No Apparent Distress

by Rachel Pearson

  “I can’t get this nurse to pay attention to him. He’s bleeding out of everywhere, and the chucks on his bed are full of blood, and I can’t get anyone to help. They don’t treat uninsured people right in these hospitals,” she said, and texted me pictures of a blood-soaked dressing on Jimmy’s chest. His skin looked dark and unnatural; it looked like death.

  So I wept on the phone a day later when Vanessa told me that the doctors wanted to pull the ventilator and let Jimmy die, but I was not surprised that he was dying. “I can’t do it,” she said. “He never got chemo, and now they just want to give up. I can’t do it!”

  The next day she said the same thing, and asked me what she should do. She was angry at the doctors for making her decide; she didn’t want to feel, years later, like she had killed her husband.

  I was still just a student, but I gave her the best advice I could. “I know how much you love him, Vanessa,” I said. “I know how much you hate to see him suffering. I’m sorry you have to make this decision, but I know that you are the only one who can make this decision from a place of love.”

  “I know,” she said. “I know.”

  They pulled the ventilator, and the next morning Jimmy died.

  VANESSA GRIEVED FOR A LONG TIME. She was also afraid, blindsided by the bills from Jimmy’s death. There was a $17,000 bill from UTMB, and $325,000 for his three-week stay in the intensive care unit in Houston. Vanessa was still unemployed, and terrified that she would lose the final thing that—now that Jimmy was gone—stood between her and abject poverty: her house. So there was the grief, and on top of the grief there was fear.

  Over time, she drew on her inner resources. She sought retraining in work skills that she could use despite her persistent back pain and the problems in her feet. She got two part-time jobs, and when she became a manager at a local store she even got insurance, so she is no longer a St. Vincent’s patient. Neither of Vanessa’s jobs are high paying, but she has kept up with the mortgage and is in her home.

  When I asked her if she thought Jimmy would have been better off if he hadn’t been a St. Vincent’s patient, Vanessa says no. Sometime during Jimmy’s illness, a doctor comforted Vanessa by telling her that there was nothing she could have done. Lung cancer is aggressive and hard to catch. There is no way she could have stopped it. Vanessa takes comfort in this.

  When I return to the question that Susan McCammon once asked me about Mr. Rose—“What do you wish you would have done differently?”—I sometimes wish that I had made sure Jimmy at least knew about the low-dose CT, so he could have made his own decision. He probably wouldn’t have gotten it anyway, with money so tight. But he could have made that choice.

  Sometimes I wish I had talked with Vanessa about hospice. A more experienced advocate—a doctor—might have suspected that Jimmy was going to die quickly. If he had had hospice, he might have died not only more comfortably but with much less of a financial burden passed on to Vanessa.

  On the other hand, hospice is not designed to be forced on the poor. Hospice should be a choice—one offered to patients when they have exhausted the available treatment options, or when they know that treatment is not an option they want to pursue. Between the time Jimmy left UTMB and the time he checked into the hospital in Houston, no doctor was talking to him about his disease. He had no regular primary care provider, who would know him and his needs and be there to counsel him about hospice. Rather, he had St. Vincent’s, where a rotating cast of volunteer students and doctors would tend to him, and where it routinely took three weeks to get an appointment.

  More than anything else, I wish Vanessa and Jimmy had had a more experienced advocate than me. Not because I did a bad job. I did a good job for someone at my level. But I was just a student, and there were many things I did not know. They deserved, as everyone does, a doctor.

  CHAPTER 20

  DERMATOLOGY NIGHT AT ST. VINCENT’S IS NOT A BOTOX party. In fact, dermatology night at St. Vincent’s cured me of my haughtiness about dermatology in general. Having observed how medical students grow progressively more taut and attractive as soon as they decide to go into dermatology—eventually progressing from being pale schlubs like the rest of us to being fine, glowing specimens, almost as good-looking as the physical therapy students who regularly humiliated me at group exercise classes in the UTMB gym—I had nothing but disdain for dermatology. One friend suggested I go into it, and I said, “Pshaw! I want to be a doctor.” But dermatology night at St. Vincent’s was mostly cancer prevention and cancer care.

  It was also a good time to do procedures, like biopsies. One derm night when I was volunteering as a junior director, I pulled a chart and began looking it over with a physician assistant (PA) student who was at the clinic for the first time. The patient had recently been diagnosed with hepatitis C, the same virus my mother had. She was a smoker, and had a history of small growths on her skin, including her face, that needed to be removed and biopsied. At this appointment, we planned to biopsy a spot on her leg that had grown rapidly in the last few months.

  “This will be a good case for you to see,” I said to the PA student. “Watch how we do the biopsy, so next time you can do one.” The PA student and I discussed the hep C—though I didn’t mention why I knew so much about it—and went over strategies for talking with patients about quitting smoking. Then, we called the patient back into an exam room.

  She was a thin woman in her fifties. She greeted us coolly, and we arranged ourselves in one of the smaller exam rooms. The patient sat in a straight-backed plastic chair, and I sat on the rotating doctor’s stool. The PA student, clearly trying to take up as little space as possible, wedged herself into a corner chair behind me.

  As we talked, the woman began to tell us about all the student volunteers who had messed up her care in the past: a student who swiped three times at a mole on her eyelid before removing it, one who was plain rude to her, and one who dabbed cautiously at a small growth on her face instead of freezing it off quickly and smoothly like she should have. The growth came back, bigger. She felt ugly.

  By the end of these stories, she was crying. “This is humiliating,” she said. “I have worked my whole life, and still. I have to sit through this. This is real,” she said, looking at me. There was an accusation in her eyes, a conviction that I was on the far side of a chasm I could never understand. “This is what it’s like,” she said, “when nobody gives a shit about you.”

  I almost protested. I wanted to say, “I give a shit about you.” I wanted to tell her that I came from a working-class family, and I’m not so far from understanding what it’s like to be shut out. She didn’t know me.

  But how could I protest now, in the fourth year of my medical education? I was different. No amount of research, and no shared experience, could teach me what it was like to be a free-clinic patient—or to be this particular woman. The white coat was on me. The knife that would cut into her skin was waiting in the hallway supply closet, and it would be in my hand.

  Anyway, this patient had good reason not to trust me. I believed the stories she was telling about student screwups. I was, after all, preparing to do a shave biopsy on her leg with a small blade that I’d never used before. I knew it was going to be awkward. There was a chance I’d mess it up, just like the students in the past. I also thought of the student sitting behind me, and wondered what she must be thinking about our clinic.

  Some part of me is grateful when a patient can just tell it like it is. Charity care patients most often keep silent when they know their care is inadequate. If they made us angry, and we stopped seeing them, they would have nowhere else to go. So whenever a patient finds it in herself to complain, I remember all the other patients who are going through the same thing, but don’t say a word.

  Instead of protesting, I stalled. I knew the woman had a good job, and might be eligible for care through the ACA health exchange. So I brought that up. “I want you to get the best care,” I said. “And I know that St. Vincent’s i
sn’t always the best care. Have you thought about checking out the health exchange? Especially with your hepatitis, you might be able to get better care.”

  She hadn’t. And she wasn’t planning to. She’d already been rejected by the county and by UTMB, and she had no faith in the federal government to get her better care. She said she already knew she couldn’t afford it, even with the subsidy. And, finally, she had seen friends go through intensive, and unsuccessful, drug therapy for hepatitis. She wanted no part of that special suffering.

  “This is not my fault,” she said. Her voice was firm even though she was still crying. “There is nothing else that I need to do.”

  I was silent for a minute. I could feel how deeply she didn’t trust me, and how that lack of trust made my advice on the health exchanges useless. The best thing for her care would be to get her insured, and into the office of a regular primary care doctor. But until she trusted me, my advice wouldn’t make a difference in her health.

  She narrowed her eyes and shook her head. I wanted to flee.

  I breathed in deeply and made myself stay. The PA student actually did flee the room, mumbling about bringing a tissue. Handing a tissue to patients is the official medical response to patients’ crying. They actually teach you, in medical school, to give a tissue to crying patients, and I’ve seen full-fledged doctors literally run out of the room in pursuit of tissues. It’s not clear if they’re running for the tissue, or away from the patient, but they clearly are trying to “do something.”

  Tissue accepted, we sat quietly a little longer.

  “I’m sorry,” I ventured.

  “Just take care of this for me,” the woman finally said. “That’s all I want. I just want you to do this, and then I want to go home.”

  So, I agreed to take care of the one small thing that I could, and we left the room. The PA student was wide-eyed. “That was intense,” she said.

  I looked at her, remembering that I was supposed to be teaching. “Well,” I said, “I think we have some work to do to establish trust.”

  “Uh, yeah,” she said, with a tone that suggested, No fucking joke, you bozo. This woman hates us.

  I DID NOT LEARN to do all of my procedures on patients. There was the MUTA-GTA, where we learn to do genital exams on standardized patients, and then there was the annual St. Vincent’s volunteer orientation, where a hundred and fifty brand-new medical students learn to draw blood—on one another.

  All of us directors liked running the orientation sessions, which happened once or twice a week throughout the fall. We liked showing off the clinic, and telling about its history, and preparing junior students to worship us as gods. The medical hierarchy has a way of promoting hero worship, and we were delighted to find that, as fourth-year students, we were finally eligible. When I introduced a whistle to orientation—Okay, the director blows the whistle, and then all the first-years run to the next station!—even the grumpiest directors began signing up to take orientation shifts.

  Practicing blood draws was the last part of orientation, and it was what really brought the students in. I would stand at the front and walk through the steps of the blood draw—find a vein, get the arm ready, swipe it with alcohol, put on a tourniquet, brace your hand, then stab the crap out of your patient at a thirty-degree angle to the skin—ha ha, just joking, quickly insert the needle at a thirty- degree angle—don’t jump if they scream, put on the vacuum tube, then remember to take off the tourniquet before you pull out the needle. Then we would instruct the students to turn to their neighbor, and practice drawing blood. I loved the moment of terror in their eyes, and was always gratified to see that the terror of drawing blood was greater than the terror of blood being drawn.

  Most of the time, they got it on the first stick. But sometimes, a student just couldn’t get it. I would walk by and gently instruct them, and then, if they had tried a second time, I would offer up my veins. I have excellent veins—dark blue bulgy veins that show clearly through my skin. They are a medical student’s dream, and many UTMB students drew their first vial of blood from me. During the orientation months, my bruised forearms were a badge of honor. Every awkward stick that I took was one spared a patient.

  I RETURNED WITH a dermatologist volunteer, a kind but businesslike older man, and did the biopsy. I shot half a cc of lidocaine into our patient’s leg, and checked that it was numb. The blade, when I began to cut, was awkward. It took me longer than it would have for an experienced doctor. I couldn’t get the blade angled under the last bit, so the piece of skin I’d cut off was dangling. I looked around for forceps, but they were still on the counter, sealed in autoclaved sterility. The doctor didn’t offer them, so I grasped the dangling bit of skin with my gloved hand. I remembered our patient’s hepatitis as the blade swiped perilously close to my finger. Biopsy done, I stopped the bleeding, and placed the sample in fluid to send it to the lab.

  With the dermatologist in the room, our patient reverted to the usual calm mask of gratefulness. She sat quietly while I did the biopsy, then grasped my arm and said, “Thank you.” The dermatologist never knew what had gone on.

  It’s painful to be told that the care my clinic gives is humiliating to patients. Even so, I’m glad that I’m not such an authority figure that the conversation can’t even begin. Was she thanking me for doing the biopsy, or for hearing her out? Maybe she was thanking me for just getting that one thing done, so she could go home.

  The next time I do a shave biopsy, I’ll do it better. I’ll begin with the forceps ready, and I’ll be able to make one smooth cut. This is how medical training works: you count on your mentors to show you the way, and you learn as you go. You make mistakes as a student—­more than residents make, and far more than fully qualified doctors make. Most of the time, your mistakes get caught by your superiors before you can do any real harm. But sometimes they don’t get caught.

  The problem, of course, is that these mistakes happen systematically, and not just to anyone. They happen to the uninsured and to people on Medicaid or county indigent programs. They happen to free-clinic patients, prisoners, and undocumented people. They happen to working-class whites and people of color.

  If you are a patient at a private clinic—as I am myself—then you can be pretty sure that most of your doctor’s mistakes have already been made. They were made on the bodies of the poor.

  CHAPTER 21

  WHEN I BECAME A STUDENT DIRECTOR, HTIN AUNG PASSED his keys off to me. Htin had been a great director, the most obsessive and dedicated of all the student directors, and he was going on to residency at the Mayo Clinic. “This is the key for the front door,” he said. “This is the key to the chapel. This is the key to the medication closet in the hallway. This is the key to the counseling room.” He went on and on, flipping through so many keys that I knew I would never remember them.

  Becoming a student director at St. Vincent’s meant that my duties changed. I was still a volunteer, but I was no longer primarily responsible for seeing patients (though directors would often see very complex patients who needed continuity of care). Instead, my job was to keep the clinic running.

  There were ten directors, all of us in our last year of medical school, and we were all volunteers. We were responsible for staffing three clinics a week: Tuesday and Thursday nights, as well as Saturday mornings. Each clinic needed at least two directors, but ideally, four or more. We would also meet once a month on a Monday evening and, along with Dr. Beach, talk through any issues that had come up in clinic. Outside of those meetings and the actual clinics, we each had various responsibilities: coordinating volunteer sign-ups, making sure faculty doctors would be at the clinic, finding and organizing medication donations, fund-raising, representing the student-run clinic at St. Vincent’s House meetings. There were also often small tasks to be done: a biopsy had been done but the doctor hadn’t signed the form, for example, so a director would run to campus to track down the doctor. Somebody’s medications had been mailed to the clinic but th
ey had moved into a shelter in Houston, so the meds needed to be mailed to them. It went on and on.

  The actual clinics were the heart of our work. On a typical Tuesday, I would show up to the clinic around four p.m. By then, our waiting room was usually full of patients and families waiting for their four thirty appointments. I’d walk in and say hello to the ladies working the reception desk, wave to patients I knew, and then head back to the banana room—the director’s office, which had a painting of a banana on the door. (It was part of a healthy-foods themed mural that stretched around that part of the clinic.) I’d unlock the office and start setting up: logging on to computers, getting the safe open to remove prescription pads and the keys to the lab, setting out laptops for the volunteers to use. Often another director had beat me to the office and was catching up on paperwork. Somebody would check our box in the front office for new lab results, and start pulling charts to call patients back about their lab results.

  Things would get briefly crazy around four fifteen when the volunteers all rolled in. We had eight exam rooms, plus two overflow rooms—the chapel and a counselor’s office—where we could see patients. This meant that we could have ten teams, with a maximum of three students per team. The number of volunteers who actually showed up ebbed and flowed with school schedules. In August, the clinic would fill with brand-new med students eager to volunteer. On the night before a med-school test, we might pull in mostly physician assistant students. And over the holidays and summer we often struggled to get enough volunteers. We’d get on the St. Vincent’s Facebook page and send out an SOS—We need volunteers right now. There are kolaches. Or We need Spanish-speaking volunteers. There are sandwiches. Or We need upper-level students. There is pizza. Keeping the food funded was a constant struggle, but it was important to show our volunteers that we appreciated them. Also, fed medical students are better, kinder medical students.