By Saurabh Sinha
VITALS: “What were they again, Melissa?” The second year on my Promise Clinic team grabs a small sheet of scrap paper from her white coat pocket and rattles them off to me and I write them down. BP 155/85. I remind myself that I want to get a repeat BP before we leave. I think we got that number in fertile ground for white coat hypertension: by ushering her into the room, sitting her down and, prior to our greetings even settling into the woodwork of the appointment, strapping her in with the cuff, swiftly sphygmomanomating ourselves an extra six points systolic in the whole cascade. She has hypertension and we recently changed her dosage of lisinopril, an experiment that started during my first year. Back then, “ACE inhibitor” was something so much more nebulous than it is tonight.
GENERAL: She is she. She is the same old (as in the “same ol'” in the sense of familiarity, and the same “old” in the sense that a soon-to-be 73 year old is old), wonderful Colombian lady who I’ve been seeing since my first Promise Clinic appointment back in the very first month of my first year. Head trauma as a child has left her cognitively impaired — she mutters oftentimes nonsensical, occasionally inappropriate jokes to herself and to the room when she’s not playing some form of pat-a-cake with us. Her niece sits dutifully in the background talking to the others about how the past month has gone. We make sure she’s eating, sleeping, and voiding as usual, and we ask about her mood. It wavers between happy, tranquil, tired, and aggressive. We catch her this time on a tranquil month, and I process it all as I look at her. The familiar resting pout of her lower lip, the bags of age under her eyes, her various congenital nevi, and her smile as I take some time out of writing our progress note to give her a high five. ]]
The rest of the note flows from my hands in a largely effortless release and I think to myself that somewhere along the road, this became second nature to me.
HEENT,neck,heart,lungs,abdomen,MSK,extremities,pulses,neuro (exhale): all of this continuous, a train firmly on its tracks in trancelike choo-choos past the countryside. When did this happen? I blinked, I think, and something changed within me.
But the facts say that, in the 2.5 years I’ve been a medical student, I’ve blinked roughly 9.12 x 107 times. Clearly, something meaningful has happened over a longer period of time than a split second. As I write the progress note on a counter next to the sink, the first year and second year on the team workshopping parts of the physical exam with the fourth year behind me, the Ghost of First Year Saurabh and the Ghost of Second Year Saurabh enter the room. For a moment, I turn around and I watch them with an odd mix of nostalgia, pride, and pathos.
Ghost of First Year Saurabh: More transparent than I, he looks on with an intense curiosity concentrated in the middle of his slightly furrowed brows. He is fascinated even by what the second year on his team knows, let alone the third and fourth year. Everything appears to run so smoothly. What fantastic rapport there is with this patient. How do they know to ask all these questions? And look at their physical exam skills!
-“Saurabh, why do we check the feet of patients with diabetes?” asks his third year.
“I’m not sure.” (Translation: I have very little idea of what diabetes really is outside of something about insulin.)
He learns about the increased risk of infection secondary to peripheral neuropathy. If that’s pathophysiology, he can’t wait to learn more. How do they know it so well? Wizards, he presumes, they must be wizards. This is magic. Will he ever be there?
Ghost of Second Year Saurabh: His body language has changed a lot, and he is now an active part of the rapport. He extends his hands to the patient knowingly. She wrestles him with her surprisingly strong grip. Feeling empowered, he leans in and asks the right questions, fueled by his assumption that he’s starting to crack some kind of secret code. Hell, he even flows through the physical exam decently well. But he’s still unsure of himself. Checking in between his patient’s toes for signs of unrecognized infection, he wonders: what are the other components of the diabetic exam again? Does he even remember the pathophysiology of diabetes? He just learned this, he has to remember! But he can’t, and so his fourth year fills him in on the details. He nods, appreciating that it was she who told him about diabetic foot infections not too long ago, and that this is the next step not just of feet, but of his medical career. He then tries to write a progress note next to me, but he’s not sure how to compress everything that was talked about and flounders hopelessly with pen in hand. His third year steps into frame and looks over his shoulder. Gently, he commends Second Year Saurabh for what he was able to put together and dictates the rest. All the while that Second Year Saurabh is writing it all down, he is processing it with an inkling that he will get there soon, and that this is all part of a longer journey.
What has become increasingly clear to me as I’ve worked my way through this first half of my third year is that medicine is a longer, more layered, more nuanced journey than I ever could have wrapped my head around previously. At the end of medical school, we’re merely ready for residency, which is where we really learn the crux of doctorhood. But the sheer rate at which we learn in this first exposure to clinical medicine is remarkable.
In Promise Clinic, I am now writing notes like they are, as I said, second nature. These progress notes serve rather unexpectedly as an ad hoc marker of my own growth. During my first year, I simply learned about the importance of a progress note from afar. During second year, I looked on with the uncertainty of whether I would be able to do it stemming from the trials of Second Year Saurabh as described above.
But now, I am actively applying the principles from all of my clerkships to both my notes and my patient care. During my family medicine clerkship, I learned to assess my patient in the context of her medical history, and tonight I discuss my assessments and plans with the team before presenting them to the attending. Perhaps we should increase the dosage of lisinopril again because the repeat BP was still elevated. What else is going on with her? We talk about her concomitant diabetes, hyperlipidemia, osteoporosis, and history of seizures as well, and plan accordingly.
I draw on presentation skills that I’ve honed in each of my four clerkships thus far to concisely summarize the medico-socially relevant aspects of the last month of my patient’s life. As my current fourth year did before me, I apply some of the strategies I learned on my pediatrics clerkship to streamline the physical exam for a patient whose mental age falls short of double digits.
Look at my finger puppet!
Now over here!
Just with your eyes!
(In the shape of an H, the choreography of EOMI lingers in the air.)
The depth of humanity I picked up on during my psychiatry rotation clues me in on the caretaker’s burden that sits heavy on the shoulders of my patient’s niece. I know her eyes well now, and her expression is probably the most potent manifestation of what the last month has been like for my patient. A full year removed from an incident where my patient was inexplicably using scissors to cut up drapery in the house and yelling at her niece’s son, her niece’s eyes look a bit lighter, a bit less bound. We hug at the end of our appointment like we do every time, and I tell her what an amazing job she is doing.
What is there to come? It’s hard to imagine. I certainly could not have told you six months ago what my understanding of medicine would be tonight. Perhaps I am better able to extrapolate now that I have some clinical experience under my belt. But really, what I have learned is that it is hard to reliably predict the experiences that one will have and what one will learn from them, not least of all in this field.
I liken it to venturing out to sea. From land, the horizon appears fixed, distant. But as you board your vessel and paddle towards that point, you realize that the horizon doesn’t seem to be in the same place that it was before. As you paddle even farther out, you see that it changes again and, rather than getting any closer, is drifting off even more. And you begin to realize that the horizon, as you define it, is completely and utterly dependent on you. The horizon is a dynamic entity that changes with your vantage point. Medicine, similarly, means something different and appears to be something different at every point in the training of physician. It appears as the horizon off in the distance, but as you paddle out towards it, it continues to move while the landscape and the clouds around it morph and shift with you.
I am out at sea right now and I am enjoying the current. I take time to admire the landscape and seascape as they are buttressed by the horizon. The smell of salt rappels down the olfactory pathways leading into my brain as I inhale, and I can taste the ocean water in its wake. The sound of gulls cawing hangs some yards above me. I reach up to the sails and feel their rhythmic undulations with the wind against my hands. The clouds above me continue moving in countless planes; they bend, they fold, repopulate.
This will all change though.
I marvel at what it could become.