Thursday, December 11, 2008

The Half-Naked Stranger

I knocked on the exam room door for my usual Thursday clinical training session with John, my usual standardized patient. John wasn't there. Instead, before me sat an old man I'd never seen before. He sat slightly slumped on the end of the examination table, his scrawny limbs dwarfed by the gut protruding beneath the flimsy hospital gown. His eyes were bloodshot. He looked tired.

I felt sick.

I introduced myself and began my usual "routine"of meeting a new patient -- asking some basic questions, making smalltalk about the weather as I washed my hands, establishing a "shared agenda" for the visit. I asked more specific questions about his symptoms and associated observations and life events. I was cognicent of how nervous I was. I was choppy, my thought process disorganized.

This should have been no different than any other standardized patient encounter (yes, this man turned out to be a "substitute" standardized patient). But it wasn't. The context was entirely different: I didn't meet him in the context of being a trained instructor tasked with teaching me to care for a human being; I met him in the context of being a stranger in his underwear and a gown. His vulnerability was threatening, reminding me again of the profound trust and responsibility in this unnatural dynamic. This felt real.

Before long, I was uncovering portions of his bare body, kneading into his abdomen, digging for the edge of his liver, tapping my own knuckles over the surface of his abdomen and back (to make sure it sounded hollow in the right places), asking him to repeatedly breathe on command as I listened with my stethescope at locations that allegedly sound different from one another.

I didn't even know his real name.

Vulnerability is a big deal to me. My own experiences of physical, psychological, and/or emotional vulnerability have carried heightened appreciation for my multidimensional trust in another human being, a powerfully rewarding awareness. But what contributes a backdrop of security during vulnerable moments is an equally powerful awareness that there exist people in one's world who deserve that level of trust.

I didn't do anything to deserve that trust other than show up with a nametag with my name and the words "medical student." The fact that my new world is structured to afford me opportunities and privileges that I haven't earned strikes me, on its face, as crazy. Just crazy.

But I guess it couldn't be any other way...

Thursday, December 4, 2008

Slicing, Sawing & Feeling

I started this blog to force myself to actively engage and process the daily experiences of my medical training experience in real time, lest I miss the opportunity to soak up any valuable subtleties. I envisioned sitting down to update it every few days or so, just to make sure I didn't miss out on anything.

WHOOOOOOOOOOOOOOOSH. Two months passed. It all happened so quickly. Just like that, I went from writing about vague fears of future hypothetical conversations with patients to an utter avalanche of profound absurdity. In two months, I had broken through a human being's vertebral canal with a chisel, cut a human head in half (and later cut off) with a saw, cleaned out a human heart in a sink, performed examinations of the limbs, eyes, nose, ears, lungs, heart and breasts, scratched away the layers of an eyeball, and memorized more than 3500 muscles, nerves, arteries, veins, and "spaces."

And I didn't write about any of it.

This is not to say that I didn't reflect on this nonstop inflooding avalanche of stimuli. I've certainly spent time thinking about the insanity that has marked my present life. I've engaged my deep feelings of inadequancy and attempted to develop coping mechanisms for every assault to my self-efficacy. I've even choreographed Spinning classes (unannouncedly) based on what it's like to feel like I'm drowning in my present AND my future, and effective ways of re-establishing control and self-efficacy -- which are as effective for me to put together as it seems it has been for my riders. I've gotten so good at reflecting and processing that I don't even MIND feeling like I suck at life a good deal of the time. I've accepted it as allllllll part of the journey, re-fueled by the times that I don't suck at life. And while I haven't been writing about the specifics of my experiences, I'm satisifed with the amount of time I've invested in maintaining important relationships with key characters in my non-med school life -- including the opportunities to share some of the things I never got around to writing about for myself.

But I'm a writer. It's what I "do." It's how I learn, how I think. How I devise creative solutions. How I take charge of my world. I suppose that each of these alternatives has served this purpose in its own way -- but to the end that I've been able to fully abstract some sort of deep appreciation for the subtleties of these experiences, that will in some life-altering way bear on my life taking care of patients? I don't know. And I guess I never will.

But today, I couldn't risk not writing about. Today, I experienced the most generous act that a human being has ever bestowed upon me, barring my own birth. Today, I performed my first testicular exam. While my standardized patient gets paid as a job to carry out these roles and to be available for my training, the idea that a person would purposefully enter this vulnerable state solely for the purposes of me to learn -- as opposed to, say, for the purpose of seeking relief from an actual medical problem, as would be the case in a regular clinical exam -- strikes me as an overwhelming gift. As overwhelming as accepting responsibility for someone's completely vulnerability, at a point where I can't possibly be knowledgeable enough to deserve that trust.

I guess that's all part of the road: accepting this life role and developing the mindset and confidence to accept the responsibilities, and privileges, that come along with it.

I did a decent job. I'm confident that, at the very least, I wasn't awkward. I was composed, methodical and deliberate. But here was another example, like the others I haven't written about but have perhaps shared verbally, of being SO aware of my limitations. You can follow protocols to a tee and still not detect the things you seek -- like the slight "wshhh" or "kkkhhh" of a heart, or the crackle of a lung (which is fainter than the crackle of your own sleeve brushing against the stethescope cord). And here with a part of the body that I've not "spent time with" in the context of looking for structures that are supposed to be a certain way (like the spermatocord), it is quite discouraging to lack the confidence of even finding what needs to be found. Today, for example, I guess I felt SOMETHING -- but as for whether that's how it was supposed to feel or is likely to feel, who knows?

On the other hand, I also performed my first abdominal exam. I had been anxious because I knew I'd be super-discouraged if I sucked at this, given my gastroenterological ambitions. But I didn't suck at this. I knew exactly what I was feeling for, knew exactly what it would feel and sound like. (As a practical matter, I can't possibly have every kind of medical ailment possible as a way to know what it feels like! But it works here...). When I heard a clicking in my patient's left lower quadrant, I nearly cried. I was so overjoyed. I looked down at her with utter glee, and I saw an amused flicker of delight in her eyes -- and I imagined that she must enjoy seeing trainees have "lightbulb" moments like that where they take confidence in a new skill (I imagine that's why she works as a standardized patient in the first place...).

It's nice to LIKE stuff for a change.