Pouring It Out in Writing
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
The Death of Mr. G
By Dan Munoz
School of Medicine, Class of 2004
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
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
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
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
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
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
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
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
"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
"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
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
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
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
"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
"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
"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?"
"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
"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
"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
"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
"You know, Mrs. Parker," I smiled back. "I did."
Looking Back, Thinking
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
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.