Preclinical
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Prognosis


Twenty years have passed since the Hale-Bopp comet sped across the sky. It was 1997, and I was newly, proudly six years old. My family went to see it on a cool spring night, the combination of sticky and brisk that marks a shifting season. We climbed the stairs to my father’s office, stood against the large glass windows, and looked out into a wide view of the night. My parents and brother stood beside me, our eyes all fixated on the tiny light glowing in the blackness. Though I’d been told it was travelling faster than I could imagine, I struggled to detect any movement.

“What’s it called?” I asked.

“Hale-Bopp,” my father replied. Perhaps I giggled at the name. The buzz surrounding the comet’s appearance indicated its importance, and I tried to be serious out of obligation rather than understanding.

“When will we see it again?” I wondered aloud.

“We won’t,” my father explained. “It will be thousands of years until it comes back, and we won’t be here anymore.”

There are things that children perceive with a weight that adults all too often forget. My parents did not conceal the cycles of life and loss that affect us all, did not shield us from the truths of birth or death. And though I had tried to envision a time before I was born, I had never truly considered a time when I, and everyone I knew, would be gone. Now, that small celestial light became a visual representation of our limited lifespans.  I spent the rest of the night in silence, my small fingers clenching a plastic toy dog.  I remember sensing the gravity of the faint light passing across the sky, its brief salute during our lifetime before it continued its orbit out of sight.

***

We all live with a sense of limited time; we grow up aware that nobody lasts forever. But awareness is not the same as acceptance, and the latter proves much more elusive. With each passing month of my medical training, the closer I come to being able to predict other people’s time and the more I must come to terms with my own.

In the first year of medical school we learn to speak casually about time: the number of days in a course of antibiotics, bleeding time, the fraction of seconds in each stage of a heartbeat, the number of beats per minute. We discuss life expectancies, five-year survivorship rates, good and poor prognoses. And we speak of the time that we have as physicians: twenty-minute visits, twenty-four hour shifts, eighty-hour weeks. Whether we consider it too little or too much, it is always on our minds. I find myself constantly counting down the minutes until our next lecture, the weeks until our next module, the months until our next break. And yet, at the end of the day, I am unsure how to let someone know that their time is running out.

These days, I frequently find myself in the same building where I watched Hale-Bopp move through the night all those years ago. In that time I grew older, moved north and eventually returned south for medical school in the city where I was raised. Now I spread textbooks across tables and my eyes trace the pathways of chemicals instead of comets. I study the mechanisms that allow our bodies to function and the failures that will claim us all in the end. The passage of time feels increasingly real as we paint clinical pictures of birth, disease and death. Mortality is no longer an abstract idea flying across the sky; it is a reality that we examine, elucidate, and explain.

Despite the days and nights spent poring over pathology and prognoses, the concept of time remains a mystery to me. I still struggle when I imagine telling someone they have limited time left. I don’t know what it would mean to have one year or one month to live. My weeks may be numbered, but they have never held that weight.

***

When a person becomes disoriented, time is the first thing to go. Next, they lose their sense of place, and finally, who they are. We describe this decline as altered mental status, and we are trained to take it seriously.

When the first year of medical school came to an end, I boarded a plane to Alaska. I wanted to go far away, to experience a northern summer with its absent darkness and endless light. When I landed in Anchorage I stripped the watch from my wrist, and for the next two weeks, I rarely knew the time. The notions of early and late became obsolete. My two friends and I formed a small band with our own circadian rhythm, sleeping periodically, eating when we were hungry. The confines of hours melted away. One evening we began a hike, only to realize later it was close to 2 AM. It was not only difficult to guess the time, it was irrelevant. Nothing would have changed.

While the timeless days felt disorienting at first, they laid the foundation for a profound presence. Instead of organizing our activities to begin an end within a standard frame of hours, we focused only on what we were doing in the moment. I did not count down hours until we arrived at our destinations, or think about how much time was left until sunset. I had not known such freedom since childhood. When I first experienced darkness again, it was a mixture of comfort and mourning.

In Alaska, the edgeless hours were a luxury. The time spent there was an extended pause, an excursion away from the rigid days at home. Though it felt like an escape, I imagine the days spent in those northern mountains are somehow similar to the days I anticipate as a resident, where minutes and hours melt within the walls of the hospital and days fade into nights and back into days. And so it is, I imagine, for the patients whose lives are temporarily suspended within wards, whose concepts of time dissolve in the process of healing. While the language of medicine may be constructed on timeframes, the landscape is often as timeless and disorienting as the north.

***

When Hale-Bopp next becomes visible as a flicker in the night, we will not be here to see it. I imagine we will be spinning through space, our particles dispersed and incorporated into new forms that we will never know. Time will continue to ebb and flow, lives will end and begin, and the ancient cycles of the Earth will carry on in an orbit that is both comforting and sad. This holds true for patients, for physicians, for us all.

The months of medical school once stretched before me in a seemingly endless expanse of time. Now, it is flying by too fast. This morning, I sat in a lecture hall clicking through exam questions that asked me to discern the prognoses of fictional patients whose bodies were failing at various rates. Each translocation, lab value and lymph node suggested a different length for each person’s story. As I read each clinical vignette, a small timer situated in the corner of my screen indicated how much time I had left to finish. Two hours became one hour, which gave way to a matter of minutes until I was finished.

Before long, I will become, to my patients, a keeper of time. With my long white coat will come the privilege of speaking to a patient who is learning what it means to have limited time left. I may be the first one to inform a fellow human that death is near. Perhaps by then it will become more familiar, if not easier. Perhaps it will not. Either way, I hope to sit humbly as we navigate together through the time that we have and into the darkness and the sparkle of the night.

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!