When my family saw me painstakingly hand-placing individual sprinkles on the apices of buttercream rosettes at age 15, I justified this obsessive behavior by telling them, “I’m just practicing precision for the day when I get to inject into people’s faces.”
Flash forward a decade and many finished baked goods later, I was spending a busy spring day in Mohs clinic. “Hey, Mackenzie, can you numb the patient in room six?” my attending asked as she quickly walked out of one patient room and into the next. As usual, the morning schedule was packed. The difference on that Friday morning, however, was that the resident was not present. Only the attending, the fellow and I were assigned to Mohs clinic. Today, I would act like a resident. Today, I would finally get to practice the clinical precision I had practiced while baking in the kitchen for the past decade.
In the usual fashion, I walked into room six and introduced myself as a fourth-year medical student with the dermatology team. Looking at the Mohs flowsheet, I put on gloves and grabbed the syringe of epinephrine and lidocaine. I saw “left inner canthus nodular basal cell carcinoma” written in the diagnosis box. Turning around to smile at the patient, I saw that a purple circle drawn around a pearly pink papule confirmed this location. Just act cool, I thought to myself as I pulled a pair of size small gloves out of the box on the wall. The patient looked at the syringe in my hand. “Don’t tell me this isn’t going to hurt that bad because that’s what they told me when they biopsied it. It was awful,” she said. Before I told her to close her eyes, she glanced at the name tag hanging on my scrub pocket. “You are the Pooles’ daughter! My husband went to high school with your grandma,” she said.
Shocked, I confirmed my identity and verified that she was also raised and lived in the same small, Southern Illinois town where much of my extended family still lives. It so happened that on the day before her scheduled procedure, she had visited her local hair salon and told her stylist that she was traveling to St. Louis University Hospital to have a skin cancer removed. Her stylist, an older woman who knows my extended family well, told her, “You know, that’s where Mackenzie Poole goes to medical school.” I was thankful that the coincidence had briefly made me forget how nervous I was to inject anesthetic near the patient’s eye. After all, I had only numbed in the inner canthus one other time before — and that was earlier that same morning.
I was born and raised in a medically underserved rural area. It is common for patients who live in the small towns of Southern Illinois and Southeast Missouri to make the two-hour drive to Saint Louis in order to have procedures done by specialists. During my inpatient rotations, I had discussed my shared hometown multiple times and used this commonality to bond with many patients who had been transferred to Saint Louis University Hospital for a higher level of care. However, this situation hit me differently as I knew that the quality of my performance — the performance of a newly acquired skill — would be reported back to others in my local community. This community is filled with people who, upon seeing my mother at the grocery store or at a local event, would repeatedly ask her if I plan to return home someday as a physician.
About an hour later, I was sitting in the pathology lab with the attending surgeon and the Mohs fellow, looking through a microscope at the slides that belonged to the patient. The margins were clear after only one stage. After a review of the defect and a brief discussion, we decided that due to the location and surrounding skin laxity in the area, the simplest, most cosmetically-conscious repair method would be with a purse string suture. I told our clinic nurse that we were ready to close in room six.
Rushing between rooms in the hallway, the fellow stopped me. “Hey, Mackenzie, do you want to throw the purse string in room six?” he asked. I remembered how earlier that morning, our attending told him that she had taught me how to do a purse string only two days earlier. But that one was on the chest! I silently thought to myself, as I internally compared the two anatomical locations. My heart jumped with excitement, pride, and inevitable fear at this new opportunity. “You should only have to undermine a little,” he added. “I would start with the bite that is perpendicular to her eye and work your way around from there.” Naturally, I agreed and walked into room six. Face it until you make it. I pulled out a pair of size 6½ sterile gloves and prepared to complete the purse string as though I had done dozens of these repairs in the past.
The patient and I spoke casually as I lifted the skin of her medial eyelid, with pick-ups in my left hand and scissors placed just under her epidermis in my right hand. I inhaled, steadied my wrist, and undermined directly towards her lacrimal duct. As I began to suture, I forced myself to remain calm when her loose eyelid skin did not want to evert with my needle angled for the first bite. Suddenly, I had a memory from the previous Christmas when my grandma was watching me stretch and press a loaf of focaccia bread dough. “You always amaze me with your patience,” she noted. I smiled and replied, “I like to think it helps me improve my dexterity.” She laughed, “I never thought about how baking could help you build medical skills.” I have known for years that my attention to detail is an artful expression that I have manifested in multiple aspects of my life. If nothing else could help me through the procedure, perhaps tedious baking projects throughout the last decade has taught me the art of patience.
Forced to move myself around the chair with each tiny bite to not break the sterile field, I remembered that same patience. I remembered the patience I had harnessed in the trauma bay a year earlier when I repaired an eight-inch combined forehead and scalp laceration on a female patient one year younger than me. With every bite, I carefully removed glass with my pick-ups and weaved the suture between individual hairs. With each turn of the needle, my grounding mantra rang in my ears: Pretend that you are decorating a cake. Be patient. Face it until you make it.
“Can you try to open your eyes for me?” I asked the patient in room six after I had cut the knot flush with the skin. She opened her eyes, and to my great relief, she stated that her vision was fine. For every ounce of me that was excited to have successfully done a subcutaneous repair in the inner canthus, I equally feared that she would live the rest of her life feeling like she never looked the same again. I could see that the symmetry of her eyes and nose were preserved. The repair had gone well. She thanked me, and asked if I planned to return to our underserved hometown area to practice someday. I explained that only time will tell and that I have not ruled out that possibility, but my anxiety increased.
Two weeks later, I found myself whipping cream. With a hand mixer in my left hand, I was using a rubber spatula in my right hand to scrape the edges of the bowl of my running stand mixer. Moments earlier, I had been simultaneously feeling irritated about how long this baking project took and also felt guilty for creating a dessert instead of revising a manuscript. Out of the corner of my eye, I saw that my grandma was calling me. After I finished constructing what turned out to be a tedious strawberry no-bake cheesecake pie, I returned the call only to hear her say, “I went to the hair salon today.” My heart raced with the same anxious excitement it had in Mohs clinic two weeks earlier, because I knew where this conversation was going.
She explained how her stylist had told her that I had sewn up her friend’s surgery site beside her eye. “The hair stylist told me that she saw the scar,” my grandma said. I held my breath. “She said that it looks perfect and that the procedure went perfectly as well. Her home dermatologist also said that the scar is healing wonderfully at a follow-up appointment last week,” my grandma added. “When she told me all of this, I have to say that I was grinning ear-to-ear,” she continued. “I am so proud to say that my friends are talking about my granddaughter, a future doctor!” I finally exhaled a sigh of relief, a sigh that had been with me ever since I took off my gloves after that repair. A repair so simple to trainees further along in their careers, but a repair that helped me realize that perhaps those hours I had previously spent perfecting baked creations could translate into a practice that would allow me to help patients feel like they belonged in their own skin after undergoing such a procedure.
Perhaps the crux of medical training is becoming comfortable with the uncomfortable. After relating the intricacies of baking to “fixing faces” for nearly a decade, I had finally done it; I had successfully fixed a face in such a way that the patient felt like it represented her pre-surgical self. At that moment, it all came full circle. While hand-placing strawberry slices in a geometric pattern around piped whipped cream rosettes atop of my strawberry, no-bake, cheesecake pie, I reflected on how the art of becoming a physician includes much more than the facts that we study.
I will continue to face it and bake it until I make it.
Author’s Note: Patient permission was obtained prior to sharing this story.