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an online version of the magazine Winter 2005
Annals of Hopkins
The Sum of All Fears
This medical student may have looked confident with patients, but she knew that beneath the surface lurked a coward.
On Your Marks... The Derby, sometime in the 1970s


It was the end of my time “on the O,” my month training on the Osler medical service at THE Johns Hopkins Hospital (or, as I affectionately refer to it, “the Hopper”). As is custom, my assistant chief of service (read: the boss) sat me down for feedback. The sleepless nights, the 80-hour work weeks, the mustered energy in the early mornings, the hard-ball questioning during rounds, the belligerence of patients, the struggles to come up with inspired and inquisitive questions—all that I had poured into this rotation now felt like a pitifully small sack of coins in my hand, and I wondered if it would be enough to purchase the coveted approval-prize.

What he had to say floored me.

“When I look at you,” my ACS said, “I see no fear. On rounds and in front of patients, you have those intangible things that are required to become a doctor, the foremost of which is confidence.”

Wow! Me? Confident? Well, if he meant that I don't mind speaking my mind on rounds, I guess that is sort of true, because someone once told me that the death of medical students is when they undermine themselves with wishy-washy opinions and self-doubt. “Be assertive!” I was told, “and your superiors will love you—whether or not you are correct.”

If he meant that I'm willing to perform venipuncture or go for the arterial stick or the lumbar puncture at the drop of a hat, I suppose that is true. Never mind that I'm very new at all of this; there has to be a first time for everything, right? And I figure that the less nervous I appear, the more confidence the patient will have in my abilities, and the less likely to ask me how many times I've done this in the past.

Freely discussing differential diagnoses, testing and pathophysiology (with either the medical team or the patient) is exciting, but the ACS's impression of me may have as much to do with my background in acting as in medical school. If I act like I've been doing this my whole life (instead of four months), perhaps I'll be able to convince everyone else that I'm really not as “green” as I really am.

What my ACS could not have known, though, was the total lack of confidence I had displayed just the night before. On my way to a classmate's wedding, I witnessed a terrible automobile accident. The car literally right behind me was hit at such an angle that it flipped over, rolled three times and finally came to a crashing halt upside-down in the middle of Pulaski Highway. Immediately I pulled over to the side of the road, shocked at what I had just witnessed and uncertain of how to proceed.

In order to fully understand the struggle that ensued in my mind, I have to explain that for a long time I've had a fantasy that goes something like this: One day I'll be out in public, and someone will shout, “Is there a doctor in the house? Someone help us please, we need a doctor!” And on that day, instead of being just one of the many rubber-necking spectators, I will be that doctor. I will rush to the side of the victim and confidently announce, “I'm a doctor. What seems to be the trouble?”

So, at last, here I was, faced with a medical emergency and everything inside of me wanted to jump out of the car, high heels and all, rush to the side of that vehicle and perform some medical intervention for the almost certainly injured people inside. My mind raced: I'm a medical student. I know more about medicine than anyone else around. Shouldn't I rush to help? But I haven't taken my emergency medicine rotation yet! I don't really know how to stabilize a C-spine injury. And won't it just be more hazardous if I add to the mayhem and start running around the middle of a busy intersection?

I wrestled with myself, not knowing what to do. Torn between my desire to be a hero and my fear of making matters worse, I sat paralyzed in my car. In the end, I picked up my cell phone, dialed 911, reported the accident and drove on. Confidence? More like cowardice.

So then, which is it? Within the confines of the hospital, I oftentimes feel ready for internship tomorrow, even though I've only taken care of 14 patients in my young career. Central line placement? Bring it on. Critically ill patient in the middle of the night? No problem. But when I leave the world of checks and double-checks, of hierarchy and balance and the comfort of knowing that many people are working to make sure that I don't harm any patients, I feel more like an imposter, as though I'm “playing doctor.”

Trouble is, in a way I am playing doctor. Every morning I don white coat and stethoscope, and rigorously examine patients for physical findings that I've merely read about in a textbook. I strap on purple gloves and perform invasive procedures that I've done maybe once or twice before. I speak to patients as a member of the “group of doctors” taking care of them. And yet, I'm just a medical student, that nebulous, ill-defined position of being somewhere between citizen and physician.

No longer a lay person, not yet a doctor, I am stuck awkwardly in the middle, trying with all my might to act like a physician even though I don't yet have the legal right or responsibility to do so. But I have to learn, don't I? And like I said before, there has to be a first time for everything. And what good does it do me or my patients if I am afraid of learning things that will one day be my job?

I think my ACS had it right when he told me: “As doctors, it's crucial that we have confidence. But we must also always be afraid of what we can do to people. We must be aware that we have the power to cause them great harm with our interventions and our treatments.”

So then, I guess really I am both, confidently and cowardly. I must walk and act with confidence because one day somebody's life will depend upon it. But I must also walk with the humble acknowledgment that being a physician is an awesome privilege, an invitation into the most intimate and vulnerable aspect of humanity. I can never lose sight of the fact that I have incredible power to help, but also to harm. Wielding all that power causes me some trepidation.

But next time, I think I'll get out of the car.

Lorrel Brown is in her third year at the School of Medicine and comes from Santa Cruz, Calif.

 The House that Sol Built
 Time Clocks in the Trenches
 Beyond the Abyss
 The Sum of All Fears
 Circling the Dome
 Medical Rounds
 Bench Press
 Annals of Hopkins
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2006