In today’s America, it is well documented that each year, more of our GDP is being devoted to healthcare spending, and a disproportionate amount of that healthcare spending is towards end-of-life care. According to a 2013 report from The Medicare NewsGroup, Medicare spending reached about $554 billion in 2011. This was 21 percent of the total spent on health care in the US that year. About 28 percent of that $554 billion — $170 billion — was spent on patients’ last six months of life.
We stood in the shadows, a staggered line of nurses, students and surgeons in matching blue scrubs and masks. It was the middle of the night. Our tired bodies sagged against the walls, our bloodshot eyes dancing between the clock above and the gasping life below. A young man was dying in the operating room. He lay on the cutting table with his arms splayed wide, like a martyred saint stretched upon the cross.
Medical students’ place in the hierarchy of medicine means we are routinely restricted in what we can (or should) say. That taboo list includes our own transformation — despite being only one of thousands impacted by medical education, all too often we are left alone to process how it changes us. Review of Systems is a series of down-to-earth slam poems by Kate Bock, putting words to the unspoken process not just of learning medicine, but of becoming a doctor.
I went through medical school without experiencing the death of a patient I had personally cared for. In contrast to what may be seen on the trauma service, my surgery clerkship was full of routine procedures: appendectomies and cholecystectomies, port placements, excisions of pilonidal cysts, and miscellaneous “ditzels,” as pathologists may refer to them as. Sure, I have had patients who were quite sick and did not have much time left to live. For example, I once performed a neurologic exam on a comatose teenager in the ICU, whose arteriovenous malformation had bled wildly out of control despite prior neurosurgery. But with the constant shuffling of rotations that medical students must endure, I was always in and out of patients’ lives before they had a chance to leave mine.
I recently had the opportunity to shadow a local occupational medicine physician over spring break. I arrived at his office Monday morning expecting a brief day of clinic, maybe some conversation over lunch; maybe I get lucky and he pays for my sandwich. Within minutes of meeting him, though, the physician offered to host me for the entire week on a “mini-rotation.”
Like poker, medicine has certain rules — patterns of clinical symptoms and lab findings each correlating with a specific spectrum of prognoses that vary in likelihood, the differential diagnosis. Physicians are like seasoned card players, trained to maintain composure and incorporate numerous variables into logical, calculated decisions at what seems like a “dealer’s table” of outcomes. Sometimes, we hedge our bets that the patient will self-resolve, so we elect not to treat; other times, we act conservatively with a battery of tests and pre-emptive therapy.
Medical school is a constant, never-ending cycle between success and failure — sometimes one occurring within moments of the other. To be a medical student is to fail. We fail at the small things: working out three times a week, being on time for a friend’s birthday dinner, working on the research that has been on our desk for months. We also fail at the big things like exams, practical skills, asking for help when we most need it and sometimes letting ourselves sulk for too long.
The old woman with long silver hair sat in her wheelchair, feet propped slightly up, smiling toothless among her layers of wrinkles. She waited for me to speak, deferring her decades of matriarchy and adulthood to the stethoscope I wore so casually after just months of earnest experience. Indeed, it sat lightly on my neck today but heavily on my heart. A few more seconds passed, as I contemplated how exactly I wanted to discuss her test results and how exactly I would ask her to proceed.
The counting of compressions permeated the air as we anxiously stood by hoping to see any sign of life. We were trying to save Adam, a young Israeli-Arab who was on our inpatient service due to complications after his hemicraniotomy. He was hospitalized for nearly four months and his vital signs never stabilized, despite our rigorous and numerous treatments.
The beginning of third year clerkships is an exciting time for medical students. The first step of my licensing exam was finally behind me and now I could focus on applying the knowledge into a clinical context. I had heard a lot of stories about the third year of medical school. Perhaps what stood out most were the reflections shared with me when people witnessed death for the first time. From full codes to hospice patients, something about death seemed to draw out the most intense emotions and thoughts that can change lives forever. Although I always try to do the best for my patients, I knew it was inevitable that I would come across death. I wondered what profound thoughts and reflections I would have when I experienced it for the first time. It wasn’t too long before I was called to do CPR in the emergency department and I found it did not play out as I expected.
They’re out of place in dirty Crocs and wrinkled sweatpants. More notably, she’s wiping tears from puffy cheeks. It’s a sharp contrast to the nurses, who are too casual. One makes a remark to the other about a tangled tube. They always get that way. The other chuckles.
My first rotation as a third-year medical student, I met a man who will forever influence the way I approach my patients. He had come to the hospital because of rectal bleeding and was ultimately diagnosed with colon cancer. As I got to know him, I learned that he had fought in two wars, started a successful business and was married for more than 50 years. And he was enormous, six-foot five-inches and 280 pounds, with a voice that reminded me of Lee Marshell — think Tony the Tiger and the guy who sang “You’re a Mean One, Mr. Grinch.”