I was designated to go first, because I’m a woman.
“Rub your hands together!” the patient said. “Don’t go touching me with those cold hands. Brrrr.” So I did, and then I started the exam, with me telling her what I was doing and her calling out instructions. “Really get in there and feel, now! If I have a lump, I sure want you to find it so don’t be skimping on me. And get up in my armpit, too, because you know there’s lymphatic tissue up there.”
“Yes, ma’am,” I said. I was pressing my fingers into her breasts, trying to feel all the way through the tissue to her chest wall.
“You ain’t gonna hurt me.”
“Okay.”
“Now, what’s the thing that tells you that you’ve done a thorough breast exam?” she asked.
“Um, time.”
“That’s right! You want to spend at least four minutes! Now that’s going to feel like a long time, but you need to do it because I want to know you’re being thorough. So take your time.”
“Yes, ma’am,” I said.
“Now, you can start on the other breast,” she called to one of the guys. After we had all had a turn, she sat up again and one of the guys retied her gown.
“Now it’s time for the vaginal exam,” she said. “Gloves on! The first thing you need to know, is be gentle. You don’t want to go leaping into anybody’s vagina like some kind of cowboy. You go slow, and you be respectful.”
“Yes, ma’am,” one of the guys said.
“Before you even touch me at all, you want to make sure I’m doing okay. Am I right?”
“Yes, ma’am.”
“That’s right.” And she walked us through it, starting with the bimanual exam, where you put two fingers into the vagina to feel for the cervix, then run your hand over the belly to feel for the uterus and ovaries. “Use plenty of lube!” she said. “And don’t just surprise me by putting your fingers into my vagina. You tell me I’m going to feel the back of your hand on the inside of my leg, and then I’m going to feel your hand on my vulva. Am I right?” she called down from the end of the table.
“Yes, ma’am.”
“I don’t feel any ovaries,” one guy said.
“That’s all right,” she said. “They’re in there. You can’t really feel them a lot of times when they’re normal. You just keep practicing and you’ll get it.”
Finally, it was on to the cervical exam. “Now you want to use both those packets of lube,” she said. “And you put that speculum in sideways, not like it’s going to be when it’s open. Put it in sideways, then you turn it and open it up once it’s in there.”
Magically, like the easiest thing in the world, her cervix popped into view at the end of the speculum.
“Hey, there it is!” one guy called out. “I can see your cervix!”
“Nice!” she said.
A FEW WEEKS AFTER THE MUTA-GTA, I was waiting to register my car at the DMV and got to talking to the woman next to me. She was a nurse practitioner who specialized in gynecology at a private clinic on the mainland.
“Oh, interesting!” I said. “I just got trained to do speculum exams.”
“That’s great,” she said. “How many have you done?”
“Just the one, so far, in training,” I said.
“Well, you’ll get it,” she said. “Don’t worry. I take students in my clinic sometimes, but I don’t let them touch my patients until they’ve spent a week at the prison clinic. You go there, and you can do twenty pap smears in a day.”
“I see,” I said. It was a simple calculus: in a week, you’d do a hundred pap smears. So before touching the genitals of an insured woman, a student needed to practice on a hundred poor women. I knew on some level that medical training worked like that, but it was strange to hear it said aloud so uncritically.
But as it turned out, my training would be just like that.
AFTER THE MUTA-GTA, I started doing speculum exams at St. Vincent’s. I had already observed a few, and finally an upper-level student turned to me in the hallway outside a patient’s room and said, “Why don’t you lead this one? I’ll watch you.”
So I led the encounter. The patient was a twenty-six-year-old mother who needed a routine pap smear. She was a Spanish speaker, and very quiet. She moved her head “yes” or “no” to answer most of my questions. Then when I asked her to undress while we left the room, she lowered her eyes and nodded. Her hands were gripping her purse.
I stepped out along with the senior student, and we waited for a minute in the hall. “She seems really nervous,” I said. “Are you sure I should do this one?”
“You can do it,” he said. “You’ve done the MUTA-GTA, right?”
“Yeah.”
“So it’s time. See one, do one, teach one, right? I’ll be there if you need anything.”
So I nodded, and we knocked on the door to reenter our patient’s room.
Inside, she was sitting on the end of the bed, with the sheet draped over her legs. Her face was tight with worry.
“Are you ready?” I asked. Silently again, she nodded. “Okay, go ahead and lie back, and I’ll help you get your feet in the stirrups.” She did, and I got into position with the senior student by my side. With the drape covering her knees, I could no longer see her face. I got the speculum and sample kit out from the drawer at the end of the bed, and began. Remembering what the MUTA-GTA patient had taught me, I said, “Okay, you’re going to feel my hand on your leg.”
When I touched her skin, she gasped. The senior student squeezed lubricant onto my fingers for the bimanual exam, and I felt her cervix at the back of her vagina, angling down from the top. I couldn’t feel her ovaries, but her uterus felt small and normal. When that was done, the senior student handed me the speculum and nodded to me.
“You doing okay?” I asked the patient, and she replied with a barely audible “Yes.” My hand was shaking with nervousness. I did not want to hurt this woman; I did not want to mess this up. I told her about each step I was taking, but she did not speak again.
It took me a couple of tries to find the cervix. I had to move the speculum around inside her, and I heard her gasp again. Then finally it popped into view, and I moved as quickly as I could to get the smear to screen her for cancer. When it was over, I said, “Okay, you’re done.” I breathed a huge sigh of relief, and helped our patient move her feet out of the stirrups. I felt a brief moment of triumph: I had done my first real pap smear. It didn’t go perfectly, but it went fine.
Then I looked at her. Her hands were gripping the sides of the bed, and her face was turned to one side. She was crying.
“Oh my god,” I said. “I’m so sorry. Did I hurt you?”
She shook her head and drew in a long, shuddering breath.
“I’m so sorry,” I said again.
“No, doctor,” she said. “You didn’t hurt me.”
“Are you okay?”
She nodded, and wiped the tears off of her cheek. “Yes, yes, I’m okay,” she said. “Thank you, doctor.”
The senior student and I stepped out again, and I turned to him. “That was nothing like the MUTA-GTA,” I said.
“Yeah,” he said. “It never is.”
CHAPTER 12
AFTER I FINISHED MY SECOND YEAR, IT WAS TIME TO begin hospital training. I chose to move from Galveston to Austin for my third year of medical school, to train in the public hospital in downtown Austin. It was hard to leave St. Vincent’s, but I knew I would be back after a year.
Training in Austin would give me a chance to see a different system: a truly public hospital, where the county indigent care program makes sure that most people can get adequate medical care.
The public hospital in Austin is a ramshackle hospital that the city always seemed on the verge of knocking down. The corridors are windowless and rambling; the scrubs are dispensed in a basement room that nobody can find, and you often walk into your patient’s room to find a plumber working on the sink. It is, however, public: Everybody who came
in was treated, and if they couldn’t pay, social workers would get them registered for Medicaid or the county health care program, called the Medical Assistance Program, or MAP. MAP doesn’t screen for citizenship, so even undocumented patients could get hooked up with hospital care and consistent primary care.
Along with two friends from college, I found a house within biking distance of the hospital. I moved my Labrador in and chose the sunniest room for us. Then, on a Monday in early June, I wandered the hospital basement for thirty minutes, collected five pairs of scrubs, and got ready to start my first real hospital rotation: three months of general surgery.
The fourth-year medical students prepared us poor third-years for surgery at orientation that afternoon. A tiny, peppy fourth-year stood before us and explained that we needed to be ready to answer a question from the doctors at any time. This is an old tradition in medicine, called “pimping.”
“Get ready!” the fourth-year said. “The surgeons are going to pimp you execution style!”
“Execution style?” somebody asked.
“Yeah!” she chirped. “Like a firing squad!” She was going into surgery herself, and she seemed to think this was a very delightful way to be questioned.
“What do you mean, like a firing squad?” I asked.
“I mean, they line you up and ask the first student a question until he gets one wrong. Then, boom, he’s dead! They move on to the next student, then the next, until everybody is dead.”
“The surgeons can’t actually execute us,” somebody ventured.
“Oh, I don’t know about that,” the fourth-year said. “Every surgeon kills somebody sometime. Who knows? Maybe it could be you!”
Another fourth-year talked to us about volunteering at the Austin student-run free clinic, which sounded way smaller than St. Vincent’s. It operates once every other week, and most of the patients get transferred out to regular primary care clinics. The students do acute stuff—lots of wound care for the homeless, for example—but they clearly weren’t managing any cancer patients. That sounded pretty nice to me.
I’ll learn how to be a doctor in a place with real access to care, I said to myself. There would be no more of the kinds of conversations I’d had with Mr. Rose. I wouldn’t have to say, “You need a CT scan, but there’s no way to get it.” Access to care, I figured, would save both my patients and me.
THE FIRST SURGERY I scrubbed in for was an inglorious affair: it was a surgery to cut open and drain a perirectal abscess on a homeless man’s inner buttock. Homeless people get skin infections a lot, because it’s hard to wash your body or your clothes or your blankets when you don’t have a home. In those conditions, any little cut or scrape can turn into a staph infection. I had seen a fair number of skin infections at St. Vincent’s, but never one that required surgery.
The patient—let’s call him Mr. Barnes—was already half-sedated by the time I met him in the preoperative holding room. I found his bed and introduced myself as the anesthesiologists were leaving. “Hi, Mr. Barnes,” I said. “I’m Rachel. I’m a third-year medical student and I’ll be assisting in your surgery today.”
“Jesus Christ,” he mumbled. “You’re not going to do it, are you?”
“Uh, no,” I said. “The surgeons are going to do it. I just stand there, I think.”
“You think?” he asked, lifting his lip. “Is this your first fucking surgery or something?”
“Um, yes, actually, it is.”
“Don’t fucking touch me then,” he said, and fell asleep.
For the record, I didn’t perform surgery on Mr. Barnes. I followed him into the operating room, then stepped out to scrub my hands and get ready. The scrubbing is a complicated affair that takes ten minutes, a special brush, and two kinds of soap. Once you’re scrubbed, you back through the door of the operating room, holding your hands out in front of you so you don’t touch any surface. Then, a scrub nurse helps you get your gown and gloves on.
Once your gloves are on, your hands are sterile. This makes it possible to put your gloved hand into the open abdomen of a patient without introducing any bacteria. But you must not unsterilize yourself. If you touch your gown below the waist, or your glasses, or your mask, or anything that is not sterile, then your hands are unsterile and you get barked at by the scrub tech, regloved, and potentially ejected from the surgery altogether.
As I got more comfortable in the operating room, I was able to help with small tasks: reaching up to adjust the lights (which have handles covered by sterile slips), or using the sucking machine to suck blood up out of wounds when the surgeon shouts, “Suction!” Eventually I was allowed to sew up some wounds, and once, I cut off a toe. But in my very first surgery, I just kept quiet and tried not to touch anything. I did not, for example, touch Mr. Barnes.
EVEN SO, HE BECAME MY PATIENT. This meant that, during his recovery in the hospital, I would wake him up at 5:15 every morning to look at his buttock. He would greet me with a bleary “What the fuck are you doing here?” and I would explain that I was here to check his wound. Eventually he got used to me, and even started making some unwanted sexual comments.
One afternoon, I came into his room and he was on the phone. “I’m calling a goddamn lawyer right now so I can sue all you fuckers for malpractice,” he explained to me.
“Okay,” I said. “Have you had a bowel movement?”
“You’ll all be fucking sorry,” he said. “And no, I haven’t had a bowel movement.” He spoke the words “had a bowel movement” in a high, whiny voice, meant to make me sound ridiculous. It occurred to me that it actually was pretty ridiculous to say “bowel movement” to somebody who used the word “fucking” in almost every sentence. Maybe Mr. Barnes would trust me more if I just said, “Have you shit?” but I couldn’t bring myself to do it.
“Any fever?” I asked.
“No,” he said.
“Are you on hold?” I asked.
“Yes,” he said.
“Good luck with the lawsuit,” I said.
“Get out of my fucking face,” he said.
“Okay! I’ll be back with the rest of the team in about an hour.”
“Don’t you want to look at my asshole?” he asked. “You always want to look at my asshole.”
“Not right now,” I said.
“Oh, so my asshole’s not special any more is it? Fuck you.”
“It’s still, um, very special,” I said. “We just checked it already this morning, and you don’t have any fever, so you’re good.”
“Go to hell, then, you fucking vampire pervert.”
“Cheers.”
Mr. Barnes was discharged after four days in the hospital, and I have not seen him since. His lawsuit, apparently, came to nothing. But his asshole healed.
ON SURGERY, WE STUDENTS TOOK Q-4 CALL. This means that, every fourth morning, we would find the most exhausted- looking student in the hospital, take the trauma pager from him or her, and prepare for a twenty-four-hour shift on the trauma team. If the beeper went off, it meant that the EMS was bringing someone into the hospital with trauma: a gunshot wound, a car wreck, the occasional stabbing. So everybody on the trauma team—a head surgeon, a resident, an intern, and a student—would run from wherever they were in the hospital out to the emergency room and get ready to receive the patient.
My first twenty-four-hour shift was led by the fearsome Dr. McAllison, a former Army surgeon. He preyed on the timid, and we learned quickly to answer his questions in an authoritative voice, even if we didn’t know the answer. By day three of my surgery rotation, I could throw back my shoulders and proclaim, “I don’t know, sir,” with the best of them. What I lacked in knowledge, I was making up for in confident tones of voice.
I was on noon rounds with my team, standing outside a patient’s room going over the differential diagnosis for abdominal pain, when the pager went off. Everyone stared at me.
I stared back.
Then I looked down at my pager. Then I looked back at the t
eam.
“Rachel, you’re being paged,” the intern said.
“Oh my god,” I said. “Should I go?”
“Yes, Rachel,” the intern said gently. “That’s what the trauma pager means. When it goes off, you go to the emergency room.”
“Right!” I said. I was still standing there.
“So, go,” the intern said.
“Right!” I turned around, with one last glance back at my team.
“Run,” the intern said. I ran.
I burst into the emergency room, clutching the jangling pockets of my white coat, and found the rest of the team waiting outside a trauma bay. The patient hadn’t arrived yet. I ditched my white coat in the nurses’ station and, with the rest of the team, slipped on a yellow cloth gown and a plastic face mask—to protect myself from blood or whatever else might spray from the patient. All we knew about the patient was on the screen of the pager: she was an eighty-four-year-old woman who had been a passenger in a car wreck, wearing a seat belt, and she was barely conscious. Her blood pressure was low.
There was a long moment of silence. Then, down the hall, we heard the ER doors swing open as the EMS pushed the woman in on a gurney. They wheeled her straight into the trauma bay and the team swung into action. Somebody pressed a pair of shears into my hand and told me to cut off her clothes. “Expose!” the attending yelled, and I sheared right through her bra and panties so that all her clothes fell off beside her. There was a huge bruise on her belly—“seat-belt sign.” When you see that, you worry about a lacerated liver or a ruptured spleen. I stood back while the team swarmed around her: checking her body for a source of bleeding, trying to start a peripheral IV, hooking her up to a heart monitor. The resident got an ultrasound machine and started looking inside her abdomen for pools of blood. Her pulse was weak and her blood pressure was dropping, so we knew she was bleeding somewhere inside.
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