
ilitate such growth.

  Despite a rich tradition of novels and memoirs about medical training, medical curricula have offered little systematic description of what it means to become or to be a physician and have given scant voice to the experience of the students. A gentleman’s agreement in American medical education seems to exclude the study of doctors: medical schools teach the development of microbes, embryos, and tumors, but not, with few exceptions, the development of physicians. Study diseases and patients, in effect, but not yourselves. The prejudice against self-examination extends to case studies: business school “cases” always describe the persons in the case, while medical “cases” usually leave out that part of the story.

  The antireflective tradition not only omits the study of how physicians develop; it can actively discourage such observations. For instance, when medical students talk about something troubling, like being yelled at by a resident, or receiving tearful thanks from the family of a patient they couldn’t save, or seeing a mistake that contributed to a patient’s death, others may disparage such observations as venting. A student who objects when a homeless person, seen repeatedly in the emergency ward, is called a “frequent flyer” may be squelched with words like, “What a typical med-student remark.”

  The stories in this book break with that tradition. They not only give voice to the learners, long silent, but also illustrate what makes the development of physicians both challenging to describe and important to understand.

  A first challenge is to recognize a developmental sequence. Physicians who can notice, think about, and use what is going on inside and around them do not appear, like Athena of ancient myth, full grown. They emerge gradually, along paths marked by a sequence of stages.

  The process begins when students, in their encounters with disease, illness, and patients, notice things that aren’t in the curriculum, like the tension between caring for a patient and doing something that causes that patient pain. At first they may feel that their reactions are merely personal incidents, rather than a part of becoming a physician. But many students begin to take these observations seriously and to see them as worth sharing with peers. They discuss them, as in the course for which these essays were written, in tutorials that a colleague, Daniel Federman, calls “havened reflection.”

  Students may also recognize that their concerns point to problems that concern all health care providers, such as defects in patient safety or quality of care, or failure to show respect to patients or providers. Some students take this step spontaneously; some with encouragement; some hardly ever. But some are prompted by their observations to do research on what they have seen, making their observations the starting points for investigation. Others see opportunities to do projects to improve care. Such outcomes represent the best in medicine—leading from personal observation to shared reflection, to study, and to efforts to make things better. Student observations, as well as those of other health care providers, can in the best situations feed the mill of continuous quality improvement. And appreciating this sequence helps educators support students at each stage.

  A second challenge that emerges as we read these essays is how to understand the puzzling phenomenon of clinical binocularity, which is the ability to think about people, and to relate to them, both as individuals and in terms of the mechanisms that produce disease. The development of this essential aspect of being a physician is worth appreciating because medical school has often been seen (and experienced) in negative terms—as a desensitizing, dehumanizing process. Our students’ essays depict something different.

  Medical training throws students into experiences that challenge their sense of who they are, causing them to revise deeply held taboos about other people and their bodies. To hear about people’s intimate problems, to have them disrobe so you can see and touch their bodies, to be with someone at the moment of death, or to examine the body of someone you knew during life—these are all extraordinary experiences.

  In contrast to the view of medical school as a time when valued capacities, like engaging with people as persons, are lost, these essays depict a more complex transformation. Before medical school, future physicians, like other people, tend to take others at face value. To that capacity is added in medical training the ability to think of people both as they present themselves and in biomedical terms. It is at once exciting and disconcerting to walk down the street, to notice a person with a certain kind of swelling in an arm, and automatically to start thinking of the anatomic features and possible causes of lymphedema.

  Increasingly able to focus on understanding the clinical problem and on carrying out the clinical task independent of their feelings, students start to feel (and to show) a quality that awes the public and may, for a while, perplex the student (as it perplexed the students in the recovery room). Sir William Osler, a great physician of the nineteenth century, called this quality “equanimity” (from the Latin aequanimitas). Our students’ stories illustrate how different is equanimity from indifference or insensitivity.

  Does it matter whether doctors study their own development? Don’t physicians receive enough attention already? As it turns out, it matters greatly. Physicians who will take the lead in patient safety need to be able to think about what they have seen and done in order to learn more. In the recovery room, compassionate and safe care requires nurses and doctors with the requisite knowledge and skills, to be sure, but it also requires professionals who are not exhausted from working too many hours without a break, who can work together as a team, who are able to tell their supervisors when something unexpected or unwanted happens, and who can monitor their own state as well as the patients’.

  These qualities are increasingly recognized in studies of medical error. For example, a recent review of an unexpected fetal death in labor in a teaching hospital took an unusual direction. While the doctors mentioned aspects of the mother’s condition that contributed to risk, they concluded that the tragedy was due to poor collaboration on the labor floor and to barriers to communication, such as the lack of permission for a resident to take a disagreement beyond his immediate supervisor. This candid—and heartrending—departmental self-examination resulted in major changes in the obstetric service, including new training in teamwork and a revised protocol governing trainees’ relationships with supervisors. The message, finally, is that doctors have to study themselves as well as diseases.

  We hope that these essays will help people understand the workings of a hospital and the ways in which new doctors learn. We also hope that they will remind medical educators that students’ stories about their daily experiences, far from being merely what students say, are the building blocks out of which students forge developing identities as reflective and problem-solving physicians. As the need for reflection on practice does not stop at the end of the third year of medical school, we also hope that providing opportunities for this sort of reflection throughout the years of training and practice will reinforce the reflective skills that emerge during the third year.

  Meantime, we have a hope for our own student authors. We hope that tying their current experiences to the high motivations that brought them to medicine and to the talents that they will use throughout their careers will foster their growth as physicians, physicians who can notice as well as perform, who can pay attention to individuals as well as to disease, and who can make the systems to which people turn for help reflect our best values of caring and healing.

  GORDON HARPER, MD

  About the Authors

  EDITORS

  SUSAN PORIES, MD, is an assistant professor of surgery at Harvard Medical School. She is a breast cancer surgeon, surgical educator, and scientific investigator. Dr. Pories has been named in the Guide to America’s Top Surgeons and is a Scholar in the Academy at Harvard Medical School. Her research focuses on biomarkers for the early detection of breast cancer. She dedicates this book to her family for all their support. She will donate her proceeds from this book to breast cancer research.


  SACHIN H. JAIN is an MD/MBA candidate and Soros Fellow at Harvard University, where he has served as president of the Harvard Medical School Student Council. In 2002, Sachin received his BA magna cum laude in government from Harvard College. As an undergraduate, Sachin cofounded a health care clinic for the homeless and was named a John Kenneth Galbraith Scholar. He was awarded an Albert Schweitzer Fellowship to support his work with the homeless, as well as a President’s Discretionary Fund grant from the Commonwealth Fund to lead the development of a health policy education program for medical students. He presently cochairs the Harvard/Commonwealth Health Policy Education Initiative in the medical school’s Department of Health Care Policy. Sachin was born in New York in 1980 to naturalized parents from India, who live in Alpine, New Jersey. Sachin plans to pursue a career as a clinician, scholar, and activist dedicated to improving access to quality health care. He would like to thank Sameer Doshi, Dr. Howard Hiatt, and Ankit Patel for their poignant suggestions on the text of the introduction. Sachin would like to dedicate this book to Subhash Jain, MD, the best physician, and Sarla Jain, the best caregiver he knows.

  GORDON HARPER, MD, is an associate professor of psychiatry. Dr. Harper, a child and adolescent psychiatrist, is a graduate of Harvard College and Harvard Medical School. He trained in pediatrics and child psychiatry at Children’s Hospital in Boston and in psychiatry at Massachusetts General Hospital. Dr. Harper was the director of the Patient-Doctor III course for many years. He also mentors residents in pediatrics and child psychiatry at Children’s Hospital. In 1997, Dr. Harper received the Award for Teaching Excellence from child psychiatry fellows at Children’s Hospital.