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A Third Year Opus: Prologue


Goes by fast.

Over the course of third year, I came to favor several select phrases to guide me through patient encounters. When patients commented on my perpetually and pathologically icy hands: cold hands, warm heart. For otoscopic examinations of children: looking for elephants.

Goes by fast is used for the question, “How far along are you?” which is asked frequently of pregnant women and medical students. It is a common inquiry, perhaps second only to “When is the real doctor coming?” which I have asked myself more than once.

“How far along are you?” Third year. “How many more years?” Just one.

Goes by fast.

Time — both its passage and its seeming scarcity — was a recurring source of anxiety throughout the year. Long days began and ended outside the confines of sunlight. They rolled into one another, indistinguishable; work punctuated by weekends and holidays, blizzards and heat waves, and Republican primary debates. These markers served as reminders that Time was still sailing forth, and that I was — for better or worse — its captive passenger. Third year would begin and end, and then so too would fourth year, and then with it medical school, and then onto the next chapter. The churning waves of Time with their relentless forward inertia would be the only constant.

Despite its omnipresence, Time seemed to be in reliably short supply throughout the year. I keenly felt its absence: less time to cook and clean. Less time to exercise; less time to date. Less time to read and to write. And it frequently seemed that my peers had a command of Time that escaped me. They finished novels, ran half-marathons and published papers all while possessing a medical knowledge superior to my own. The only indulgence Time afforded me was enough to follow the aforementioned Republican primaries — a gift that I would have gladly gone without.

Alas, this was a fiction, a self-delusion. Time was not as out of reach as I pretended. There was enough for family and friends. Enough for the occasional (and not-so-occasional) Netflix diversions. Enough, generally speaking, for a decent night’s sleep. The truth is that there was less productive time, whether from a failure of time management or a deficiency of discipline or some combination thereof. What time I had was dedicated to the least physically, mentally and emotionally taxing tasks I could conceive. All others would be swiftly eliminated from my schedule.

The first on the chopping block was consistent bed-making, that most jaw-droppingly inane, tedious and loathsome of household chores.

More slowly abandoned was writing, and this I regret deeply. The clinical year meant that I ostensibly had more to write about, but I spent less and less time putting the stories to paper. A daily ritual became a weekly ritual, which ultimately became a monthly ritual. My notebook remained atop my desk to brazenly remind me of my neglect. It evoked shame and guilt that surpassed that of my parents (Hi Mom). In an act of self-preservation, I banished it to my bookshelf, wedging it between a copy of Inferno, Brown not Dante, and Crime and Punishment. It was a temporary exile, I promised myself. It would soon be lifted when I had more time.

As the frequency of the entries dropped off, so too did their length. Pages accustomed to long vignettes were now populated by short paragraphs and one-liners in increasingly imperceptible scrawl.

An elderly gentleman, previously a force of nature, lay trembling in bed, his face freckled with rapidly multiplying beads of sweat.

A 54-year-old female schoolteacher with a newly diagnosed tumor of the small bowel.

69 y.o. F w/chronic pancreatitis 2/2 longstanding EtOH abuse.

85 YO  PMHx CHF, HTN, DM2, CAD s/p CABG, COPD on 2LNC presenting w/SBO. 

I told myself that these were merely placeholders. That I would go back and fill in the details. Later. When I had more time.

But these weren’t people — they were diagnoses. These weren’t narratives — they were board questions.

Part of the allure of a journal is its ability to capture Time, that elusive companion, within its pages. My motivation in keeping one was to document my advancement in medical school as Time pressed on. A vignette from first year would seem feeble and naïve compared to an essay written in second year, which, in turn, would most certainly contain newly realized truths. And so on and so forth. I imagined myself forty years on dismissing the entire journal as rubbish, having achieved a deeper, more sophisticated level of understanding buttressed by a lifetime of caring for the sick.

But as the essays became one-liners, as the people became reduced to their diagnoses and as the faces and names swirled into one giant amorphous pool, it became clear that I was not documenting my progress, but rather my regression.

Studies have suggested that medical students lose empathy in the clinical years. I was aware of this phenomenon — we all were. But I foolishly thought that awareness would be sufficient protection. Maybe this was the explanation: I had experienced a loss of empathy. Time was wearing down my humanism, and after only one year. What would be left of me after another year? Another ten? Another forty?

However, these losses must be weighed against incontrovertible gains. I may have been more empathetic a year ago, but I was also infinitely more ignorant. Hypertension in a child once screamed “pheochromocytoma!” But now, it means that the blood pressure cuff was probably just too small. I have gained knowledge. I have gained skills. I have gained confidence. I have gained weight.

So, how then can I restore humanism to my experience? How might I insulate it from the erosive effects of time? I don’t pretend to have the answers. But I presume that my drop-off in writing hasn’t been particularly helpful. That might be a good place to start.

To my journal — I promise never to banish you to the bookshelf again.

I can’t say the same for Dostoevsky.

Ajay Koti Ajay Koti (11 Posts)

Columnist and in-Training Staff Member

Morsani College of Medicine at the University of South Florida

Ajay is a Class of 2017 medical student in the SELECT program at the University of South Florida. He is passionate about delivering primary care to underserved populations—specifically, low-income and homeless patients in urban centers. Ajay is particularly interested in the potential of patient-centered medical homes for mental health and chronic disease management.

M.D. or Bust

Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.