Wednesday, August 5, 2009

Power & Privilege

Drip. The septocaine dripped pristinely from my needle as it approached her shiny, pink flesh. I caught the drop with my gloved finger, then tightened my grip on the steel ring. Pulling back the patient's cheek pinched between my two fingers, I squinted one eye to verify the alignment of the most lethal thing I've ever held in my hand with the pterygomandibular raphe between her gum and her bone. Breathe. PLUNGE. Holy shit. I just injected a human being's jaw.

Yesterday, I injected a toe. The idea of sticking a needle into a human being -- having them trust you to literally seize control of a body part and insert a sharp object, introducing a dangerous substance into said body part -- is, on its face, absurd. Not as absurd as taking a pair of forceps, gripping a toenail, and peeling it off like an orange peel. But I did that, too. This somehow became my life.

Later in the day, I observed one of the PAs perform a physical exam on an adolescent girl. I contributed little; I was content to stand in the corner and observe a series of awkward interactions and then return to my regular scheduled programming of color-coded Excel spreadsheets. Suddenly, a voice interjected itself into my concentration.

"Sparky!" called a nurse (yes, that's what they call me at the clinic; and, yes, I answer to it). "Do you want me to do a vision test?"
"A vision test. Like, with the eye chart. Do you want to order that for the patient you just saw?"

Order a test? Like, without consulting with someone else who's licensed to practice medicine or remotely knows what he or she is talking about? Am I even qualified to make this decision? No. Definitely not qualified. Wait. It's a vision test. Duh. You can totally decide to do a vision test. Why wouldn't you do a vision test? Why is this person even asking me? Oh shit. Because I'm a medical student; I'm a stand-in for a representative of medical decision-makers.

"Uh, sure, go ahead. Why not?"
"Ok, Sparky! Right away!"

WHAT?! Did that just happen? Yes, it did. And welcome to reality. This is how it's going to be: someone who knows a shit ton more than you about, well, EVERYTHING (i.e., a nurse) is going to look to default to your judgment just because you are en route to one day to a prescribed position of hierarchy. On its face, absurd -- just like peeling off a toenail. But this, too, somehow became my life.

I continue to spend a lot of time reflecting on the profound privilege, honor, and absurdity that is being trusted by people without expending any effort to earn it, apart from putting on a white coat. I didn't earn the trust of the two men who let me examine their testicles today. Or the woman who let me witness the unveiling of her painful, gnarly atrophic vaginitis. Or the guy who let me insert a lubed, gloved finger in his rectum. No, I did not earn any of that.

When it happens, I am always grateful. I thank people for their generosity in contributing to my education and development: I look them in the eye and tell them how much I appreciate the opportunity they afford me -- how I'm always so surprised at how generous people are, how I can never believe that anyone lets me do or see or learn half what I do all day. I rant and rave because a) these folks deserve to be thanked, and b) it's almost an act of earning trust/confidence in reverse order -- as in "See? I'm a good person! You let me do this absurd thing, and look how good a person I am -- you should feel great about your decision to let me do this absurd thing." In the end, it's the only effort I expend to earn their impression of me. I earn the warm and fuzzy smile I get next.

Today, a patient consented to let me observe the interview portion of her visit with a PA but not the exam. Totally understandable. I stood in the corner and tried to stay out of the way. I fixed my eyes on the woman, her pearl necklace and earrings in jarring contrast to her examination gown. In jarring contrast to her elegance, to her pride. I listened thoughtfully with my eyes. I smiled and nodded at appropriate intervals. She snuck sideways peeks at me.

"So when you said that you've had these symptoms for th..."
"Wait. When we get to the exam, she can stay," the patient interrupted. "I feel comfortable with her... you... now." She turned towards me and smiled.

It was a routine physical exam, with a routine pap smear. But it was one of the most memorable visits I've had the privilege to observe -- because I actually felt like I EARNED the opportunity to be there. When I thanked her afterwards, my words gushed with effusive gratitude.

"You're going to be a great doctor," she said.

I touched her shoulder on the way out of the room, knowing that this moment would touch my life forever.

Armed by this dose of validation and confidence later in the evening, I grabbed the chart of a patient who came to see my preceptor for a cough. Great. An acute problem. I am TOTALLY qualified to go in and take a history and do examinations of organ systems I've actually formally learn how to examine. Then I can come out and present to my preceptor and feel really great about myself. Yes. Good plan. Let's go.

I took a history, did a few basic exams, wrote up a pretty good note. Pseudo-awkward guy, a bit unfocused -- yet I found that I was able to reel him in, inject structure and chronology into his account, and connect with him about the context of his life. He's a cyclist: that was my hook. Just as I was about to go present the patient's case to my preceptor, he shot off a bunch of questions about the heart. What steps could he take to reduce his risk of heart disease? I totally could handle that but wanted to do it in the presence of my preceptor, so I validated his exercise habits and said that we'd talk about this more during the visit. Then he asked something about surveillance ultrasonography -- which I somehow, in that moment, felt more qualified to speak on. What?! So there I was, fielding his question which I have NO idea why on earth I felt comfortable fielding. Sure, I fielded it ambiguously and said we'd talk about it during the visit -- but responded with far greater detail than the diet/exercise (i.e., the things I know most about in the world) question. I gave him stuff to latch onto, stuff that overshadowed my "yeahhhhh, I'm just a medical student" disclaimer.

I left the room and presented the case to my preceptor, who praised me for my workup. Again, felt on top of the world.

We go back in, come up with a plan, wrap up the acute issue -- then I prompt the patient to raise his "heart questions." When he asks about cardiac risk prevention, I launch into an extensive discussion about fish oil, exercise, blah blah blah. Wonderful. Then he raises the ultrasonography question, and my preceptor's eyes widened. "Actually, there is no relationship between [insert EVERYTHING I said to this guy]." He continues by citing studies and important international bodies' positions on his question, distracting him from the fact that [insert EVERYTHING I said to this guy] was totally and utterly wrong.

Gulp. Breathe. Tongue on the roof of teeth, inhale (my new favorite trick, taught to me by my friend Shefali, to enforce diaphragmatic breaths). Exhale long. Breathing my heart rate down. It's ok. You didn't ruin anyone's life. You're allowed to sound like an idiot. Nobody expects you to NOT be an idiot. It's ok. Breathe.

Downside of the privilege of being trusted: Every word out of your mouth counts. If you don't have confidence in the words that leave your mouth, do not guess. If you think you know of a concept that is peripherally related to another concept, do not link them unless you have specifically seen them directly linked. I was mortified.

After my preceptor left, I apologized to the patient for misspeaking and thanked him for the prompt to learn something along with him. He told me it was no big deal. I then spent 30 minutes providing dietary consultation (we had referred him to a dietitian, and I doubted that he would ever go). I felt like I redeemed myself and re-earned the trust that I'd enjoyed before I decided I was a sonography expert.

I waited around an hour before my preceptor finished up with his last patient, so that I could apologize to him and assure him how careful I would be in the future. So that I could thank him for not embarrassing me in front of the patient, for finding a way to correct me without undermining my confidence.

He surfaced: "We need to talk."

Oh shit. This was worse than I thought. My whole relationship with this clinic was over. They trusted a first-year medical student to interact independently with their patients, and now look what happened. I failed. I disappointed them. I suck. How did I do that?! Why did I do that?!

I followed him to his office.
"I am so sorry..." I began.
"For what?"
"For misspeaking about the ultrasound. For disappointing you."
He laughed.
"That was so not a big deal. Come on, let's go meet about your project."

Crisis averted; lesson learned. Being trusted to answer a patient's question is the equivalent of being trusted to inject a potent, potentially lethal anesthetic into a patient's jaw. It requires just as much preparation and precision, assuming just as many risks. And when you do it right, just as many rewards.

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