Acquiring clinical modesty

Like many medical students before me, my preparation for medical school included time spent as a volunteer assisting in clinical research. The attraction of research was partly the intellectual challenge of the work—I was a psychology major interested in human development—and partly the opportunity to participate in a socially useful project. But I felt a further attraction when I discovered a research project centered in the heart of Manhattan, drawing on the locals and focused on the difficulty of raising healthy children. As a pre-med student, I tended to think of myself as a junior-grade physician and signing on to an investigation of childhood nutrition sponsored by Bellevue Hospital seemed tantamount to jump starting my career in primary care. The Bellevue project was part of a national inquiry into an epidemic of childhood obesity affecting poor urban families. The aim of the project was to address that epidemic by finding better ways to teach basic nutrition to parents—or in the language of the study protocol, “to extend health literacy to caregiver-infant dyads.” Our subjects were recruited from the lobby of the pediatric department of Bellevue, a staging ground thick with commotion and polyglot voices where parents waited with their infants and toddlers to be summoned for well-child visits. When I put on my white coat and guided parents and their children through the congested hallways of the pediatric clinic into the sanctuary of my tiny office, I sometimes felt I was already launched on the popular inner city practice I hoped someday to acquire. On good days, I would register the favorable impression I was making on my patient-subjects and forget altogether that a host of medical school deans were still perusing my medical school applications with a critical (or was it a disapproving?) eye.

The subjects in our study were parents and their two-month-old infants who reported to Bellevue for their first well-child checkup. During their initial study session, parents were tested for their knowledge of nutrition, and the physical and psychological health of the family was assessed. Next came a series of visits during which we distributed items from “low literacy toolkits” illustrating essential elements of a healthy diet (avoid sweet drinks, serve smaller portions). Great care was taken to deliver messages that were plain, pragmatic and, as it were, easily digested. At the end of 24 months, the children were weighed, and the impact of the program on obesity rates was assessed. Because I am fluent in Spanish, I was sent only subjects who spoke little or no English. This was gratifying for both parties. My subjects were happy to converse in their native language, usually treating their participation as a form of public-spirited entertainment. I could concentrate on perfecting my ability to take histories and to provide counseling, two skills I hoped one day to put to use as a primary care physician.

Most of my conversations with the subjects followed this benign formula, but the resemblance to an unfiltered family practice could be closer than I was prepared for. In one case this was particularly true. Rafael was a Puerto Rican man in his 30s who arrived for his study interview with his infant son. The father’s hair, which he wore in a ponytail, had been dyed at least three colors—blonde, black, and snow-white. There were dark circles under his eyes, and his fingernails were dirty and untrimmed. While not physically ill, he moved tentatively, as if he were testing the severity of some injury that one couldn’t see. His speech was slow, toneless, and became animated only when I told him he would receive a $20 subway pass, a prospect he asked me to confirm several times. His semidrawl struck me as very odd, because the heavily accented speech of puertorriqueños is normally so much like the musical chatter of excited birds (I should know, I talk this way too). His son looked well cared-for, but small for his age. When he was set on a mat to play, he vomited without warning, throwing Rafael into a torment of rage and shame which ended abruptly, like a passing squall, when his son began to sob.

I had been taught in my psychology classes that the way to gauge the moods of others is to monitor the parallel events happening inside oneself. It must be true because inside I felt an unpleasant physical heaviness: gravity had been recalibrated and now all of us—me, the father, the little boy—were being dragged centripetally downward. Perplexed over how to proceed, I stuck to my rehearsed routine, which now required me to complete a depression inventory called CES-D. Rafael’s responses were scary. If I had been administering an MCAT, Rafael’s stratospheric percentile score would have earned him a spot in medical school. Of course, I knew I was trapped in a routine that had become absurdly inappropriate, but I couldn’t see any way out of it. By now, Rafael had carefully cleaned up his infant son with a napkin he had pulled from his worn carry-all. But being denied, the outlet of scolding his boy simply meant that Rafael looked even more dejected than when we began.

At last, we concluded the formal interview, and I could discharge Rafael with his “core booklet” containing its trove of sound nutritional advice. He did not thank me as the other subjects had done. A period of silence stretched out unpleasantly, and I felt my face slowly turning red. How, I wondered, does a primary care physician deal with the patient who comes to the office and doesn’t want to leave? But my next careless comment—maybe he was “ready to go home?”—had an animating effect. Rafael, it turned out, did not have a home. He and his son were living in a shelter. In a voice hobbled by misery, he fleshed out the part of his history that had not been covered by our protocol. Two years before, he had migrated from a neighborhood of Ponce, Puerto Rico, coincidentally just a half-hour drive from the barrio where my maternal cousins still live. Like thousands of others, he had come to New York looking for work, lured by those dubious reports of success that friends and relatives seem inevitably to have retailed in immigrant stories of disillusionment. In very short order, he had been married (to a salvadoreña, a registered nurse with many times his earning power) and installed without prospects in a tiny thin-walled apartment. Then a son had arrived—yet another (unplanned) burden. Worse still, the arrival of the little boy seemed to pull Rafael’s wife over the brink. Her social trajectory had been upward. Now, in Rafael’s view, she saw herself tied by an unwanted marital tether to a skiff that was sinking without ever having left harbor. Without any warning, she abandoned the household. Had there been another man? Rafael couldn’t say for sure. In any event, he soon transferred with his son to the homeless shelter where he now resided, occupying a communally shared bedroom where little sunlight could enter, much less the illumination provided by my well-intentioned lectures on nutrition.

As I made my way back to my apartment after my first meeting with Rafael, it occurred to me that my fantasy of primary care practice had been premature: I hadn’t anticipated that anyone coming to my office could be so miserable, or that I could so quickly be made to feel ill-equipped for the role I coveted. This thought, disturbing in itself, became intermingled with a memory that had stayed with me from months before. I had been working on medical school applications, struggling to explain to two dozen schools in as many far-flung places exactly how each of them was my perfect “fit.” The sidewalks were congested with pedestrians moving in that breakneck flow that reminds you of movie extras brought into a scene to illustrate the busyness and impersonality of New York. I was matching my pace to the flow when I saw a homeless man moving slowly in my direction, a little way off the curb, dangerously close to the slipstream of unyielding traffic. Of course, I didn’t really know whether he was homeless or not. It may just have been something odd about the way he barely lifted his feet, and the unnatural way his arms hung from his shoulders. I had seen that gait previously, doing volunteer work on a locked ward.

But what made the scene painfully memorable was that the homeless man was followed by a small black dog, who trailed him at a distance of several yards, doing its very best not to be left behind. Half of my brain stood by miserably while the other half imagined the backstory: the small black dog had been abandoned. Near starvation, it had wandered into the trash-strewn alley where the homeless man camped out, husbanding the little pile that was his worldly estate. A morsel of food had been carelessly tossed, an indifferent word uttered, and the small dog had decided in its innocence to link its own fate to the source of its unexpected good fortune. Now (I persuaded myself) it was risking its life on the lethal concourse of sixth avenue, clinging to a tenuous connection with the benefactor who was, as I watched, shuffling heedlessly out of reach.

I had looked on this street-scene, in its first incarnation, as an ironic commentary on the vagaries of fate. New York City tosses up sad tableaux like this one every day. Now I thought of it again, after my interview with Rafael, and I felt my eyes begin to moisten. It was like those perfect anecdotes in Freud’s The Interpretation of Dreams, when the meaning of a dream is suddenly revealed. I had been haunted by the vision of the homeless man, worrying in an obsessive way about the plight of the small dog (I am devoted to dogs). But it occurred to me now that what had disturbed me even more was the bad faith of the homeless man. The haunting street-scene had come at a time when I must already have been feeling stirrings of anxiety over my future role as a physician, but I had thrust these out of my mind altogether. Now my uncertainty over how to grapple with Rafael’s depression had allowed these feelings to reemerge with much greater force. Buoyed by unrealistic expectations, I was now vulnerable to an excess of self-doubt. Someone should alert the medical schools: I was not ready to be a doctor. The homeless man had become for me a symbol of presumption in the clinical upstart who is unworthy of the trust that has been placed in her.

Of course, thoughts like these did not prevent me from continuing to report to Bellevue weekly. A chastened sense of the limits of my competence did not make me any less determined to succeed. I soon discovered that Rafael had been “sacked.” The psychiatric resident had determined that he was “clinically depressed,” which meant he was excluded from the study. This was liberating in a way, because I was still permitted to participate in his “well child” visits, but no longer had to worry when our conversations strayed from the study protocol. As it happened, Rafael on his second visit looked rather less like a condemned man. In fact, he seemed happy to see me. His little barometer (I thought of his son this way) told me that something had changed: the boy played contently for an hour on the plastic mat set out for him.

After receiving a new gift from the nutrition toolkit (a place mat illustrating appropriate food portions), Rafael took up his story where he had left it. When his wife left him, he had thought of killing himself but had been restrained by the thought that his son would then be alone in the world. Reflecting on the origins of his emotional torment, he made a connection between his rage and his depression that struck me as remarkably sophisticated. I had myself discovered this connection in my readings in psychology just a few months earlier. I complimented him on his insight, and not for the first time, I discovered the paradox that acknowledging his depression seemed to dispel it a little. I was also surprised to discover that, for all his self-absorption, he had been a keen observer of his son’s behavior. He noticed, for example, that the boy was fixated on the playthings that had been given to him by his mother. In response to these revelations, I could only offer Rafael modest tokens from my personal “toolkit.” In truth, these amounted to no more than common sense: he should invite his wife to reenter the life of their son (“You don’t have to stop being angry”); he should stop skipping his clinic visits as he had recently done; he should check the employment notices in the Human Relations office at Bellevue. We ended our second meeting with the discovery that we were both addicted to the same telenovela from Mexico, always a favorable sign when one is struggling to build a durable scaffold for a therapeutic alliance.

Rafael and I met several more times before he disappeared from Bellevue’s pediatric clinic for good. I continued to teach him about nutrition, but increasingly we spent his visits reviewing his efforts to piece together his life. There had been some tentative progress on his extracurricular assignments. He had contacted his wife, who was reportedly weighing the possibility of visiting him. His clinic attendance had been faultless (the free subway passes may have contributed to this). On one occasion, he brought with him a job notice that he had copied from a bulletin board at Bellevue. His mood was sometimes depressed, but he had reacquired a sense of humor: a peculiar twist in our favorite telenovela involving a frozen corpse and an identical twin (don’t ask) gave us something to laugh about. On reflection, the fruits of our many months of contact had been modest, but they had required considerable effort from both of us. And if my triumphs had not been earth-shattering, they had been fully in keeping with my fledgling status. Achieving them had allowed me to see that in disparaging myself as a failed clinician before I had even entered medical school, I had perhaps been a little too grand.

Of course, as a medical student, even in my second year, I face challenges of a different kind now. Socratic teaching in the medical setting is not quite what Plato had in mind when he compared the method of Socrates to midwifery, a didactic technique intended to bring forth what you already know. Medical school convinces you quickly that you do not know nearly enough. If it is a lesson that is salutary and necessary, it is still comforting, especially when you are reeling from high academic expectations, to remember what my conversations with Rafael taught me: human relationships, even in medicine, rest on something more fundamental than technical knowledge. Every relationship can profit from common sense, from a willingness to listen and from insight softened by tact. Now that I am learning the mechanics of history-taking, that lesson has served me as a safeguard against the temptation to see only symptoms and to forget the person they inhabit. It has also provided me with greater confidence in my patients. Like most students, I enjoy taking part in exercises with our brilliant surrogates, who so vividly portray such nemeses as “The Seductive Patient,” “The Aggressive Patient,” and so on. But useful as these exercises are, they can become simply tests of one’s composure in the face of escalating provocation, a kind of cage-match in which the “patient” is instructed to respond to every intervention with more of the same. It is instructive to recall that Rafael, a “Depressed Patient” by anyone’s account, was perfectly capable of laughing at the absurdity of the telenovela we both loved, if one only took the trouble to discover he was a fan. Real patients are not indifferent to the responses they elicit. They usually act in the imperfect but fathomable ways of the people you have known before.

In retrospect, the lessons I acquired by working with Rafael were perfectly pitched for someone like me at the bottom of the medical pyramid. Unlike the interns and residences who are several years ahead of me, I do not have enough knowledge in my brain to worry that technical prowess is crowding out my capacity for empathy. For a student at my stage, a textbook of medicine still makes for heavy lifting—when you read it, not just when you carry it. Coming onto a clinical service for the first time brings a further hit on one’s self-esteem. It is like intruding upon a close-knit family: at its head, the matriarchal or patriarchal attending physician; one tier below, a cohort of degree-bearing house staff “siblings;” and several leagues farther down, toiling on sufferance, the medical student—a distant and sparsely educated cousin.

And yet (another paradox) giving up illusions of premature competence—learning clinical modesty—allows you to see that you arrive at medical school knowing a great deal more than you think you do. That is because you have already learned something indispensable to the practice of medicine in struggling to become a moral person: you do not need expert knowledge to make human contact, sometimes against the odds, and to lend comfort to a near-stranger. “To make human contact against the odds and to lend comfort”—the phrase probably sums up a good deal of the practice of medicine. It seems well worth remembering at this moment, with so much study ahead, that the phrase also defines a goal that can be achieved even by the awestruck medical novice, if she possesses enough incentive and a sympathetic ear.