IF EVERY YEAR OF MY LIFE were like the first year of medical school, my tombstone would read, “She studied.” Seeing the body in its parts seemed to obliterate the rest of the body’s meaning, but studying hard enough to keep up in medical school seemed to obliterate the entire world. As I slipped out of contact with friends, my old life began to feel impossibly far away. Caitlin commented that I sounded “very professional” when I would leave a message on her voice mail. Whoever I had been before was gone, but I wasn’t anything like a doctor yet. I was just a shade of a woman, struggling to memorize a thousand facts.
St. Vincent’s was my relief. I would make it to the clinic once a week, or once every two weeks. At St. Vincent’s, I could lose myself in blissful concentration on another person’s problems.
As the older student had promised on my first day at the clinic, many of these problems were complicated. I saw a patient with heart failure who could not walk half a block without gasping for breath. I saw people with schizophrenia and bipolar disorder, and sat stunned as they described the changes in their thinking that the mental illness brought. I learned to carefully check the feet of every diabetic patient for the sores that they might not notice after their skin had become numb from the damage of the disease.
Many St. Vincent’s patients were still suffering from the effects of Hurricane Ike, even though the storm was now a year behind us. One woman with an anxiety disorder told me that her panic attacks were more frequent since she’d been forced to move into a crowded house with her cousins. Another patient told my friend that her asthma was worse because there was a boat in her house. The boat had crashed through a wall during the flood, and she was still living in the moldy wreckage.
One Saturday afternoon, I cared for a homeless man who walked into the examination room with three plastic bags full of belongings. His name was Mr. Tran, and he had diabetes. I wanted to know if his medications were working, but what he really wanted to know was why I wasn’t married.
“No ring?” he commented.
“No sir,” I said. “Do you ever get tingling in your hands and feet?”
“Yes I do, in my toes,” he said. “But you are so lovely.”
“How long has that been going on?” I asked.
“A long time,” he said. “You know, I am not married either.”
“Okay. A long time—do you mean weeks, months, years?”
“Oh, for years,” he answered. “I’m homeless, but I am very strong. I’m a gentleman.” He smiled, leaning back against the wall of the exam room. It was a truly joyful smile.
“I’m sure you are, sir,” I said. “I’m going to check your blood sugar now.”
“Okay, well, think it over,” he said.
“You’re going to feel a little sting in this finger when the needle goes in,” I said.
By that time, I had checked the blood sugar on a dozen patients, so I felt comfortable with the procedure. I cleaned his finger with an alcohol swab, and pressed a tiny needle into the fleshy part of the fingertip. With my gloved hand, I pressed a bead of blood out of the puncture, then scooped that bead into a special strip that inserts it into the handheld glucometer. The glucometer gives a number—blood sugars under 120 are normal for someone who hasn’t eaten recently.
This time, the glucometer gave no number. It read, “Err.” So I tried again. When it said “Err” again, I excused myself to check with Katie, who was directing the clinic that day. She told me to try again with a different glucometer, which also gave an error message. Having pricked this man’s finger three times, we decided to draw blood for a hemoglobin A1c—a test that shows the average blood sugar level over the past three months—and leave it at that. We wouldn’t change his medications based on a single blood sugar reading, anyway.
So Mr. Tran gathered his plastic bags and left, smiling at me joyfully and asking me once again to consider his proposal. “We’ll see you back at clinic in three weeks,” I said.
After I left the clinic that afternoon, Katie called me on my cell phone. “Did you get a phone number for Mr. Tran?” she asked me. I hadn’t. I had assumed he didn’t have a phone because he was homeless—not a good assumption.
“Did his lab results come in already?” I asked.
“No,” she said. “It’s that glucometer. I checked with Dr. Beach, and he says it probably read ‘Error’ because Mr. Tran’s glucose was over 600.” A glucose level that high is an emergency. If we had caught it, we would have sent Mr. Tran to the ER at UTMB. But we missed it. Our supervising doctor hadn’t caught it because the glucose reading was an afterthought—something he’d reminded me to do after he had already seen the patient and signed his prescriptions.
Katie spent the afternoon calling anywhere she thought Mr. Tran might be—the Salvation Army shelter, the Our Daily Bread group that feeds the homeless, the Jesse Tree organization. Nobody knew where he was. Then she drove around the island looking for him, but she never found him.
When I imagined making mistakes in medicine, I always imagined something more dramatic—cutting through an artery in surgery, or making a wrong diagnosis. I didn’t imagine these pedestrian mistakes, like forgetting to report the results of a urine sample or forgetting to get a phone number. Even more so, I didn’t foresee that such mundane errors could cost my patients their lives. And, as it is with so many patients I have seen as a student, I don’t know what happened with Mr. Tran. I hope he found help.
ANATOMY ENDED WITH A BRUTAL multiple-choice exam and a lab practical. The only way to describe our studying before this test is to say that it was constant.
For the practical, we gathered in the anatomy lab, tense and silent. We each received a number, and walked to the tank with that number on it. At each tank, a structure in the body had been tagged with a colored pin. We had to name the structure, or its function, or answer another question about it. We had roughly one minute per tank, and then a buzzer would ring, signaling us to rotate to the next tank.
I moved from tank to tank at the buzzer, scribbling down answers for my exam. At one, I answered the question quickly and confidently, so I had a moment to glance up around the lab.
All was silent. By this time, the bodies were utterly dissected. Here and there across the clean stainless-steel surfaces of the lab, a human leg was strung up with its muscles flayed. On one tank, a dissected hand sat alone, its rose-colored nail polish still perfect. Another had a woman’s pelvis, split in half with a yellow pin stuck in the labia minora. Sawed-open heads stared out from sockets dissected down to show the tiny muscles that move the eye.
All of these were things that I could see, recognize, and name. And when I looked out over my classmates, I noticed that each of them was as haggard as I. We were pale from studying, with shadows under our eyes and shoulders slumped as we stared at the corpses before us. One woman’s brow was furrowed and her eyes were closed as if in pain. I could name that, too: it was suffering.
The buzzer sounded, and we moved as one group to the next cadaver.
THE DAY AFTER THE FINAL, I went to St. Vincent’s. I needed something good, something that made me feel like medicine was alive and human.
That something good came in the form of a fifty-five-year-old woman with high blood pressure. She worked in a hotel on the seawall, and shopped at the same grocery store I go to. She’d been sent to St. Vincent’s after doctors at a community health fair had noticed that her blood pressure was high. And she had spent two weeks worrying while she waited for her appointment.
“My father had high blood pressure, and he died of a heart attack,” she told me. “I’m terrified. I have kids myself. My son is at College of the Mainland, and I have a little grandbaby on the way.”
I took her history and found that her blood pressure was still high. I didn’t see any signs of advanced disease, though: her heart sounded fine, her feet and ankles were normal. Then I talked with the doctor, and listened as he slowly and calmly walked her through everything she needed to know: what hig
h blood pressure means, what the risks are, what she could do to reduce her blood pressure on her own, and how we would help treat it.
“Good job coming in,” he told her. “At this stage, we should be able to treat you and help prevent any heart problems.” I walked out with the doctor, and returned to the exam room with her prescription in my hand.
“Here you go,” I said.
“Where can I get it filled?” she asked.
“It should be four dollars at Walmart, so I’d go there,” I said.
And at that, she burst into tears. “Thank you so much,” she said. She touched my skinny wrist where it stuck out from the rolled-back sleeve of my short white coat. “God bless you.”
It was an ordinary problem, and the treatment was simple. I felt I had done so little. I knew so little—I wasn’t even sure I had passed my anatomy exam. But when this woman stood and reached out to hug me, I opened my arms.
* Edward C. Halperin, “The Poor, the Black, and the Marginalized as the Source of Cadavers in United States Anatomical Education,” Clinical Anatomy 20 (2007): 489–495.
† Jason E. Glenn, “Dehumanization, the Symbolic Gaze, and the Production of Biomedical Knowledge,” in Black Knowledges/Black Struggles: Essays in Critical Epistemology, ed. Jason R. Ambroise and Sabine Broeck (Liverpool, UK: Liverpool University Press, 2015), 112–144.
‡ Boulware et al., “Whole-Body Donation for Medical Science: A Population-Based Survey,” Clinical Anatomy 17, no. 7 (October 2004): 570–577.
CHAPTER 7
NOT ALL MY LEARNING HAPPENED AT ST. VINCENT’S, OF course. In the Practice of Medicine (POM) course, I was formally taught to do what a doctor actually does: physical exams, history taking, writing notes. I learned how to counsel people about cigarette smoking, when to call Child Protective Services, and why one shouldn’t have sex with her patients. (Answer: because it’s in the Hippocratic oath.) POM is a two-year course that begins the first week of medical school and lasts until we start on the wards in third year.
At St. Vincent’s, I had already learned a lot of the skills that were taught in POM. But POM was a protected space. There, I could do what a medical student really should: practice. Not on real patients. Not on poor people who were bewilderingly ill and had no other choice but to see a student. In POM, I could practice on well-paid actors from the Galveston community.
These actors are called “standardized patients” or “SPs,” and they learn to act out illness by script. Like the students, they learn what is proper in the physical exam and in history taking. And so, after each encounter with a student, the standardized patients would grade us on our skills.
Many of these encounters took place in an elaborate theater: a wing of our lecture-hall building that was designed to look like a clinic. There were cameras in each room, so that our professors could watch us interact with patients and—I happen to know—make fun of us.
Some of my friends from the Institute for the Medical Humanities had side jobs working as standardized patients. They had to put my name on a list of friends so that I wouldn’t ever walk into a fake clinic room and find them pretending to worry over a sick (fake) baby or trying to avoid disclosing a (fake) exposure to gonorrhea. But through them, I got the scoop on the SPs. Yes, they and our professors were laughing at us in the room with the video monitors. How could they not?
There was the student who had clearly been taught the “clinical pearl” that he must reach out to touch his patient if the patient is upset. He reached out and placed a comforting hand directly on one standardized patient’s inner thigh. There was the student who told one standardized patient that her vaginal discharge was “awesome, because we can totally treat that.” There were plenty who turned bright red at any mention of a vagina.
As second-year POM students, we saw not only SPs playing straightforward cases, but also what were euphemistically called “complicated cases.” Lots of the complicated cases had to do with sex, because medical students are a virginal bunch—at least in Texas. We’re great at studying. Really great! Not always so great at the rest of life. In the 1970s, they used to show pornography to medical students so they would have some idea of what was going on when patients described their sexual activity.
Other cases were just socially complicated. There was the patient addicted to pain medication, the delusional young mother who was deliberately making her child sick, and the pair of Uruguayan American brothers who tried desperately to convince me not to reveal to their imaginary father that he had pancreatic cancer. The brothers were wonderful. They screamed and shook their hands in the air, and one of them—for reasons I will never understand—had fake blood all over his forehead. (I assume it was fake.)
“In Uruguay,” he shouted, “it would be wrong to give him this terrible diagnosis!”
“You will kill him if you tell him!” his brother screamed.
In the feedback session afterward, the brother with the bloody forehead complimented me. “You were so calm!” he said. “I found it very challenging to scream at you.”
Each week, someone from my POM small group would venture to the fake clinic to see a complicated patient. Because we were the bilingual POM group—some more bilingual than others—our encounters were made even more complicated by the fact that they were in Spanish.
After the feedback session, the student would be given a DVD recording of their encounter, and our small group would watch it together. To watch yourself, as a second-year medical student, stammer and blush through a half-hour Spanish encounter with an actor trained to deceive you about the problems he is having with his erections, is an experience so acutely humiliating that it should properly be undertaken only with copious amounts of gin. In those afternoon sessions where we watched one another on video, I was grateful for the bonds that were growing between my classmates and me. We were all pretty awkward, and some of us were hilariously easy to shock. But at least we were kind to one another.
POM WAS ALSO LACED with “clinical encounters”: half-day sessions in which we poor inept junior students would shrug on our immaculate white coats and trot over to the hospital to meet up with an actual medical team. In these clinical encounters, we performed exams and took histories, but it was purely for our own education. Nothing we did actually contributed to patient care. This made the clinical encounters feel awkward: we were bothering a sick person with an exam that was, for them, unnecessary. Even so, patients were usually very generous with us.
I was seeing lots of patients at St. Vincent’s, but the hospital felt different. The first floor was still being repaired from Ike, and so it had been converted into a maze of temporary walkways past demolished spaces where industrial fans hummed and men in construction hats worked away. The UTMB hospital complex would be confusing under the best of circumstances. It seems to defy physics. You turn a corner and suddenly find yourself in a totally different building, and somehow—mysteriously—you cannot reenter the previous building from this floor.
No matter which of the entrances to this complex I started through, I immediately became lost. To make matters worse, we would be told to report not to a numbered room but “to the IMC” or “to the NICU” or “to the cardiac care unit.” I always felt embarrassed to admit how lost I was—I was in a white coat, right? I should know exactly where I’m going! When I finally found myself near where I was supposed to be, I would stand around looking panicked until somebody from the medical team took pity on me.
“POM student?” they would ask.
“Yes!” Thank god.
The clinical encounters were meant to get us a modicum of experience before we started our third-year hospital rotations. They also served the purpose of getting us excited about third year. At that time, anything seemed more exciting to me than another night of studying the sodium channels in the distal convoluted tubule of the kidney. So, the clinical encounters worked for me.
One of my very first encounters was on surgery. I was invited into the operating room for
an hour to observe while a senior surgeon removed a patient’s gallbladder. I got there after the surgery had begun, so I never saw the patient awake. But as soon as I entered the operating room—masked but unscrubbed, because I wouldn’t be allowed anywhere near the surgical field—I felt that I had come into a holy space.
The room was square, and tiled. The overhead lights were dim, and people in light blue gowns and gloves, with masks over the bottom half of their faces and paper caps covering their hair, stood silently with their hands folded in front of them. (This, I would learn, is a way to make sure your gloved hands stay sterile.) In the center of the room, floodlights poured down over the body of a draped woman. Only the skin of her belly could be seen, and it was taut from the carbon dioxide that the surgeon had inflated it with. Through a tiny incision, he worked a camera into the woman’s inflated belly.
“POM student?” the surgeon said, breaking the quiet.
“Yes,” I said.
“Is this your first time in surgery?”
“Yes.”
“Welcome. Don’t touch anything.”
“I won’t. Thank you.”
“I mean, do not touch anything.”
“Got it,” I said, suddenly feeling that somehow I was making a mistake by letting the bottoms of my feet touch the floor.
The lighted camera—called a laparoscope—was at the end of a long-handled tool. And as the surgeon worked his way in, images from inside the woman’s body appeared on a screen beside the operating table. I realized that the overhead lights were dim so that we could see this screen. And the belly was inflated, also, so that we could see around inside.
“Make sure you can see this,” the surgeon said to me, and I moved slightly for a better view.
The inside of this woman was nothing like what I had seen in anatomy lab. Her intestines were bright pink and slippery, and they moved rhythmically with the action of peristalsis. She was alive. I remember making the obvious—but still, in its way—astonishing observation that the inside of the body is not bloody. The blood is contained in veins and arteries, so if you enter the body carefully, you see the smooth, clean surfaces of human organs working as they should.
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