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A Third Year Opus — Chapter Two: Curtains and Red Flags

Part One

I was quite confident that it could happen to other people. I was quite confident it wouldn’t happen to me.

What do you want to be when you grow up? I mistakenly expected this question to be laid to rest after starting medical school. But it comes to occupy a position of great priority and urgency: sure, you want to be a doctor, but what kind? — as if the former decision had been a minor one.

The considerations in choosing a specialty are multiple. There are matters of lifestyle and compensation, of competitiveness and rigor. There is the push-and-pull of breadth versus depth, of procedure versus prose.

Fortunately, medical students are surrounded by people who can help navigate this existential mire. There are more senior students who, leaning back and angling their chair legs off the ground, offer: the three things you need to figure out are [platitude, platitude, platitude]. There are online assessments — powered by reliable, rational algorithms — that give different results based on the time of day and day of the week. What changed — the test or the test-taker? There are residents and attending physicians who will either share their own journeys or bark: dermatology!

At first, the indecision is thrilling. It makes available to the imagination limitless possibility. But as Time pushes on, the indecision becomes inconvenient, then vexing, then torturous. Because, at some point, pros need to outweigh cons and plans need to be made. Surgery? needs to become Surgery, period. Decisions must be made.

I counted myself fortunate that I was spared from grappling with this process. After a few months of obligatory vacillating and non-committal statements, I quickly and emphatically decided on family medicine.

My resolve on this was ironclad. By my estimation, there were only two significant drawbacks. First was the prospect of joining the ranks of one of the most beleaguered medical specialties. I was not blind to the statistics on primary care shortages, the burdensome scale of patient panels or the grind of squeezing thirty minutes of patient care into half that time. Far from being repellants, these challenges were irresistible to my sociopolitical (read: bleeding-heart) inclinations. You got into this thing to serve others, it is thus entirely appropriate to do so under relatively punishing conditions. I would make the requisite sacrifices in service of medicine’s moral mission.

My Messiah complex is a subject for entirely another essay.

The second problem was less assuredly dispensed with. The broad scope of family practice also meant a broad patient population — one that included children. Hmm. For reasons that I could not articulate, this produced some hesitation. Children. Hmm. Kids. Youths. Yoots.

I tabled this concern, deciding that I could address it later. At any rate, it made no difference in how I felt. When people inquired about my plans, family medicine was always the answer. Those who had been through the process told me to keep an open mind during clinical years, that they started medical school so certain of their specialty, only to fall in love with something completely different. I nodded politely but hubristically dismissed them.

I was quite confident that it could happen to other people. I was quite confident it wouldn’t happen to me.

Six weeks of pediatrics zoomed by, and I could feel myself falling in love with it. The diversity of ages. The role of the parents and extended family, and the opportunities for education and advocacy. The boundless resilience of body, mind and spirit that is revealed when a sick child becomes well.

Pediatric patients harbor little of the cynicism and tunnel-vision that plagues adult life. We are all afforded exposure to new experiences, ideas, and emotions every day, but adults are less sensitive to them. Children feel the exhilaration of novelty in their bones. A sixteen-week-old smiles broadly at a new face, a sixteen-month-old marvels at the occupants of a fish tank, a sixteen-year-old forgets his iPhone and his angst, even if only for a moment, to play with a therapy dog.

To experience life through the eyes of a child. That was, and is, the promise of pediatrics. You might imagine my irritation at being reduced to a cliché worthy of the Lifetime channel — an heretofore narrow-minded medical student discovers enlightenment and broader horizons — but the unqualified enjoyment I felt on the pediatric floor was ample distraction.

In retrospect, my initial resistance to the specialty was rooted in ignorance. I had spent little time around children, and I was, frankly, intimidated by them. Adults were so much more straightforward — you could talk to them. They could tell you what they needed from you. How on earth do you talk to a child?

The answer is simple, of course: you just talk to them.

But when the patient is just one week old, the conversation is a little one-sided.

Part Two

Baby Ahmed was swaddled in a crib. His father sat in a chair adjacent. His mother sat behind a curtain. His sister, three years his senior, bounded about the room, indefatigable. Ahmed, by contrast, did everything one expects a nine-day-old to do: not much. For most of his five day admission, he slept, stirring only to feed or yawn, his mouth gaping to gargantuan proportions relative to the rest of his jaundiced body. Behind his shut eyelids was more evidence of the jaundice and feeding failure that caused a thirteen percent weight loss and a direct admission to a hospital room for failure to thrive. The hospital machinery whirs to life — fluids, labs and lights.

Medically speaking, failure to thrive in a child is not a particularly esoteric diagnosis. Its management is similarly straightforward, premised on rehydration and addressing the underlying cause of the weight loss. A lack of education? A lack of care? In Ahmed’s case, it was the former. During the admission history and physical, his father, a generally pleasant man in a stained work uniform, was unfazed by the events. Ahmed isn’t feeding well, so, logically, he must not be hungry.

His mother, dressed in a traditional Punjabi suit, her face framed by a hijab, sat silent on the other side of a curtain that divided the room. His sister grew increasingly gleeful at the parade of short and long white coats who came to greet them. A face on an iPad translated our recommendations into their native language. Ahmed’s mother nodded placidly in agreement behind the curtain, Ahmed’s father thanked us and left (he was due at his second job). Ahmed’s sister giggled.

Part Three

Much is made of red flag symptoms in medical school, and appropriately so. These symptoms are indicators to the clinician that the diagnosis is serious — debilitating, or even life-threatening — and demands immediate evaluation and treatment. Red flags of cauda equina syndrome, in which the nerve roots that trail off the spinal cord are compromised, include severe back pain, progressive neurologic dysfunction and both urinary retention and incontinence. As with all things in medicine, it is one thing to learn these from a textbook and quite another to learn them from a patient.

So when our team was alerted of a direct admission from an outpatient site — a six-year-old male with all of the above symptoms — I must admit I did not appreciate the grim faces of the attending and residents.

Comparing Hunter to a pretzel may sound trivial, but I can think of no more apt description. The boy sat contorted on the bed, tearfully shouting away any would-be examiner. His head was in a torticollis-like position. His parents weren’t much older than me and seemed to have no more than a high school education. They explained the four week chronology of the symptoms — beginning with pain that built to excruciation and progressing to virtual paraplegia, all in the setting of fever and weight loss. In that time, they had sought medical evaluation at two emergency rooms, only to be reassured and discharged. Red flags must have been absent or unrecognized — or perhaps the parents, young and ineloquent as they were, were dismissed by a system that is more easily navigated by the privileged. Hunter went for an MRI, STAT.

Part Four

By the second morning, breastfeeding was still not going well. The baby’s weight had dropped again, albeit by less. He’s still not hungry, translated the face on the iPad, as Ahmed’s mother looked on expectantly. She still doesn’t get it, I thought. Ahmed’s sister was oblivious; she tried to engage me in a game of peek-a-boo.

Stupidly, I spoke louder and slower, as if this would make my English any less foreign. Perhaps the interpreter translated my irritation as well. Over the day, nurses, consultants, and members of our team visited her again and again and again (much to her daughter’s delight), to reinforce the teaching. Each time, she indicated that she understood and had no questions. Each time, my voice dripped with increasing condescension. The thinness of my commitment to patience, to progressive values and to cultural sensitivity was seemingly laid bare. Empty words, easily derailed.

Highlighting the cruelty was her consistently courteous and deferential nature. If only she had been resistant, argumentative, unreasonable — anything that might justify my arrogance. But she seemed to pay it no mind. I wore a white coat and I was a man — it was to be expected. It was the appropriate order of things.

Part Five

The MRI images were uploaded piecemeal just after signing out to the night shift. An enormous tumor had grown in Hunter’s retroperitoneum, extending to — and seemingly into — his spinal cord. Hunter had been transferred to the post-anesthesia care unit (PACU), still under the sedation from his MRI. Neurosurgery, pediatric oncology, and anesthesiology were called. Neurosurgery recommended immediate laminectomy to relieve the cord compression; they would meet us and the parents in the PACU, just yards away from the operating rooms where a suite was being prepared. Before that, there was the matter of telling the parents. They would be the last to find out.

The sight of a human being crumpling is not one easily forgotten. Her hand moves, not to her chest — she is not yet heartbroken — but to her abdomen, where she carried Hunter for nine months. Her eyes grow distant and wide all at once, and she chokes and gasps. Then the floor opens up, and gravity pulls her down. She falls to her knees. She crumples like paper and weeps.

We walked the parents down to the PACU, where a surgeon rapidly earned their trust and consent. Hunter remained sedated on a stretcher, his brow dotted by his parents’ tears. Then he went into surgery.

Part Six

By the third morning, Ahmed’s weight had finally ticked up, and I went to offer words of encouragement. In their hospital room, Ahmed’s sister beamed at my entry and tugged at my pant leg. She and her mother were wearing the same garments today that they wore yesterday, and on the day prior. On the table, a breakfast tray was largely untouched. The eggs and pancakes were exotic, the bacon was a religious taboo. Instead, they had subsisted from a foil wrapped plate of more familiar foods, brought in by her husband during his brief visit between jobs. Ahmed’s mother and sister had not left this hospital room in three days. Beyond the door were unfamiliar white faces, who spoke unfamiliar words, who ate unfamiliar foods, who wore unfamiliar clothes, who lived unfamiliar lives in an unfamiliar world.

The weight of my own ignorance and blindness sank in my gut. How little I knew about this woman, even though she was, for all intents and purposes, our real patient. I had waited three days to learn that she was even younger than I was, that she had been in the United States for just a few months, that she had married at eighteen to a man more than a decade her senior. I had waited three days to learn her three-year-old daughter’s name (Maya). I wanted to apologize for my impatience, but the words felt feeble and inadequate. I offered to take her daughter to the playroom, so that she might have a break from the toddler’s relentless energy.

Half an hour later, little Maya returned to her mother triumphant, regaling her with what I can only assume was a retelling of her voyage onto the unit — the faces of nurses and doctors, with whom she exchanged waves and high-fives, the vibrant colors of an enormous fish tank, the room with a seemingly endless supply of toys.

For the first time in three days, Ahmed’s mother smiled.

A year later, I met Hunter again as an outpatient. His tumor responded dramatically to chemotherapy, shrinking enough to make surgical excision possible. Miraculously, he had no lasting neurologic deficits, and he nimbly and idly rolled about on the exam table, eager to leave the clinic and get back to his summer vacation.

I hadn’t seen him since the day after his surgery, in the pediatric intensive care unit, where he stared blankly and silently ahead. Now, he looked right at me and grinned. Life blazed in his eyes. I asked what his plans were.

I’m going fishing.

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.

Ajay Koti Ajay Koti (17 Posts)

Columnist and in-Training Staff Member

Morsani College of Medicine at the University of South Florida

Ajay is a pediatric resident and a Class of 2017 graduate of the SELECT MD 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 will be specializing in pediatrics, with a particular interest in child maltreatment.

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.