Building Trust after a History of Systemic Abuse

By Naeemah A. Munir, MPH

A physician draws blood during the Tuskegee Syphilis Experiment, c. 1953

I. Blood Transfusion

As the clock approached noon in the internal medicine resident workroom at Hillcrest Hospital, I eagerly awaited to hear a stimulating lunch talk, and to enjoy the free food!  Before lunch, my intern asked if I wanted to observe him consent a patient for blood transfusion. Although I wasn’t directly following the patient, I joined my intern for the consent.

A typical consenting process may take 1-5 minutes, but this was not a typical patient interaction.  The patient was in his mid-60s, with stage-4 colon cancer, and had been  transferred from a skilled nursing facility (SNF) to the emergency department for an upper respiratory infection.  The results of the respiratory pathogen nucleic acid amplification test indicated that the patient had a parainfluenza infection that was spread by droplets during coughing or sneezing, and thus was placed on droplet isolation precautions.  He was confined to a single bed, enclosed by glass doors, and healthcare workers were required to wear gowns and masks upon entry to his room.

During the consent process, the patient began to express his concerns regarding his hospital stay and questioned his placement in confinement. My intern patiently and empathetically addressed the patient’s concerns, which mainly surrounded his placement in  a SNF after being in confinement.  As a 3rd year student, I quietly stood in the corner and observed the 30 minute tense conversation.  From my observations, the patient felt trapped, caged, like he was being experimented on; he was not aware that his infection required this level of confinement.

After my intern had addressed his concerns and educated him on the plan of care, we reflected on the encounter and thought of ways to ensure that the patient felt cared for and aware of the continually evolving plan of care and discharge placement.  I concluded that the patient had developed a mistrust of everyone involved, healthcare providers as well the healthcare system in general.

The patient’s terminal condition, lack of patient autonomy during droplet precautions, and the rapid progression of care definitely contributed to the patient’s apprehension.  However, although we aren’t certain that race played a role in this scenario, we would be remiss not to acknowledge the history of deceit and experimentation that certain populations have experienced. The patient was African American.

II. Beyond Tuskegee

“It is a mistake to attribute African Americans’ medical reluctance to simple fear generated by Tuskegee Syphilis Study, because this study is not an aberration that single-handedly transformed African American perceptions of the health-care system.  The study is part of a pattern of experimental abuse, and many African Americans understand it as such, because a rich oral tradition has sustained remembrances of pain, abuse, and humiliation at the hands of physicians.” (1)   

Everyone knows about Tuskegee, right?  You may have learned about it during a medical humanities class in college or if you conducted human subjects research and paid attention to the online CITI training.  But in medical school, we do not have any formal training on the topic or other instances of unethical coercion of physicians; nor do we learn how the rippling effects of this recent history influence our relationships with patients of color.

I recently learned more about the Tuskegee/Syphilis Experiment, when I was reading Medical Apartheid by Harriet Washington.  The book provides a detailed historical account of the interaction of the health care delivery system and people of color.  Before Tuskegee, during the antebellum period, Black slaves were used as clinical material for physician researchers.  They were sold, kidnapped, and murdered, and their graves exhumed to supply medical schools with clinical material to further medicine.  Physicians such as Dr. J. Marion Sims withheld known and available anesthetics from Black patients while he tested gynecological surgical procedures.  When Sims perfected the vesicovaginal fistula repair, he administered anesthetics to White women. (1)

The Tuskegee Syphilis Study is the longest and the most infamous- but hardly the worst- experimental abuse of African Americans. It has been eclipsed in both numbers and egregiousness by other abusive medical studies.” (1)  

Such acts include the eugenics nature of the development of Planned Parenthood, providing or coercing minority and low-income individuals to receive contraception in order to better the American population by decreasing the Black population.  In the 1970s, many Blacks believed birth control to be a government ploy to eradicate blacks, comparing it to genocide.  Or in the 1990s, when a research institute received ethics review approval from Johns Hopkins University to evaluate cheaper lead-abatement techniques in low-income, minority housing units. Although the information provided to parents implied that the study was protecting children from lead, the researchers encouraged landlords to rent known lead apartments to families with young children.  Some children’s blood-lead levels increased fourfold during the study and researchers withheld this information from parents. (1)

Why is this history relevant today and to this patient interaction?   Because, as Washington stated, these atrocities are a pattern.  The pattern existed in the mid 19th century, when a physician decided to amputate a slave girl’s leg without considering other conservative treatments, as though the decision to amputate should be weighed differently according to a person’s race and class. (1)   And the pattern exists today: Blacks are two- to four-times more likely to receive limb amputation compared to whites–independent of comorbidities and insurance status–and are less likely to receive revascularization or wound debridement prior to amputation. (2)

III. Medical Mistrust

The physician-patient relationship may be compromised when medical mistrust is present.  When patients have mistrust they may feel uncomfortable in health care settings, fearful of health care professionals, doubtful of the intentions of diagnosis and treatment.  Individuals from communities of color that have been historically marginalized typically exhibit higher rates of medical mistrust. Current research has demonstrated that the influence of medical mistrust materializes in perceptions of provider communication regarding medication adherence and uptake of preventive services such as vaccinations and cancer screenings.

Among diabetic patients, individuals with greater mistrust had worse perceptions of provider communication. (3)   Mistrust predicted lower medication adherence among African American men living with HIV. (4)   Black Americans are more likely to go to emergency departments than outpatient clinics for primary care, compared to White counterparts. Mistrust accounted for racial differences in primary  source of care (emergency department vs. primary care clinic) between African-Americans and whites.5   Medical mistrust has also been studied among college-aged, racial and ethnic minority women.  Women without established primary care physicians and women who reported difficulty communicating with providers had higher mistrust scores.  Additionally, women who had not received the HPV vaccine had higher rates of mistrust compared to vaccinated counterparts. (6)

IV. Conclusion

As I reflect upon this patient’s interaction and the medical history of experimentation and abuse, I wonder what role, if any, medical mistrust played. A recent meta-analysis demonstrated that the majority of quantitative studies found negative associations between higher rates of mistrust and lower colon cancer screenings rates.  Additionally, among African American men, fear of experimentation and intrusiveness of screening methods were unique themes regarding mistrust and colorectal cancer screening literature. (7)   Without trusting relationships between physician and patient, patient interactions can be very frustrating and may contribute to further bias among providers towards ‘difficult’ or non-adherent patients.  What are medical schools doing today to address the persistent ripples of our profession’s past?   Conclusions from the majority of mistrust literature call for cultural competency training and policies to create equitable and safe spaces for African-Americans.  But does our cultural humility training include historical medical mistrust and how it influences health care delivery and outcomes among minority populations? How can we regain the trust of those that we have wronged?

References
UCSD SNMA Black History Month Movie/Reading List

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Appreciate Recs

By Scott Nomura, MS4

StoriesInMedblogpic_pocketwatch.JPG

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

This past year, BEEPs and bzzzzs sometimes interrupted my talks with patients, the former from my pager and the latter from my watch, alerting me of a new text or email. To my chagrin, I could not silence my pager. But I often debated whether or not to put my watch to sleep: would the patient consider it disrespectful if I didn’t? Would it be best for my own privacy? Maybe it would startle someone and trigger an event? Ultimately, I chose not to touch it. And I’m glad I didn’t.

Watch: “Move! 3721 steps left”         //         Patient: 8 year old girl

“Lauren, what are you doing? Sit still, the doctor needs to listen to your heart.”
“Mommy, his watch told me to move!” Lauren continued to wiggle along the length of her bed, like a snake with a checkerboard grin, with little bits of applesauce peeking out.
“Lauren, please? You look like a worm.”
“It’s ok, I’m your pretty worm, Mommy…Mister, are there other watches like yours? I want one, but yours has cooties already.”
“Of course there are! Maybe your Mommy or Daddy can get you one for being so good?”
“Umm…I don’t know. Daddy used to be rich, but now he’s not.”
“What happened?”
“He married Mommy,” Lauren giggled.

Watch: “noReply@aamc.org”         //         Patient: 72 year old man with dementia

Current and recent 4th year medical students applying to residency programs know the nervous excitement when receiving an email from this sender. If the contents relay good news (an interview invite), the scramble to sign up for an interview date begins, and you might see a classmate run “to the bathroom,” phone in hand, with ERAS/Thalamus/other interview scheduling software open. If the contents are less ideal, there may just be a quick glance at the message, a pause, then a slow slide of the smartphone out of sight. Mr. R noticed me in this situation, and though he usually spoke off-topic on account of his dementia, this time he shouted a perfectly-timed statement:

“THE MICROSCOPE WAS INVENTED BEFORE THE TELESCOPE!”

After a quick bedside Wiki search, I was astonished to find that most historical accounts do agree that the microscope was first built in 1595, while the first telescope was invented in 1608.

“How weird,” Mr. R’s neighbor said from a nearby bed. And with all the cosmos towering above mankind, it is interesting that minuscule building blocks may have attracted our magnified eyes first. Yet the more the fact stewed in my mind throughout the day, the less “weird” it seemed. Perhaps especially amongst medical students, minds can get lost in minute details and forget the proverbial big picture: the well-being of both the patient and themselves. Medical school is a satisfying time of exponential growth but can also be constricting at times, a simultaneously expanding and collapsing universe. With so much to learn, it’s easy to forget about life outside of medicine if not for gentle reminders like the outburst from Mr. R. I thanked him for helping me remember what was important, hoping he had enough clarity to receive the gratitude. As I walked away, I could faintly hear once more, “How weird.”

Watch: “Incoming call: Mom”         //         Patient: 62 year old man, waiting for hospice

This patient noticed I ignored my Mom’s call while our team talked to him and later expressed his displeasure. As a former writer, he addressed this issue with a poem about his own relationship with his mother. With his permission, part of it is shared below:

“…I always hung up saying, ‘I’ve got to go, I’ve got to go, I’ve got to go.’
Until finally the place to go was home,
And face the face I had disowned, thrown
Away to ‘To-do’s’ of tomorrow,
‘I love you,’ ‘Happy Mother’s Day,’ ‘Are you okay,’ all delayed.

You were there for my first steps,
I should have been there for your last,
To catch you before you collapsed
Under the wait, too much to bear
Atlas, at last time to rest.

I filled a fountain with liquid lament
Collecting, cradling pennies for my wish
Of connecting once more by cord to you.
I would give it all back, for one minute.
Please, to amend my one regret?

Take my arms so that I may feel your embrace,
Take my eyes so that my tears can flow freely,
Take my ears so that you may hear, ‘I miss you’
And leave me deaf to ignore those words,
‘Darling, I have to go.’”

A Case Report

By Jordan Stone, MS4

Background: During medical school, many students conduct clinical research studies involving human subjects. These projects often emerge from powerful visions of a better way to deliver care, and each vision is itself an engine propelling the unemotional, tedious labor performed in its service. Done assiduously, the day-to-day work draws out a familiar pattern of symptoms. To spend prolonged periods turning medical records into workable data, for example, entails pain behind the eyes, a headache encircling the forehead, a bridge of ache across the wrists, progressively poorer posture, and, if one is not judicious, a Spotify “Discover Weekly” dominated by “research music” (this is perhaps the most enduring of the symptoms described). In this author’s experience, the young clinical researcher develops two identities. One is the objective, dispassionate repeater of tasks; the other, the passionate, emotional humanist glimpsing the forest beyond the trees. Much has been written about the latter. Less is recorded, however, on the emotional dimensions of day-to-day clinical research.

Purpose: To explore how it feels to be a young medical student conducting clinical research about very sick patients in challenging clinical and life circumstances.

Methods: Review the charts of 250 patients diagnosed with gynecologic cancers, that is, cancers of the uterus, ovaries, and other organs along the reproductive tract. Note that these patients’ tumors all underwent molecular profiling, where the tumor is analyzed for meaningful changes in the tumor DNA. These changes enable the tumor to grow like a wild vine or to invade far-flung corners of the body. They are also targets for new drugs, and that is the true purpose of the molecular profile, to match new drugs to critical DNA changes.

Start with bread and butter data gathering — name, date of birth, sex, insurance coverage. All in the medical record, all neatly templated on the same page. Reflexively click on this page as soon as the patient’s chart opens. Document race; wonder what to do when it’s documented as “Other”; ponder the disappointing lack of specificity in amalgams like “Asian/Pacific Islander”, or “White, Non-Hispanic”. Smirk when you find a 70-year old patient who shares your birthday.

Open the chart of a deceased patient—a pop-up message asks if you are sure you want to open the chart of this patient, as they are deceased. Notice the background color of this patient’s chart interface is a much lighter shade of gray than charts of the living. Document the patient’s birthday, feel a pit form when you type the year, “1987”. Take off your headphones, go to the bathroom, wash your hands, come back, put your headphones on, click hurriedly through her chart. Open a new patient. Piece together from years of clinic notes the number of distinct chemotherapeutics she’s received. Balk when you arrive at 12. Recount them—13, actually. Gloss over the side effects: “nausea refractory to several medications”, “profound fatigue”, “depressed about hair loss”. You do not have a column in your spreadsheet for these—no sense in reviewing them. Catch yourself reading about a patient admitted 8 times in 4 weeks for obstructed bowels. Recall, with shame, that the 2.5 days you spent in the hospital for appendicitis felt like an eternity. Silently thank an OBGYN resident for documenting all of another patient’s discreet chemotherapy cycles in a single line of clinic note text.

Marvel at your own efficiency—now, you can parse 10 paragraphs of a GYN Oncology clinic note to fill 5 spreadsheet cells in under 2 minutes. Initially read notes from Social Workers, Palliative Care, Hospice, then begin to filter them out when they prove hollow for the purposes of your work. As time wears on, notice yourself disconnecting from the patient’s narrative altogether as you process each chart down to bones and repackage it into neat spreadsheet rows.

Find the molecular profile report for each patient—some have undergone the process several times, you learn. Note when the report was issued, where in the body the tumor sample came from. Copy down the alphabet soup of DNA changes identified, the list of suggested experimental drugs printed in a box along the bottom like lottery numbers. Read the appended pages of text about each drug; realize their contents are unimportant to the experiment and stop reading them altogether for subsequent patients.

Develop a way of entering the alphabet soup and the drugs into Excel so they are easy to analyze. Reward this absolutely brilliant idea—to separate each DNA change or drug name in its own cell instead of clumping them together— with a handful of trail mix.  Sigh with relief and eat another handful of trail mix when you come across a report with only one or two DNA changes to transcribe into Excel. Visualize a graph charting the inverse relationship between number of DNA changes and ease of transcribing the report into Excel. Tuck your knees to your chest and ponder over another handful of trail max: many of these reports have only one or two DNA changes, zero or one experimental drugs recommended. Attempt to fathom the pits formed in the stomachs of patients receiving this news: we found no actionable DNA changes; no new drugs targeting your mutation; no highlighted clinical trials in the report. Reach into the bag of trail mix, feel around the empty bottom, take your headphones off, go to the bathroom, wash your hands again.

Results:

Sample Documentation from Patient Charts:

“…Though molecular profile suggests the patient may respond to this drug, the patient’s insurance denied coverage for the drug. Called insurance company last month per patient’s request and submitted formal appeal. Insurance company sent denial letter this week. Patient is devastated, is asking about costs of drug out of pocket. Patient given out-of-pocket estimate, requests information regarding additional financial aid. Patient to return to clinic next week to discuss options.”

“…Patient discontinued drug due to intolerable side effects.”

“…Discussed with patient absence of curative options at this juncture. After lengthy discussion, patient elects hospice.”

“…Patient reports she is hopeful, as she is a potential candidate for clinical trial”

“..Patient reports relief in hearing from clinical trial coordinator this week, continues to be hopeful about the trial’s potential. Return to clinic in one week.”

“…Patient without clinical or radiographic evidence of cancer following recent treatment with Drug A, no further treatment recommended at this time, return to clinic in 1 month.”

“…Patient’s daughter says she would like to take her mother home from the hospital for her 70th birthday. Inquires whether mother can eat a small slice of favorite cake in context of recurrent bowel obstructions. Risks and benefits discussed.”

Discussion: Recently, I sat down with a gynecologic oncologist during a residency interview, and we got to talking about the potential of these molecular profiles in women’s cancer care.

“Sure, molecular profiling opens up the door for a more personalized, targeted way to treat women’s cancers.” She folded her hands on the table and twisted her body toward the bookshelf. “But it can also offer patients false hope.”

She offered an example of a patient under her care, who underwent profiling of an advanced ovarian tumor. The profile turned up a dozen actionable mutations, and a drug tailored to one of the DNA changes in the report. .

“It was a lifeline for the patient. Really. She was ready for battle in my office that day. I recommended we start the new treatment quickly, assuming her insurance company covered it. A week later, the insurance company denied coverage for the treatment citing lack of evidence that it would provide appreciable benefit.”  I thought back to the walls of appended drug text I’d skipped over in the reports—‘unimportant to the experiment’.

And what about paying for the drug out of pocket?

“Would have bankrupted her.” Without the negotiating power of a large insurance company, patients paying out-of-pocket often bear the “sticker price” for a drug—that is, the price before any negotiated discount is applied. For new drugs, the cost to the patient could be financially ruinous.

“So the ethics are gray here. Is it right to stoke a cancer patient’s hopes with advanced diagnostic tools and the promise of better treatments, when we know we could fall short of delivering? When we know the insurance companies are reticent to give the green light?”

How about clinical trials? Those often bypass insurance companies altogether, and the molecular profiles highlight several potential trials tailored to a patient’s results.

“That’s another challenging issue, because clinical trials for women’s cancers are horribly underfunded.” To her point, funding for Phase 3 clinical trials—the last hurdle companies must jump to demonstrate that drugs are safe, effective, and at least no worse than what is already on the market—has plummeted for gynecologic cancer drugs since 2010.

“That’s what keeps me up at night—the knowledge that what stands in the way of my patients receiving the best care possible comes down to insufficient funding, not insufficient knowledge or clinical capability.”

We heard a knock on the door just then, signaling the end of the interview.

Conclusion: Research is meant to be an objective undertaking, strongest when the emotional biases of the researcher are tamped down to a minimum. This says nothing of the emotional experience young researchers may face in engaging with saddening, frustrating, or even traumatic subject matter. Predominantly, it is the heady process of developing a big research idea that draws on humanistic qualities like empathy or compassion for sustenance. But, the day-to-day mechanics of research should not be discounted in their potential to draw from young researchers a spring of emotional engagement with those subjects that make us most human. More research is required to depict the full scope of this experience.

 

A Fleeting Nostalgia for Art Appreciation

By Nicola Natsis, MS3

I encountered a pleasant surprise during my Surgery 401 orientation. The session discussed basic logistics of the surgical rotation and what we medical students could expect over the coming months. The room of 30 or so third-year medical students was buzzing with nervous excitement as we learned about Grand Rounds, 30-hour shift limits, and when to wear our white coats.

Finally, the PowerPoint slides reached the required reading: The Essentials of General Surgery and The Essentials of Surgical Specialties, both by Peter Lawrence.

The books were massive tomes, filled with hundreds of pages of detailed descriptions and diagrams. What I was most excited to see on the screen in front of me, however, were two familiar Thomas Eakins paintings, serving as the cover art for these required texts: The Gross Clinic and The Agnew Clinic. I remembered both fondly from my time at Cornell in an art history seminar.

My first reaction to seeing both paintings again for the first time in several years was that of quick joy in the recognition of title, painter, dates, and media, just as I had been trained in my former art history studies. I wondered if any of my classmates were familiar with these famous works, or noticed the cover art. I peeked around the room searching for eyes that were also twinkling at seeing the works, but did not find any. I found it interesting that both of these works had been chosen by the publisher, as they have had such unique significance in history.

Thomas Eakins, the artist, had a sordid past. He worked in Philadelphia in the late 19th century, at the time a center of intellectualism, science, and democracy in America . Eakins was captivated by the use of the human body as narrative and would often use anatomical dissections while teaching art to university students. However, he was met with resistance for his fondness of the male nude form. The general public at the time was more comfortable and familiar with the female nude and it had a greater acceptance for consumption as art. In this Gilded Age of America, males and females had unique gender spheres and society was tied to these constructs. Eakins was eventually fired from his position as an art professor.

The Gross Clinic was painted by Eakins in 1875. As I scanned the familiar image, I felt myself slip into art historian mode. The painting features Dr. Samuel Gross, an orthopedic surgeon with whom Eakins studied. Eakins wanted to present the magnificence of medicine to the general public through art. In the center of the painting is an obscured and foreshortened, faceless patient. Three men in formal suits make an incision on the lateral thigh as Gross, hand bloodied, looks off. To the left of Gross is a seated woman whose hands are clenched and clawed in front of her face. She appears to be reacting to the operation before her. The painting was rejected by The Centennial Exhibition — a major art showing at the time — because it was thought to be too gruesome. It was instead displayed in a first aid clinic.

The Agnew Clinic was painted by Eakins in 1889, commissioned by Dr. Agnew’s students. It strikes me as so different from The Gross Clinic. While it also boasts a pride of science, reason, and intellectualism, Agnew stands as a singular figure in the image – glowing white as if he is the room’s light source. His gloves are unbloodied and his white smock is clean. He represents knowledge, reason, and purity. He is is a stark juxtaposition to the representation of Dr. Gross. The men around the operating table are also dressed in white. In this operating theater, we as viewers of the painting are sitting in on a mastectomy. An incision is being made on the breast which is furthest from us, hiding it away from our view. We see the patient’s exposed right breast. Her face is visible, though shadowed. A nurse looks on, the only conscious woman in the room, as if protecting the motionless and nude patient from the gaze of the many men eagerly seeking a better view. She is a chaperone and is stoic compared to the grimacing female in The Gross Clinic.

I wonder if the publisher of these two Lawrence texts knew anything about Eakins, or Dr. Gross, or Dr. Agnew, or the art and American history that surrounded the creation of these two paintings. I wonder if they just saw the paintings as representations of surgery, and therefore found them an apt fit for a text on surgery. I wondered if any of my classmates appreciated either painting before quickly jotting down the text titles for later purchase on Amazon.

As a medical student who studied humanities, I can sometimes feel separate from my classmates who focused their efforts solely in the sciences. The experience of being reacquainted with these images made me grateful for my different perspective and ability to find enjoyment in topics outside of the sciences, but also made me aware of my differences. The few moments of diving back into my humanities past felt refreshing and also isolating – like a fleeting nostalgia.

Wordplay

By Nicky Herrick, MS4

Vanilla_ice_cream2

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

My first day of medicine wards my resident assigned me to Ms. R. “She’ll be a great learning case, autoimmune hepatitis on the transplant list. But, she’s Spanish speaking only, is that okay?”

I was working on my Spanish, Ms. R on her English, but neither of us were very good yet. I used a translator for the daily medical questions, but we practiced with each other on everything else

“Mi hija esta visitando hoy,” she said one Saturday morning with a big smile. We laughed together when one morning I called her liver helado (ice cream) instead of higado.

As my weeks caring for her progressed, I discovered her life outside of the hospital – she was a loving mother, sister, and wife. I met her husband, daughter, three sisters, and two brothers-in-law. Her husband told me how they spend half the year in Alaska, making their living on a fishing boat. These were her precious few months at home, and Ms. R was desperate to get out of the hospital and spend time with her 15-year-old daughter.

I relished my new responsibility as the primary contact between Ms. R and her family. I finally felt like I was the doctor. She and her family listened attentively when I explained what our next steps were, how the new medication worked, and what our long-term goals would be. We shared in the joy when she made progress and maintained hope when she had a bad day.

I will never forget Ms. R and her family, but it was her husband, Mr. R, who taught me the most important thing I learned in medical school.

My fourth week caring for Ms. R, she decompensated. Two days prior we were discharge planning, then suddenly she was encephalopathic, febrile, and maxed out on antibiotics. I talked to Mr. R about how we were looking for a source for her infection and trying to make her strong enough for transplant.

He looked down, took a breath, and quietly asked, “She isn’t strong enough to wait for a transplant at home?”. I explained how it was safer for her in the hospital and that we still had a lot of progress to make before she would be strong enough to go home.

I went back to check on Ms. R later that afternoon. Her husband was there, but not in his normal chair next to her bed. He was holding her leg mimicking the exercises the physical therapist had performed the day before. The realization hit me that just a few hours prior I had explained to him that she needed to get stronger before she could go home. Now here he was, doing what he could to help her get stronger.

Mr. R taught me more about the power of our words in that moment than a lifetime of reading could have. As physicians, patients look to us for guidance and support, and I hadn’t fully appreciated until then that they often they take what we say at face value. When I said she needed to get stronger, I meant everything from finding the source of and treating her infection, to improving her mental status, to removing the Foley catheter, and finally getting her strong enough to get out of bed. But, what I said was ‘stronger’ and to Mr. R that meant to make her muscles stronger, and that was something he could help with.  My interaction with Mr. R taught me first hand that what we choose to say, and how we say it, matters.

The moment was equally beautiful and heartbreaking, and moved me to my core (the next few minutes were spent in the stairwell crying). I collected myself and went back to thank Mr. R for his help with her physical therapy and talked to him in more detail about the many hurdles that she was facing.

After 4 weeks caring for Ms. R, she was transferred to the ICU the day I was off-service taking my Shelf exam. Three days later, surrounded by her family, Ms. R died peacefully.

I always smile and think of her when I see an Alaska license plate or yet again mistakenly ask a patient about a painful helado. Though her case was emotionally and mentally challenging, it was a privilege taking care of and knowing Ms. R and her family.

The New Kid

By Daniel Kronenberg, MS4

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

Anyone who has been a third year medical student will tell you how difficult it can be. Very little in the first two years of medical school can prepare you for the long hours, finding energy to study after coming home, not knowing much about the specialty  you are rotating through, not understanding how you are evaluated, finding time to eat. Did I mention not knowing anything?

Being a fourth-year sub-intern adds new challenges. After a month or two on the wards, you may have grown comfortable with the workflow and may even know a thing or two about your specialty. However, “with great power [kinda] comes great[er] responsibility.” You are now expected to function at the level of an intern, managing the care of your own personal group of patients. You must follow up on labs, images, culture sensitivities, outside hospital records. You might hold the consult pager for your service and be “first-to-call” for the patients you are assigned.

Now imagine being a sub-intern on an away rotation. Suddenly you are not only painfully inept and often ineffectual in your nascent career choice. Now you don’t even know where the bathrooms are. No longer do the nurses vaguely remember you and let you know how your patients did overnight. Imagine you just stumbled through rapid-fire rounds and you have been assigned to a case starting in 15 minutes. How will you get scrubs before the case? Where can you change? Where are the ORs?

These are the kinds of thoughts that swirled in my head long before the plane ride. Maybe it was not the best mindset to have going into a new rotation but what medical student doesn’t perseverate about the details? My mentor back home once said, “Any surgeon who isn’t a little worried all the time is probably a sociopath.”

Yet what I found during my sojourn away from my medical school for nearly five weeks, was actually very reminiscent of home.

Day one on Monday morning was a “morbidity and mortality” report-style grand rounds. Assembled in the conference room were faculty and residents of various years. There were also three other visiting fourth-year medical students. I smiled and made pleasantries but the blood left my hands and a lump hung in my throat. We were asked to stand and introduce ourselves to the group. They spoke the names of impressive home institutions. The carnage of a Mad Max-like battle royale between us played out in my head. It didn’t end well for me. The girl from the prestigious school in Philadelphia was too quick with her flamethrower.

I shook it off and introduced myself. The residents came to meet us after the meeting. They were an intimidating but smiling bunch. “Welcome! Welcome! We’ll talk more later in the week about expectations. You all have cases to go to,” one of the chiefs said. Then they showed us where to get scrubs, where to change and where the ORs were.

From then on, the rotation played out much like my sub-internship back home. I woke up at 4:00 every morning and I left the hospital at 7:00 in the evening. I read up on my patients, and studied for clinics. I assisted in the OR, and sewed up the skin when we were done.  To be sure, I got lost. A lot. However, I eventually found the bathrooms. Some of the nurses started to vaguely recognize my face. I found the break room where the free peanut butter-and-jelly sandwiches were and scarfed them down in-between marathon cases. I held my patients’ hands when I introduced myself in pre-op, and apologized for tapping on their sore bellies days later on the floor.

I was surprised how quickly I began to feel at home. The faculty didn’t seem interested in trying to break me down to make their own students look good. They wanted to teach me and help me grow, even though I might not end up as “one of them.” The residents were familiar with feeling foreign on away rotations. They strove to set me up for success and bought me lunch on a number of occasions. They spoke often of why they love their city and why I would too. And instead of chain-sawing each other’s heads off, the other sub-interns and I grew close. We shared cases and secrets about attending idiosyncrasies. We spent time together outside of work, joking about the arduous journey ahead and confessing how impressed and humbled we were with one another.

In the end are we just interchangeable parts, like Lego blocks? Could we be happy at any number of places? Maybe, I thought, as the sun came up over the last day of the rotation. I found myself falling for the place. Somehow it made me feel guilty: my medical school had ushered me in behind the curtain into the secret world of medicine. Could I simply pick up and move elsewhere? What about all the sweat, blood and tears–not all my own–that had gone into making me a fourth-year medical student?\

I thought long about this. Perhaps the answer is that if you work hard, and feel passionate about what you are doing and the people you do it for, “home” can be anywhere. My first away rotation was instrumental for a number of reasons and I did learn some truths. I got to meet very inspirational people and I was exposed to procedures I had not seen before. Most importantly, it took a lot of the fear out of the prospect of moving away somewhere unfamiliar  for residency at the end of medical school.

As fate would have it, a couple days after the rotation ended, a total solar eclipse would be passing through the region I was staying. The best man at my upcoming wedding had recently started graduate school at a university literally within the path of totality. I joined him, his classmates, and nearly 500 students and families stretched on picnic blankets that bright morning. People lounged and gazed upward, enthralled with the slowly disappearing sun.

As totality neared, a pall swept over the now silent, grassy quad. The daylight faded, the crickets began to chirp, and the temperature dropped 20 degrees. My heart was pounding as the last sliver of sun was obscured. We threw off our eclipse-viewing glasses nearly in unison. I heard a collective gasp from the crowd. It took a moment for my eyes to adjust but once they did, stars and planets replaced blue sky and white clouds.

And then I saw it. Where the sun once was in the morning sky, was a solid black disc. Surrounding the eclipse was the scintillating, white corona, the sun’s normally invisible atmosphere and fiery bursts of solar flares. In that single minute I was overcome with both the awe and eeriness of an eclipse. I couldn’t help but think that shimmering black hole in the sky was a metaphor for the future: full of uncertainty, and potential beauty, until we experience it for ourselves, it will always be a mystery.

Killer Heels

By Lillia Cherkasskiy, MS4

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Alex was about 5’2’’, including her endless parade of dangerous-looking heels, which she drove determinately into the floors of the busy hospital where she was a resident. I never saw her take the elevator, even when she needed to get to the 10th floor in 2 minutes and we were walking with a group of colleagues, including some with legs as long as she was tall.

As a team leader, she was stern but fair. Always the first person to arrive at the hospital and the last to leave, she expected nothing less from the rest of us. Her pride in her work and leadership was palpable and I could tell that she had worked hard to get to where she was.

Over time, I learned that she immigrated to the US as a teenager with her parents, who poured their last dollars into getting her the education that would support her ambitions to be a world-class doctor. She worked her way through college and medical school as well, mostly at minimum wage jobs, and graduated nearly debt-free.

I saw her as a competent and accomplished leader who always put her patients first. Sometimes, however, I could see how some of her patients viewed her, and it broke my heart. To them, she was Dr. Ethnic Barbie, fiercely stomping around the hospital in her too-tall heels and her too-long white coat with elbows that did not quite bend enough to get the job done.

Day after day, I watched patients talk down to her. They asked her to go get their “real” doctor, to fill their water glasses, and to give them a sponge bath. She would laugh as if they had made a funny joke and then proceed to treat them. As far as I could tell, she never became upset or said a single unkind word about any of her patients. Only a few times over the whole month did I see her shoulders start to slump after particularly vicious onslaughts of sexism and racism. I cannot begin to imagine the endless compassion she must have for her patients that gives her the strength to treat them all with such kindness. As I move through my training, I often find myself wondering what she would do if she were in my shoes.

Her first order of business would surely be trading my Dansko’s for some killer heels.