Pouring It Out in Writing

Getting to know patients for the first time and then watching some die has a powerful effect on medical students. Here are three who found their outlet at their laptops.

• In Search of True Medicine by Troy Madsen
• Looking Back, Thinking Ahead by Michelle A. Petrovic

The Death of Mr. G

By Dan Munoz
School of Medicine, Class of 2004

Dan Munoz, 23, was raised in Baltimore, where both parents are on the Hopkins Medicine faculty. A Princeton graduate, he plans to earn a master's degree from the Bloomberg School of Public Health along with his M.D.

It's 1:15 a.m. and I can't sleep. the blinking cursor on my laptop stares back at me. I've never really liked to write, yet it's all I can think to do. What began as a routine Wednesday (according to the clock, now yesterday), in the end produced one of the most upsetting, yet affirming experiences that I have had as a medical student at Johns Hopkins. The day delivered an intimate introduction to the most critical of life events-death.

Every Wednesday, my classmate Brian and I spend the afternoon at a local Baltimore hospital with Dr. B, a pulmonary specialist and director of the intensive care unit. The sessions are designed as a formal introduction to clinical medicine, a setting in which as second-year medical students we can hone our clinical examination and history-taking skills. In essence, it is a chance for us to begin translating our extensive classroom studies into the everyday practice of helping patients.

Yesterday afternoon, Dr. B sent Brian and me to the cardiovascular intensive care unit. The CVICU is where patients who have just had heart surgery or have other major cardiovascular disease are cared for in a highly controlled setting. Dr. B's goal was for us to learn firsthand what it is like to examine a patient whose condition is critical.

As we approached Mr. G, an obese man in his late 50s, Brian and I sensed this was a man in bad shape. The ominous chorus of beeps, hums and solid tones made it immediately clear that only modern medicine and technology were keeping him alive. No longer able to breathe for himself, Mr. G's lungs were filled and emptied by a mechanical ventilator whose predictable, robotic conduction set the beat for the odd harmony of sounds filling the unit.

A week ago, Mr. G underwent heart surgery. The goal had been to restore blood flow to a heart whose arteries had become thickened over the years, likely a result of heredity and/or an unhealthy diet and limited exercise. Following surgery, Mr. G was discharged and sent home to continue his recovery. Soon thereafter, something destructive occurred. Just a few days after his discharge, an unexpected drop in his heart rate and blood pressure pushed Mr. G into sudden cardiac arrest. His heart stopped beating and his breathing shut down, prompting a frantic 911 call by his wife. After doing almost 30 minutes of CPR, paramedics were able to resuscitate him. He was rushed back to the hospital, where he remained in critical condition throughout the past night and into this Wednesday morning.

As Brian and I stood by his bed and the countless, intertwining wires and tubes that linked him to life, it was clear that there would not be much to examine. Mr. G appeared to be in a deep coma.

There is an unavoidable level of intrusion associated with examining any human being. As a medical student, and part of a team, my charge is to help sick, vulnerable individuals. Yet, the act of asking intimate questions and placing my hands on personal areas of their body make me feel as though I am invading their privacy, trespassing their sense of self. I try to mitigate this feeling by explaining why we need certain answers and why we need to perform particular portions of the physical exam. My hope is that this will help patients appreciate the process and perhaps even feel comfortable with the care we provide.

In the case of Mr. G, there was nothing to explain, or rather, no one to whom we could even talk. Mr. G could not protest. He could not respond. Brian and I could not ensure his comfort. We could not give him a choice or ask his feedback. As we examined him, I felt a deeper sense of intrusion than ever before. He was simply there, in body but not in spirit.

We performed a neurologic exam to assess the level of Mr. G's brain function. I felt a chill as I peeled back his eyelids and tested whether his pupils could still respond to light. Nothing. We tested the cranial nerves that control eye movements and those that control the gag reflex. Still nothing. Our exam indicated that his cardiac arrest the day before had severely compromised his brain function. Mr. G showed all signs of clinical brain death. His prognosis appeared dismal.

As the evening wore on, Mr. G edged into multiple-organ failure. Steadily his functions ceased-his kidneys, his liver, one organ after another. His body was slowly but surely losing the battle. No doctor, machine or procedure would be able to alter that course. This man was dying.

Shortly after the last of our neurologic assessments, Mr. G's heartbeat began to slow. His dangerously low blood pressure began to sink further. There was no bang, no fireworks, no orchestral crescendo. His heartbeat and blood pressure (the last remaining signs of life) just sank…sank… sank…and then tiptoed off into nothingness.

Brian and I turned to the nurse. The expression on her face confirmed for us what had just happened.

It's striking how simple-minded I felt as I experienced the death of a patient for the first time. Despite all of my classroom study of the pathophysiology and cardiovascular mechanics that underpin human life, all I wanted to ask when the monitors showed no heartbeat or basement-level blood pressure was, Is he dead?

I knew the answer. Yet, there was an involuntary delay, a human defense, in admitting it to myself.

Brian and I joined Dr. B in bringing Mr. G's family into a nearby conference room. They were aware of his dire condition, but as anyone would, they clung to every last, irrational hope. They leaned forward with frightened anticipation as Dr. B described how, in the last hour, the situation had taken a final turn for the worse. He delicately explained that their loved one showed no remaining brain function and that his various organ systems had irretrievably deteriorated.

Dr. B then paused and softly said, "We did all we could." As if on cue, several family members gasped and broke into unrestrained sobbing.

Then there was silence-uncomfortable, but appropriate silence.
The family embraced for several minutes, literally wrapping themselves around Mr. G's wife. She trembled with grief. She was a thin, plainly dressed woman whose face and demeanor bespoke working-class Baltimore. Before the eyes of strangers, she was now forced to face the thought of an empty chair at the dinner table, a lonely bed, and a life without someone to love.

The family asked to see Mr. G, to kiss him goodbye. We accompanied them into the unit in a procession of silence. As always, the area was a cacophony of activity, but I heard only our footsteps. Mr. G's family surrounded his bed. His color had faded to a lifeless gray. The machines around him, which a few minutes ago were humming with activity, now lay soundless and still. They too seemed to realize it was over.

Family members took turns kissing Mr. G's now-chilly forehead. One daughter in particular caught my eye. From the moment she arrived at his bedside, she clutched his hand in hers. She would not let go. She kissed his forehead. Her grip tightened as tears streamed down her cheeks. She kissed him again…and then again. She seemed to tune everything else out. Why was she having a harder time, I wondered? Was she the closest to her father? Or was she being more honest with her emotions? Was she thinking back to him holding her bike seat as she ventured for the first time into a world without training-wheels? Was she thinking about how he would tickle her until she was sore from laughter? Was she remembering how he kissed her forehead every night before she went to sleep? Maybe she was now trying to return the favor...and hurting because maybe it was too late…or perhaps feeling comforted by the chance to say one last goodbye.

Even now, as I sit in bed with the clock reading 1:54 a.m., I cannot rid my mind of the image of Mr. G's daughter leaning in to kiss her father goodbye. What has stayed with me after all these hours and these typed words is the permission I was granted to participate in this most vulnerable of human experiences. No one asked Brian and me why we were there. Everyone involved considered it natural, or at least normal-everyone except maybe us.

At this late hour, it occurs to me that throughout this career that I've chosen, I will be expected to console the inconsolable, to deliver undeliverable news, to explain the inexplicable-death. In a year and a half of medical school, that subject had not been taught. Today, I began to learn it. Mr. G was a husband and a father before, for the briefest of moments, he was my patient. He never knew me, but I will never forget him.

In Search of True Medicine

Troy Madsen, 27, grew up in tiny Price, Utah, where his father's a pediatrician. He attended Brigham Young University. Last summer, he interned at Baltimore's WMAR-TV, the local ABC affiliate, where he reported medical news. Eventually he plans to combine medical journalism with a specialty in emergency medicine.

By Troy Madsen
School of Medicine, Class of 2003

Psychiatry is the last true form of medicine," Dr. Slavney began with an air of satisfaction. Vivian, Adeyemi and I, his three new students on the psychiatry rotation, sat attentively in a perfect half-circle around his neatly ordered desk. "It's the last true form of medicine because it focuses on the patient history. We try to get to know the patients. And we try to understand where they're coming from." Getting to know patients sounded good enough to me. In fact, getting to know anything besides the cold, hard desks of the William H. Welch Medical Library sounded good. After a grueling second year of medical school, psychiatry was to be my first clinical rotation, my first real contact with patients. I was ready for medicine.
Dr. Slavney explained our responsibilities as medical students on the hospital's general psychiatry consult service to us. Patients had been admitted to the hospital for various medical or surgical conditions. As psychiatric questions arose, attending physicians would contact the Department of Psychiatry for assistance. That's where we medical students came in. Our job was to evaluate the medical history and interview the patient. We would then present the patient to a resident, who would follow up on our findings and work with us to formulate a diagnosis and a treatment plan for the patient's psychiatric condition.

The centerpiece of our conversations with patients was to be the "mental status examination," a series of questions with a concise set of parameters: the patient's orientation to person, place and time; the ability to recall information; and the capacity to formulate written and spoken sentences. We would score the patient's performances on a scale of zero to 30. Dr. Slavney urged us to administer these tests daily in order to provide a record of a patient's progress.

With my clipboard and mental status examination in hand, I went forward that afternoon to tackle my first assignment: a psychiatry consult for a 67-year-old woman who was experiencing extreme anxiety and loneliness. The resident in charge of her care told me she had been admitted for sudden onset of kidney failure. Her medical condition had improved over the two days since admission, but her BUN [blood urea nitrogen] and creatinine, which my second-year courses had taught are indicators of kidney function, were still markedly elevated. In addition, she spent most of the night crying out for help. She seemed inconsolable, and the staff on her hospital unit wanted input from the psychiatry department as to what might be done.

As I rounded the corner onto the floor where I had been directed, I saw an older woman sitting in front of the nurses' station in a reclining, light-blue chair. She looked toward the nurses with an expression of despair, her grayish-white hair rising above the ghostly whiteness of her pale face.

"Help me!" she called out loudly. Her eyes turned and met mine. "Help me, doctor! Won't you please help me!" I figured I had come to the right place. I went up and shook the trembling hand of my first patient, whom I'll call Mrs. Parker.

When I sat down to talk to Mrs. Parker, I learned that the hospital environment and the multiple diagnostic tests caused her significant distress. More than being distressed, though, she was suffering from an altered state of consciousness, a "delirium," as Dr. Slavney later explained, which resulted, in part, from toxins that had accumulated because of her kidney failure. To evaluate the extent of the delirium, I pulled a mental status exam off my clipboard and started into the questions.

"Do you know where you are?" I began. She burst into tears.

"I don't want to be in the hospital," she sobbed. "I don't want their tests!" I marked one point for the correct answer and looked down at the next question.

"Can you tell me what day it is?" I queried. Mrs. Parker continued sobbing.

"I'm so scared," she whimpered. "Won't you please get me out of here, doctor? Please, please help me." I felt helpless. I tried to calm her. I put the mental status exam sheet aside. I asked about her family, her home and her grandchildren. She was reluctant to talk. Her sobs gradually subsided, though, and she agreed to complete the questions. I tallied the score at the end: 16 of 30. Not exactly a stellar performance, but I was just happy we had actually made it through the questions. At the conclusion of our chat, I wheeled Mrs. Parker back to the nurses' station. She repeatedly called out to me while I looked through her chart to gather more information. She informed the nursing staff that I had promised to take her down to the first floor. After 15 minutes, she turned her attention more completely to the nurses in front of her. She begged them to take her home. I sneaked out the back way and carried my findings to
the psychiatry resident.

When I visited Mrs. Parker the following day, things were looking better. She sat comfortably in bed as she ate her breakfast. I introduced myself, since she didn't have much recollection of our first meeting, and I launched into questions about her mood, sense of hopefulness and general health. Mrs. Parker seemed to have other things on her mind.

"Why aren't you married?" she interrupted.

"How did you know I'm not married?"

"You don't have a ring on your left hand." I mumbled something and tried to steer her back to the mental status exam.

"You're cute, you know. I can't believe you're not married. You know, if I were 20 years younger, I'd give you a run for your money." I felt myself blushing. I did some calculations in my mind. Twenty years younger than 67 is 47. Hmmm, I thought. Maybe the 22 points I had given so far on the mental status exam were too many.

We moved on to the last task: write a sentence.

"You are nice," she scrawled. I had to admit I was flattered. After the previous day's encounter, I had doubted Mrs. Parker was going to talk to me again. This was encouraging.

I spent the weekend away from the hospital, and on Monday I greeted Mrs. Parker for what were now becoming our routine morning visits. She sat comfortably on her bed, her hair wet and combed back.

"You look great this morning," I greeted her with a smile.

"Oh, come on. How can I look great? I'm in the hospital," she responded with an annoyed frown. I sat next to her bed and told her about my weekend. She seemed to like hearing about the Franklin D. Roosevelt Memorial with its waterfalls, statues and inscriptions. When I launched into our daily mental status examination, it became apparent that Mrs. Parker had caught on to the routine.

"Have you seen anything strange lately?" I inquired.

"I saw the boogeyman last night," she shot back.

"Can you tell me where you are right now?" I questioned.

"We're in a space ship," she grumbled.

"Okay, we'll switch things up a little today," I tried to coax her. We were on the memory question. I threw in three new words for her to remember- "car, hamburger, statue"-so she didn't have to remember "nickel, pony, chair" for the 10th time in five days. I prodded her through the subtraction question, promising to give her the day's weather report later in the test.

"Today is a very sunny day in the month of May," I asked her to repeat. She seemed to like that.

"Today is a very sunny day in the month of May," she repeated perfectly. "Is it warm outside?" she wondered.

"Oh, yeah," I said. I was happy the weather report had piqued her interest. "Hot enough to fry an egg on the sidewalk."

She moaned. "Come on. You can't fry an egg on a sidewalk." I shrugged innocently.

We finished up with her sentence. "You are cute," she wrote. I didn't blush this time. I realized, though, that any future mental status exams were going to require some bribery. I promised Mrs. Parker I would bring pictures of my recent backpacking trip to show her after our exam the next day.
The pictures provided the leverage I needed for Tuesday's visit. I informed her that at the completion of our exam, I would show her a photo taken on the last day of my week-long hike: me with a beard. We made it through the exam in record time. I pulled out the pictures.

"You look awful!" she blurted, appalled. I explained to Mrs. Parker that at that point, I hadn't showered for a week.

"I'll bet you smelled like a goat! How could these people stand to be around you?"

I tried to defend myself. "The others hadn't showered, either, and out in nature you really can't smell things that stink." She didn't seem convinced.

Mrs. Parker continued to improve as the week progressed. By the time Friday arrived, she was scoring 27 to 28. I walked into her room that morning to find her eating breakfast.

"Well, good morning, Mrs. Parker," I hailed her cheerily. She looked up from her meal of eggs, dry toast and pasty oatmeal.

"You again?" she replied. "What do you do, follow me around the hospital?"

"That's my job, you know. Your insurance company has employed me to give you an exam every day until you get so sick of it that you leave this place." She rolled her eyes. She poked at her eggs with her fork, then pushed the tray aside. She leaned back against her pillow and settled in for our daily interview.

"You look like you're in a good mood today," I observed.

"Not really. It's just the company." She looked down for half a second, almost embarrassed, and then looked back at me with a playful scorn. "That's a compliment, you know."

"Thank you," I said. Mrs. Parker always kept me wondering whether she was absolutely repulsed by my daily visits or actually enjoyed the time together. I was happy to hear she didn't consider me a complete nuisance.

The expression on her face changed slightly. "Whoever said getting old is great was lying through their teeth." She looked disgustedly at her hospital gown.

I steered the conversation. "So you got a chance to see your family last night?"

"Yeah, I saw my husband and my son."

"What about your grandkids?"

"Spoiled, no good, rotten kids. The one kid, he's 10 years old, and he hangs on his mother like a leech. And the other one's old enough to drive, and he never comes to see me. But, yeah, they came by." I could see beneath the rhetoric that she had enjoyed the visit, but she wasn't about to let on to actually feeling any of that mushy, warm fuzzy stuff with those "rotten kids."

"I have another son, you know, and I haven't seen him in years and years. He can stay away, though. He used to upset me so bad." I heard a hint of regret and sorrow in her voice. I paused and looked down at my clipboard.

"That's got to be painful."

"It used to be. But I don't let him bother me anymore. I did what I could, and if he doesn't want to see me, then that's his problem."

I paused again. Maybe a mental status exam would cheer her back up.

"So how about we do another round of these questions?" I asked with feigned enthusiasm.

"Not again! How many of these do I have to do?" She let out a painful moan.

"You know, I'm planning on taking all the sentences you write to create a novel we'll publish together," I tried to encourage her. "It's time now for our weather report. Repeat after me: Today is a very sunny day in the month of May."

"Today is a very sunny day in the month of May," she echoed with distaste. "Why do you always say that?"

"Say what?"

"The weather report."

"I've got to make this interesting, so I have to do something different."

"Well, maybe it is a sunny day, but I'm sure we'll be getting some rain soon. We get lots of rain here because of those Rocky Mountains."

"What?" I responded with dismay.

"Yeah, those Rocky Mountains we have. They make it so the clouds stop here and rain on us."

I laughed. "No, sorry, but there are no Rocky Mountains here," I replied with Westerner conceit. "The highest mountains you have here are at 3,000 feet. My home town is at 5,000 feet, and I've hiked to 12,000 feet."

"Well, it's no wonder you're so weird then. You don't have any oxygen to breathe." I smiled a sheepish grin, realizing she had effectively thrown my arrogance back in my face like a Rocky-Mountain goat dropping.

"Okay, you got me," I conceded.

We continued the exam, and I asked her to write a sentence. She took the pen in her hand and placed the tip on the paper, then paused. A blank look came across her face. She stared down.

"I don't know what to write," she complained.

"Well, write anything," I urged, not about to let her out of the task. "Just write what your name is, or whatever." She stared down again at the paper. She started to scribble a letter, then stopped. The pressure of her developing novel seemed to have taken its toll. She finally scrawled a hurried sentence and pushed the paper toward me with a flustered sigh.

I took the paper in my hand and smiled. "Twenty-nine out of 30," I reported. "Congratulations. You've set a new personal record."

She shrugged off the achievement.

"Well, I hope your day's good," I said. "And I'll drop by to see you again tomorrow morning."

As I walked out of the room, I took another look at the sentence she had written:

"Today is a sunny day."

I was glad to see my weather report had impressed her, after all.

The following morning I wandered up to see Mrs. Parker. Her room was empty, the bed pushed against the wall and stripped of its sheets. My heart began to race. What could have happened? I hadn't heard of any plans to transfer her or to discharge her from the hospital. I approached the nurses' station.

"She's in the CCU," the nurse directed me. "She had an exacerbation of her CHF." Mrs. Parker's weak heart, diseased by congestive heart failure, or CHF, had apparently backed up and filled her lungs with fluid the night before, leaving her unable to breathe. I thought about the tube they must have placed down her throat to give her the oxygen she needed to stay alive. She must have been scared to death.

Mrs. Parker was lying on her bed, her face distorted by a plastic mask delivering oxygen to her mouth and nose. The tube had been removed earlier that morning as her condition had improved. We talked about how she was feeling. I told her about my soccer game the night before, describing goal-for-goal how we had come back from a 4 to 1 halftime deficit. She seemed almost proud. But she also appeared weakened by the previous night's episode. I tried to explain the balance her body faced between having too much fluid and too little.

"I'm tired of being here. I'm going downhill," she said. I reassured her the doctors were getting things figured out. She seemed guardedly hopeful. Still, she had been hopeful a week and a half before.
"I've been here two weeks now. I'm sick of this place."

"Well, how about that," I tried to cheer her. "Two weeks. We'll have to put together some sort of party."

"Yeah, me party like this," she observed, her voice muffled by the oxygen mask. "I don't think so."

"Things are going to get better," I said. She looked tired, so I squeezed her hand.

The following morning it was time to abandon the mental status exams. Mrs. Parker's progress had been excellent. Her delirium had cleared, and her scores had been in the high 20s for a week. But I wasn't about to abandon our daily visits. Mrs. Parker was the highlight of my psychiatry rotation, and each day I looked forward to our conversations.

She looked much better when I entered the room for our morning chat. The mask was off her face and a small tube delivered oxygen to her nose.

"I looked in the mirror this morning and scared myself," she said. "I look like a dog."

"Well, to me you're looking great. Your health is improving, and the big news of the day is..." I paused to build the anticipation "...no more exams!" Mrs. Parker seemed only mildly enthusiastic.

"You know, when I get out of here I'm going to come back all dressed up and you'll see how I really look." She paused to imagine the scene in her mind. "I told my husband about you yesterday and he didn't even bat an eye," she continued. "He figures because I'm old nobody's interested in me." I couldn't be sure what she had said to her husband. I trusted her delirium had cleared. But, quite honestly, I was interested in her. It had scared me to see her empty room the day before. It had bothered me to see the oxygen mask on her face.

Our conversations continued all week. I learned more about Mrs. Parker's family, her home and her childhood. In the meantime, her health improved. And, with mixed emotions, I knew her progress meant that our visits would soon come to an end.

Friday morning found us together once again. Mrs. Parker's oxygen tube was gone. Her kidneys looked good, she was breathing well and, thanks in part to the work of her psychiatry friend (or so I liked to think), her delirium had resolved completely. It was time to go home.

I greeted the news enthusiastically. "You've got to be so excited to get out of here and go home! The weather's wonderful, and it's no fun being stuck in this hospital."

Mrs. Parker's face revealed her wide spectrum of emotions. "The CHF scares me," she confessed. "I'm afraid to go home because I'm afraid of the CHF."

I knew something of the anxiety she was feeling. I worried that she might have to go through the same thing again. The CHF scared me, too.

"I know that's a difficult thing," I tried to comfort her. "If you do have another episode, head to the emergency room. In the meantime, you'll be able to enjoy your home rather than hanging out in this dreary place."

"I know," she agreed. She smiled a weak smile.

We chatted a bit more. I told her about my most recent soccer game. I asked about her family's visit the previous evening. We talked about the weather. Soon, we both realized it was time to say goodbye.
"Well, I guess this is it then," I said. I looked at Mrs. Parker sitting in her bed, her face painted with a mix of anxiety and anticipation. I thought back to our first day together. I remembered her reactions to our daily mental-status exams. I recalled our talks about her family.

"So did you learn anything?" she interrupted my thoughts. I refocused my eyes on her inquisitive stare and nodded pensively. I have learned something, I thought. And it was more than how to coax a delirious patient through daily mental status examinations. I had learned about Mrs. Parker. I had come to understand her likes, her regrets, her fears. I had felt a sense of compassion, a hope to understand her anxiety, and a desire to bring her a certain level of comfort and happiness. I had learned medicine.
"You know, Mrs. Parker," I smiled back. "I did."

Looking Back, Thinking Ahead

Michelle Petrovic, 25, hails from Los Alamos, N.M., and first came east to attend Harvard. She's just made the decision to specialize in pediatric anesthesiology.

By Michelle A. Petrovic
School of Medicine, Class of 2003

In the spring of second year of medical school, I began my life on the clinical wards. Behind me were 18+ years of classrooms. Ahead, nearly a decade more of learning through experience. Until this point, I owed most of my success as a student to three qualities: independence, creativity, and motivation. But would they benefit me on the wards? I wasn't sure.
For the first time, my education would revolve around a team. Its schedule would become my schedule, its concerns, my concerns, its goals, my goals. From morning to night, we would round together, attend conferences together, read together. We would even share overlapping sleep-wake cycles. I would enter this world of hierarchical learning at the lowest rung of the educational totem pole. I would be the weakest link-at least from the standpoint of clinical knowledge. This wasn't a position that I was accustomed to holding.

Thus I prepared to begin my surgery rotation. The day before I spent in earnest preparation. I made a trip to the Costco wholesale club, where I purchased three boxes of 20-count SlimFast Meal-on-the-Go bars, two boxes of 30-count honey-sweetened granola bars, and one crate of Ensure. Rumor had it that there was little time to eat on this rotation, and I wanted to be equipped. I didn't sleep well that night. I tossed and turned until early morning and awoke groggy and slightly nauseous for my first day on the wards. A few hours later, I was lost somewhere near General Operating Room 15.

Nothing could have prepared me for that first day or for my first night of call two days later. I was awakened at 2 a.m. by the electrifying shrill of the trauma pager. Half asleep, I rushed to the pediatric OR to assist with a duodenal repair of a 4-month-old premature infant who had developed free air under the diaphragm. After five hours of exhaustive efforts by the surgeons, the child passed away: my first patient. I didn't have time to grieve that morning. The night was over, and I was already late for rounds. Tired, dizzy, confused and hungry (amidst the early-morning chaos, I forgot to grab the Costco granola bar from the nightstand), I somehow made it through the next 12 hours of the day-and, in fact, through the next 12 months.

During that long year, I struggled to adapt my old standbys-independence, creativity and motivation-to my work on the wards. But, to be frank, I had never felt so dependent in my life. I needed the security guards to navigate me through the hospital, the unit clerks to help me find patient folders, the nurses to interpret patient vitals, the residents to assist with physical-exam findings and the attendings to expand my differential diagnoses. My creativity took second slate to my superiors': resident X likes his presentations in this format, resident Y prefers hers this way. And the cornerstone of my ability to be motivated-adequate sleep, exercise, and nutrition-was replaced by long nights on call, 10-minute waits for hospital elevators, and eating donuts from morning conference for my breakfast.

But somehow, between my first rotation on pediatric surgery and my last one on pulmonary medicine, I learned to adapt. My greatest asset as an apprentice-scholar, I discovered, was my lack of preconceived notions. I was in the unique position of being able to benefit from different approaches to patient care. I could incorporate the demeanor of attending physician X with the efficiency of attending physician Y and the literary resourcefulness of attending physician Z and formulate my own approach. I realized that I was best served by using my own creativity outside of direct clinical duties. Although it is rare to "invent" a new disease at the bedside, it was quite possible for me to correlate previously unknown clinical variables as I went through the medical literature and think creatively. Indeed, I have come to understand that by speculating on a patient's seemingly unrelated clinical findings, I often learn the most about a disease process.

And while I still believe that adequate sleep, exercise, and nutrition are as important to the well-being of physicians in training as they are to their patients, I have found new sources of motivation within the nooks and crannies of the hospital. I draw incentive from the cystic fibrosis patient on a respirator who clings to life in his 15th month at the top of the lung-transplant wait list. I am inspired by the selfless actions of a post-call surgical intern who stays late at the Wilmer ED with me when I develop a case of the condition called periorbital cellulitis.

Over the course of this year, my final year, I must decide in what field of medicine I want to specialize and where I want to apply to do my residency training. My decision this time will dictate much more than how I spend the next four years. I've entered a realm where the choices I make will affect the rest of my adult life, and also my current and future family's. What I'm relying on is that all the things I now understand about independence, creativity and motivation will serve as touchstones as I carve out my life in medicine.