Upon entering medical school, we all knew that we would have to deal with some difficult diagnoses, emotional situations and even death. In fact, even the earliest portions of our training were centered around a cold, lifeless cadaver that we cut into to learn the intricate anatomy and beauty of the human body.
To a first-year medical student, gross anatomy symbolizes the profound meaning of what it is to embark on the long journey of becoming a physician. When one first picks up that scalpel and sets his or her eyes upon the pale skin, with the pungent odor of formaldehyde filling the room, an image is engraved in his or her mind that sticks with them for a lifetime. With the amount of time that is spent working with one’s cadaver, one is bound to wonder about that shell of a person that lays before his or her eyes. One recognizes that this body holds the story of a life once lived, bearing life’s scars and the wrinkles of time and gravity. It is most medical students’ first real encounter with death beyond the extent of attending a funeral.
Yet, as profound as that first experience with the cadaver may be, there are no books, no lectures, no seminars and no words that prepare us to embark on our third-year clerkships. It is a year that starts out with such excitement and flies by quicker than one can believe, yet during this time period, one sees himself or herself grow and mature more quickly than he or she ever believed possible.This transition from a student to a caregiver does not happen overnight. Sometimes it does not even happen until the third-year clerkships are almost over.
Yet for each of us, this transition occurs. Somehow, all of the initial anxiety and nervousness that floods one’s mind on the first day of clinical responsibility seems to fade and is replaced by a feeling of “Hey, I can do this! And I’m not half bad at it either!”
But what is it exactly that that fosters this transition? Well, in my opinion, it is a combination of a number of factors. There is great responsibility put on each of us as we progress through the third year. You are now both a student and clinician trying to balance enough patient care with reading and doing well on exams. It is a year in which one feels overwhelmed, overworked and utterly stressed out on many occasions, but somehow each period of stress or anxiety is offset by wonderful memories and experiences gained from both our peers, whom work closely beside us, as well as the individuals that probably teach us the most, our patients.
My third year began with my pediatric rotation. I did not know what to expect, except that I knewthat I was not interested in pursuing a career in pediatrics. As the rotation went by, I saw everything from babies seizing from herpes encephalitis to children bedridden and bald battling acute lymphoblastic leukemia.
There was one patient who changed my life forever: an adolescent girl, who was in a head-on motor vehicle accident, sustaining bilateral femur fractures, a radius fracture and pelvic fracture. But more importantly, this was a little girl who watched her mother take her last breath at the scene of the accident. From the first day she was on the floors as my patient, we had an unspoken bond. I stayed many late evenings in the hospital helping to ease her worries and concerns and simply talking to her about anything that comforted her. It was not only a moving experience, but it was an emotionally trying experience. On the one hand, it was amazing to see this littler girl improve and get better. On the other hand, my heart was filled with such pain and sorrow watching her cry and tell me about the relationship she had with her mother.
That is when I learned one of my biggest life lessons: the hardest question that a patient will ever ask a physician does not involve the mechanism of action of a drug or the pathophysiology of their condition. Rather, it is the question, “Why?” Whether they say, “Why me?” or “Why my mom, dad, sister, brother, etc.?” This question is the hardest question to both answer and wrap one’s mind around.
As my third year progressed, I saw teary-eyed families surrounding comatose patients as we “pulled the plug.” On an overnight call, I had my hands deep inside of an abdomen assisting with a ruptured aneurysm, when the patient expired in front of us. I helped to complete bowel resections and to remove tumors. I delivered babies and saw babies die before they could even experience an hour on this earth. I watched a 48-year-old mother of three with pulmonary adenocarcinoma take her last breath in front of her family as they cried verses from the Bible. For every third-year medical student, the list of life-changing experiences is expansive, with each person finding strength and meaning in different connections that we make or lose.
My third year ended with my internal medicine clerkship—one of the most difficult clinical experiences of my career. We had just admitted a 74 year-old male who was complaining of dyspnea and generalized weakness. Several months earlier he had been told that the B-cell lymphoma that he had been receiving treatment for was in remission. However, six weeks later when he came in for a routine PET scan follow-up, his oncologist found that the tumor had recurred and was now the size of a small grapefruit. We hospitalized him for a congestive heart failure exacerbation, giving him the usual Lasix and contacting his oncologist to visit him in the hospital to administer his chemotherapy regimen.
The patient’s oncologist asked me to assist him in relaying to the patient that, despite his chemotherapy, he was most likely going to pass away within the next year. Entering the room with one of the oncology nurses, we explained to the patient that his recurrent cancer was not only aggressive, but also that his comorbidities put him at further risk. If his cancer didn’t kill him within that year, one of the other issues could.
First there were a few seconds of painful silence. Then, he asked the nurse some questions about his chemotherapy before asking if he could just talk to me. My heart, having already sank from the initial difficulty of watching a person respond to being told that he only had a year left to live, felt like it was in my feet. I was nervous, scared, sad and wondered, “Why would he want to talk to me?”
I sat down on the patient’s bed beside him, as I always did each morning when I rounded on him and said, “I know that this must be hard. I can’t imagine what you’re going through, but I just want you to know that we are all here to help you every step of the way.” That’s when he said to me, “You know what, doc? I’m not even scared … How am I not scared? I’m about to face God and I’m not scared? Do you think I should ask for forgiveness now? How do I prepare myself to die?”
I paused for a moment to collect my thoughts. Slowly, trying to spit my thoughts out, I began telling him that it is normal for people to be numb at first. I tried to address his questions about facing God by telling him that we each have our own connection with the creator we choose to believe in and that he needs to follow what is in his heart to bring him the most comfort. He then proceeded to say, “Well, doc, what do you think it’s like, you know … right before you die?”
Stunned, I tried to collect my thoughts and after a few moments responded with, “Well, I suppose I don’t know. I mean I honestly don’t know. I don’t think anyone could tell you that, which is why it’s such a scary thought.”
We continued this conversation for over an hour talking about both life and mortality and how he could tell his family members. Over the next four days I spent around an hour with him each day, talking about anything that was on his mind. Some days were tearful and difficult, and other days were a bit more lighthearted. One day we talked about whatever food was being featured on the Food Network.
When the patient was ready for discharge, he gave me a big hug and said, “Doc, you’re my savior. Thanks for talking to me for all of these hours. I’d have gone crazy otherwise. I know … I won’t probably see you again before I die, but … I’ll watch from up there.” He pointed up towards the ceiling. “Good luck with your career. You’ll be great.”
There is nothing to prepare a medical student for the experiences of third year. One will laugh, cry, feel overwhelmed and stressed. One will feel pride, awe and happiness. Maybe more importantly, though, one will witness the full circle of life from birth to death. The beauty of life and the human body make it a true privilege to be a part of this field. These experiences not only change us as people, but they help shape us into the physicians that we will become. In the words of Sir William Osler: “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”