Med School Is Like a Box of Donuts

It's been a whirlwind of exams. It seems that every time I finally bite the bullet and take one, it's about time to start studying for the next. I'm nowhere as busy as a real medical student (I call PISCES life Med School Lite), but it's been a while since I've had the time to catch my breath. OK, that's a lie. I watched 4 seasons of Grace and Frankie while procrastinating for my Surgery shelf. I also got sucked back into playing Tetris and 2048, but in my defense, these are the outlets that are keeping me sane at this moment, aiite?

Last week, we had a reflection session at PISCES school to talk about "meaningful" encounters. I found it extremely difficult to identify one. It's not because I haven't had any meaningful encounters thus far in my medical training. Far from it. On one hand, I think it's because most of these "meaningful" encounters have been meaningful to me, probably not so much for my patients. Let's be real, how much impact am I making in my patients' lives? At the end of the day, I'm not their doctor. I'm just the person who came in and asked them questions before the doctor came in and asked the same questions all over again. Maybe I held a few hands. Maybe I exchanged a few comforting smiles or sympathetic grimaces. Most of my patients would have been happier if I had been a box of free donuts in the corner. Hell, I'd be happier if I were a box of free donuts in the corner. Donuts make everything happier, but I digress.

Other students talked about ways in which they had directly improved patient care. Times they had stayed after hours to do something extra for their patients -- true advocacy through action. Feeling contrary in the way cornered animals do, I declared, "I can't say I've had any meaningful encounters." Then feeling defensive at the pointedly leading questions and prompts I began to receive ("You know, anything that confirmed that you wanted to be a doctor, that moment."), I may have responded flatly something along the lines of "I don't get off on saving lives.", but I'm sure less crude. Maybe.

I had nothing to share because a.) I have an attitude problem and I don't like feeling compelled to over-sensationalize my experiences for the sake of "aww" moments, and b.) all the moments that came to mind felt self-centered and insignificant to anyone other than myself.

After the session, I wracked my brain. I know I've had meaningful encounters throughout my time in medical school. I have phantom memories of tightnesss in my chest, burning behind my eyes, leaden weights settling in my stomach, excitement bubbling at the back of my throat, a buoyant skip in my steps -- but no concrete memories, no names to faces -- entire narratives dissipated into the ether.

I fucked it up. I got so caught up in the stress of the moment -- there's never enough time, always something else to do, something else to study for  -- I failed to take the time and truly reflect on my experiences. And everyone knows my long-term memory is god-awful. So I made a resolution to start more faithfully reflecting on patient encounters that make me feel something. Because God knows I've been struggling with apathy. 

A few days ago in surgery clinic, I met a patient who had terminal esophageal cancer -- an insidious growth that was compressing his windpipe, prevented him from swallowing, and had robbed him of his voice . He already knew that the cancer would eventually kill him, his only question was how much time he had left. For his physical exam, I dutifully noted that the patient was breathless and audibly having difficulty breathing. My preceptor frowned. Having never met the patient before, I was unaware that this was a new development...and made for a terrible prognosis. I found myself standing mute in the corner as the surgeon explained to the patient that, should breathing get more difficult, he should report to the ED right away for a tracheotomy, a hole cut in the windpipe to facilitate breathing. The patient, an elder gentleman who hoped to live long enough to officiate his son's wedding just a few weeks away, didn't meet anyone's eyes as the surgeon explained the necessity of the tracheotomy. "Suffocating is a horrible way to die." My surgeon paused. "You don't want the trach." It was more of a statement than a question. The patient shook his head. His wife pressed his shoulder and urged him to take some time to think about it, reconsider. "Think about the kids. It will be hard for them to see you like that."

After they left, my surgeon made a few calls to try to squeeze the patient in to see another specialist who might be able perform the tracheotomy later that day. But even if the specialist agreed to see him, it was ultimately up to the patient whether or not he would agree to have the tracheostomy placed.

It was an important moment for me because I was reminded that sometimes the patient and the provider have different goals for treatment. A tumor is gradually paralyzing your vocal cords and you can no longer breathe -- it's OK, we'll cut a hole below the obstruction and buy you some time.  The cancer will kill you in weeks, months even. Not being able to breathe will kill you in minutes. Our goal is to prolong your life. But to the patient, this means an invasive procedure when he already feels weak and drained, breathing out of a tube that protrudes from the front of his neck, suctioning mucus that he can't cough out from a literal hole in his neck. If this isn't a life he finds tolerable, then why are we seeking to artificially prolong it?

At the end of the day, it is the duty of the doctor to make sure that the patient has all the information they need to make a decision. Once that decision is made, we must respect the autonomy of our patients. As someone who gets off on being always right, this is excruciating. But it's something I need to learn how to accept.