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Differentials


***

Summer

It didn’t take long for the truth to come out. We had just completed our second week of medical school, the anticipated “Week on the Wards” in which each student was matched with an attending physician in an experience that officially marked our transition from layperson to health care professional. “From now on,” our deans told us at orientation, “society will see you as a doctor. Sometimes you may not feel like one, but that is what you are becoming. This week marks the beginning of that transition, which will continue in the months and years to come.”

That Friday afternoon I sat with a group of women at a table outside the medical school to debrief. The air was thick with the heat and humidity of a southern summer, and though we hadn’t known each other for long, the jarring nature of a new experience and numerous hours spent sitting through orientation lectures lent us the illusion of intimacy. We compared notes from our assignments: one person had observed surgeries at the VA, another had been on internal medicine at the city’s public hospital. I had happily followed the infectious disease team at the esteemed children’s hospital. We chatted about the long hours and our attempts to explain to residents and nurses that yes, we are technically medical students, but no … please, please don’t expect us to know anything yet. We recounted highlights, interesting cases and the intimidating thrill of the fact that we had really made it to medical school.

I don’t remember who said it first: “I’m not sure I want to do this anymore.” The bold honesty rang out among the hum of positivity. We hadn’t yet started classes, and the uncertainty was beginning to surface. “I don’t know,” she continued. “It was cool to be with the doctors, but … I’m just not all in. I almost wonder if I should get out now before it’s too late.” A few others nodded in agreement, laid out their own misgivings like offerings. I had spent each lunch break that week on the phone with my then-boyfriend wondering aloud if I’d made a grave mistake. “What if I don’t want to do this anymore?” I’d asked him. “I should have done nursing,” I said one day, and the next day, “maybe I should have been a teacher.” Now, my classmates and I remembered our past jobs: consulting, farming, research, advocacy, education. The positions we’d worked hard to move away from suddenly seemed alluring, and we wondered why we’d left. One week earlier we had learned the term “escape fantasy” from a faculty physician, and we discussed our own premature escape fantasies, feigning humor to disguise anxiety. We imagined alternate futures, populated by versions of ourselves that seemed, already, to be slipping out of reach.

***

Autumn

As the seasons turned, we began to learn the language of medicine. We studied words for things we’d never known to name, to appreciate nuance in what had once seemed straightforward. Simple squamous, cuboidal, transitional, columnar. I’d never known our casings to be so complex. We began to match symptoms to processes and processes to pathologies until we could, by autumn’s end, try our hand at diagnosis. Our small group sat with printed copies of chief complaints, lists of vital signs and associated symptoms. We learned to craft a differential, a list of diseases that could cause the suffering described in these fictional patients. It felt like a game: we would try to find a possibility in every category, imagine the many biological stories that could be occurring inside bodies we would never see. Our untrained minds ran wild with ideas.

Though the art of crafting a list of differentials was new, the concept felt familiar. I had been turning over a list of my own possible paths in the back of my mind since the summer. The categories I populated were not based on organ systems; instead, they represented people, places and professions. I nurtured some steady fantasies: working as a teacher, a social worker, a nurse. These were the horses, my most likely differentials. Occasionally I would entertain zebras, imagining my life unfolding as an ecologist, a journalist, a park ranger, a cook.

As the days grew darker, we learned the art of dissection. I found myself in the medical school more than in my apartment and felt less at home in each. The longer I lived in Georgia, the more I cultivated visions of living in Colorado or California or Alaska, the late nights in anatomy lab tempered by distant ridgelines and the curves of coasts I’ve never seen. I envisioned alternate endings to my relationships, imagined staying with the love I’d left behind. I fantasized about leaving school, starting over. I practiced the lines I would use when explaining it to my family and friends. At first my mind’s wanderings were confined to the quiet of the evenings as I studied and lay down to sleep. But the meanderings metastasized until they clouded my mind during lectures, meetings, afternoons in clinic. The days became blurred by thoughts of a thousand futures unrealized, futures that had or had never lured me before.

***

Winter

I know now that I was never alone. Initially, the students who surrounded me seemed so sure of their decision to come here, to walk into those wards and begin becoming doctors. Perhaps some of them were. But for every person who seemed so convinced of their decision, another wore the weight of uncertainty, embarrassed, as I was, by their confusion. These truths came out slowly, on long days when we arrived at school before sunrise and left long after the cool night returned. We asked in low tones, “How are you holding up?”, aware of each other’s fragility. And always there was an air of guilt: we would explain our unhappiness while expressing our gratitude, acknowledging the paradox of displeasure and privilege. We sent each other photographs of signs reading “Now Hiring!” at coffee shops, clothing stores, and car washes with messages that both teased and tempted. When my family asked how school was going I simply told them I was working hard, though I never felt I was working hard enough. Well-meaning friends outside of medicine told me they couldn’t fathom committing to such a lengthy and arduous path. I laughed, silently thinking, “Neither can I.”

Many of us were drawn to medicine for its promise of flexibility, of open doors. As the year came to an end, we could almost hear the soft clicks of doors closing behind us. In a particularly low moment, a group of students admitted that they had wished for accidents that would render them unable to continue medical school but free them from the shame of consciously quitting.

It is a common question in medical school interviews: what would you do if you could not be a doctor? I had been warned before I heard it. “Tell them you’ll try again,” I was instructed. “Say you won’t give up.” But what had seemed like a threat during interviews now sounded like an invitation. What would I do? Many people who had struggled to answer that question a year ago now had countless replies, could name other plans and different paths that were often vague, but always somehow better.

***

Spring

The warmer weather brought a welcome change: the first stages of understanding. The words we had practiced pronouncing in September now rolled effortlessly off our tongues; the heart became connected to the lungs and the liver and the skin in a system that was still opaque, but increasingly elucidated. I no longer felt like an outsider in the clinic. Not quite a citizen, perhaps, but also not a tourist.

To study medicine is to study trade-offs, to become intimately aware of the costs of success. We learned early on that there are no perfect remedies; even our best medications have the potential to do harm. As we study pathology, it is clear that the crooked path of evolution has left us with bodies that thrive or fail depending on context. Our tendency towards salt retention has allowed us to survive in environments with limited resources; now it manifests as hypertension. Our appetite for sugar, so crucial in times past, leads to dangerous diabetes. And so it is with the most human of traits: imagination. Our capacity to envision alternate futures carries us through doubt and allows us to plan for the future. Surely this, along with our physiological adaptations, has sustained us through the harsh realities of many millennia. When uncontrolled, however, it can cause more suffering than salvation.  When our minds become restless and wander, lonely among ideas of various futures and fates, we must tend to them like the other cravings born of humanity’s past. We must honor and understand our imagination’s presence, and learn to discern true hunger from ancestral appetites thrown out of context in a modern world.

The journey ahead will feed our imaginations day in and day out. We must nourish our imaginations; it is what will allow us to see patients in new lights, to initiate creative therapies and to think beyond the confines of medicine’s established framework. On the hardest days, it will help us remember that things will get better. And it will, undoubtedly, cause us turmoil. I see this in older students, residents, fellows, attendings. I hear murmurings of “What if?”, some simply musings on lives unlived, some despairing statements of resentment or regret. I’ve seen simple musings become realities, when people choose to walk a different path away from medicine and are all the happier for it.

We live in a culture that celebrates certainty and encourages decision. We play into a myth that we know what we’re doing, and that the harder we had to work for it the more certain we must be. In reality, it is never so simple. Many of us are molded by misgivings: on good days, they are fueled by curiosity; on bad days, they are the sequelae of discontent. We live with the consequences of the choices we made, as well as the ghosts of the ones we did not. I sometimes imagine a world in which our résumés listed not only what we have done, but also the opportunities we considered but did not pursue, and the experiences we gave up in exchange for others. Are those experiences, pondered and passed by, not as intrinsically important to the people we have become?

A friend once told me that the extent of our serenity is measured by our ability to let go of the things that we are not meant to have. It is a difficult task, to let go with grace. And while we find occasion to practice letting others go, we seldom think of applying the same mercy to ourselves, of releasing our grips on alternate versions of our own lives.  It is an exercise in self-acceptance, in trusting the paths and process we each took, strategically or serendipitously, to arrive here.

***

Onwards

A list of differentials represents a beginning. It is the physician’s task to chip away at the list, to carefully consider each idea in the context of what we know and do not know and cannot know. We may order tests or treat empirically. Sometimes we will rule options in and out until we achieve a diagnosis; other times we may find a cure without ever fully knowing the culprit. In some instances, we might arrive at a conclusion only to look back, weeks or months later, and realize we had been wrong. We may start over, re-think, alter course.

And so it is with us. We are dynamic. We can rule in and out, employ processes of inclusion and elimination, change our minds and ideas and plans until, eventually, we find enough comfort and confidence in our decision to keep on moving forward.

Amara Frumkin Amara Frumkin (2 Posts)

Writer-in-Training

Emory School of Medicine


Originally from Atlanta, Georgia, Amara has bounced around the country a bit before landing back in her hometown for medical school. She enjoys hiking, traveling, exploring the city and thinking about fun things like human evolution. Email her if you’d like to talk!