Dave and the person in the room

I spent my first two years of medical school occupied with three things: stress about pending tests, mourning my rapidly departing hair follicles, and gratitude for the library not having invoked eminent law to charge me rent. In contrast, my clinical years brought just a single truism. In spite of my newfound encyclopedia of knowledge, retreating hairline, and commitment to library vending machine diet, I was a third-year medical student who knew absolutely nothing about real medicine. I chased the carrot that is the understanding of human pathology; only to snag a small bite and find it was like any other carrot I’ve ever eaten—bland and unsatisfying. But it was not for nothing. I got to help people who were at their most vulnerable. Throughout my time on the wards, diagnosis of human malady and conceptualization of it have shown themselves to be two separate things for me. I have learned that they cannot exist separately in a vacuum if I ever want to be any good as a doctor; if I ever want to be any good as a person.

Six weeks into my third year, I was in Northern Arizona on a rural Family Medicine rotation. The learning curve was steep, the weather was beautiful, and the patients were eccentric. Being an eager, outdoorsy, and peculiar person myself, I felt home. Many of the patients at the clinic lived in the surrounding wilderness. For lack of a better word, they were “wanderers.” Some had diagnosed mental disorders, and many others were missing their DSM-5 stamp but were not lacking for the symptoms. They arrived for their checkups with the piggybacking disease you would expect of people living on the fringe of society. They had all of the traits hard living entails, not to mention the personality and inimitability to go along with it too. In my short time on the wards, my attempts to see enough patients, know enough facts, and just generally check enough boxes left room for omission. However, in my understanding, I thought I needed to rely on this approach to be a “good” medical student and have my efforts validated. It left little time for anything more in the hospital. At times I had to ignore the patients’ suffering to be fast and efficient. “It’s fine if they’re mostly fine,” I told myself. I was just trying to survive my days without incident and I thought that was ok. It was best to limit my thoughts to numbers and textbook responses. Those are objective, and I could hide behind that.

Part rehearsed speech, part sales, but ideally all human enough to warrant a connection, I knew how I was supposed to approach the patients. My role as a medical student at the Northern Clinic was simple. I entered the room prior to my supervising physician, took the patient history, and conducted the physical examination with the reason for the appointment as my guide. I would then report back to the doctor with an abbreviated summary and treatment plan. Hoping he agreed with my assessment, we would enter the room and he would doctor based off of my report. The questions I asked and my ability to “sell” my ideas about the responses were my utility, my grade, and therefore my worth. In this context, with the pressure not to disappoint and prove my knowledge, being ‘human’ was easily forgotten, inexplicitly absent, and unbeknownst to me at the time, it was infinitely important. In family medicine, the ability to treat is largely dependent on a patient’s trust and comfort. I didn’t have enough familiarity in the rural town but thought the wealth of knowledge my hair had died for would make up for it. I began to see that with these patients, and in this setting, it was necessary for me to be one hundred times the person I was, in one-hundredth the time. But the busy clinic schedule and complexity of the patient population further limited my conversations. Their complaints demanded more attention than I could give. It was difficult for me, but I cut any and all small talk. I addressed the problem as listed on the schedule under the name, age, and gender. My patient’s misery was categorized and prioritized exactly as I learned in the hospital. I was a good medical student.

At 3:50 p.m. on my third Friday, our last patient was roomed and waiting. Dave was a 54-year-old man in for a postop follow-up. He carried a unfortunate previous diagnosis of large bowel cancer that led to an ostomy placement just two weeks before. I was tasked to look for signs of infection or other surgical complications; strange coloration, clots, fevers, and all of the usual symptoms that a Google search could have qualified my grandmother to do. I could handle it. Dave was also schizophrenic. I earnestly read through his chart, disregarding some of the more personal but less medically relevant details of his life. I only needed his operative indications, current presentation, and to assess where we would send him next. I wanted to go home and so did the clinic staff. My physician preceptor on the other hand, threw me a simple caution as I exited his office, “be quick, but be thorough.”

Having an interest in mental health that began with dysfunctional family dinners and followed me into my prospective career, it occurred to me that on this one, I might actually heed this warning that I had brushed off the past two months while I was trying to learn “practical” medicine. I opened the door to find Dave taking turns stacking his thumbs over his fingers and looking down, as if awaiting a verdict from a damning jury. I began to take his history and was struck by his familiar demeanor. Kind, humble, and shattered. He was ‘healthy,’ he believed in medical terms, and couldn’t bring himself to think of a single complaint no matter how much I kept digging. I asked about his pain, nausea, and changes in bowel movements as I eyeballed his clean, dry, and nonerythematous wound. I wasn’t concerned. But I needed a full history to report per my attending’s prompting. So I continued with my questioning. Every time he pulled away, I pushed forward with another interview question, no matter how uncomfortable my questions were or how tangential they seemed as I attempted to gather my thoughts. He was stale from the immense amount of energy he spent trying to fit in. He continued to give me “normal” answers. The whole time, however, his obvious discomfort told a different story than his guarded words, as did the defeat on his face. It showed how he intellectualized normalcy and the toll it took fighting to fit that image. It showed his mind left him with a perceived debt to society that he could never actually pay we as medical professionals were some sort of loan officers. In that moment, I felt more like a bookie. Removed from the human component our interaction while feeding his misery and habit of being an outcast. And no good bookie gives up on a collection. His attempts to push off the questions were frustrating. They weren’t honest and I was too insecure in my lack of knowledge to settle for anything less than the full picture, especially under the pretense that this would be thorough. His demeanor was so soft and so benign—it didn’t belong in medical encounters. My prying lead me to ask him about his mental illness, and finally his words failed him. He went quiet. Forcing him to admit to his mental illness like so many healthcare providers had in the past made it clear he was a prisoner to it.

“How are the voices,” I sputtered—unable to think of anything else while remembering his chart notes about auditory hallucinations. “Still there, but I don’t listen. I know they’re not really there and I…” he paused. “They’re much better.” He squeezed his eyes tightly in embarrassment. Now, for the first time in the interview, I found myself feeling more than thinking. His thumbs stopped moving. Maybe if he froze long enough I would forget he wasn’t just part of the room’s décor. His silence screamed at me. I wanted to promise him that he was like everybody else. I just wanted to be a person, not a cog in system of helping, hurting, hating, and caring that is modern healthcare. But I was a bystander to his illness. As a bystander, I realized for the first time how peculiar it was that a profession designed to promote and permit humanity could have robbed me of it. Moreover, how cruel it was that we were never cautioned about this inevitable devolution. I reflected as he broke.

As a medical student, we’re worried about getting things done well. We are desperate to attain some degree of approval or self-worth to validate the toll the years of work have taken. Our souls are for sale. I imagine as we enter the workforce, the same threat will be looming. Validation comes from quotas, grades turn into salaries, and egos stay egos. An emphasis on just being quick and objective makes it difficult to truly feel great remorse for anything. Being efficient turns into not being fully present because half of your mind is always on the next room. We’re never fully in any one room at all, leading with our brains and forgetting our empathy. Instead, we learn how textbooks define perfect health. We believe that our will to subdue our humanity is healthy and any deviation from it is incompatible with life. We follow the flowchart, allowing for not the slightest bit of variability, and we move on.

Albert Camus said: “What matters—all that matters, really—is the will to happiness, a kind of enormous, ever present consciousness. The rest—women, art, success—are nothing but excuses. A canvas waiting for our embroideries.” Dave sat there waiting to be told his reality and harmless illusion was a sickness. He was ashamed after decades of everyone telling him how wrong his reality was. He wasn’t happy. That was his true pathology. He was a husk in a chair. I tried my best to get him to tell me how he really was. We spent 20 more minutes in the room and for the first time in my clinical year, I allowed myself to empathize.

As we spoke, he opened up more. He explained his illness, and I tried to comprehend how one man’s harmless and innate nature could become such condemning evidence against him. He told me more. Not all, but more. He opened up about his cancer, his family, his schizophrenia, and his friends. His concerted efforts to fit in began when he was diagnosed at 26, my age at the time. It forced him out of his career in the military and had been breaking him since. Neither his cancer nor his mental illness defined him as much as he thought. His love for his sister, passion for woodworking, and time in the military were just as interesting to me and equally impactful of how I viewed him. Eventually he expressed a single concern. He had noticed blood in his urine. This, compounded with his smoking history, gastric cancer, and absence of pain meant two things: a prostate examination and an increased likelihood of bladder cancer. Had we practioners not ostracized him through the decades, he would have mentioned it. Had I not allowed myself to be a person for a change, I would have missed it. I reported back to my doctor and we centrifuged his urine ourselves in the office. Unfortunately, there was no exaggeration or misunderstanding of his symptoms, as the bottom of the centrifuge tube was stained red. We sent him to urology immediately.

I guess the keepsake of my encounter was that we are meant to define ourselves by our own make-believe. There is a uniquely human component to this. This is too easily disregarded in medicine to meet the demands of the profession. It was ignorant of me to think I could be a renovator of humanity while opting out of it. Keeping in mind, at any given moment, there is a delusion in our own head unique to us can be uniting. While our interpretations and misconceptions of reality separate us, the universal nature of our happiness, fear, guilt, anger, and pain bind us. It’s unfortunate that some people are born with an interpretation so unique that they don’t fit into society’s paradigm of normalcy, because sometimes fate isn’t only in us, but around us. Whether it’s a fault of heredity or circumstance, I hope I never again forget that the same loneliness of Dave’s mind matches the potential of my own, with it’s different interpretation of life. The capacity for emotional anguish is one of the most pivotally defining factors of our humanity, and its recognition is necessary in order to empathize. When we as healthcare professionals, and we as society, assure others that our make-believe is a more correct one, we create conflict for them. When we dismiss it, we alienate them. Maybe we don’t create their idea of their illness on our own, but maybe we don’t make it much better either. Furthermore, in doing all of this, it is not only probable but also inevitable that we miss opportunities to help them. While I’ve been continuously impressed by the efforts I’ve seen put forth to “understand” patients, I am unnerved by how quickly in doing so; I forgot to just be another person in the room as well. I don’t know what the results were of his cancer screening, though I do often wonder. I think the lesson remains the same regardless. Whether or not he had cancer isn’t the point, because the fact is, he could have.

It was easy to forget the value in this as a medical student trying to gain my footing. It was also hard to fully conceptualize the notion that I was paying for the opportunity to view a unique component of human experience rather than anything quantifiable to hang my hat on. Life and school taught me to think in numbers and facts but left little room for empathy. Moreover, it taught me that was how to validate myself and how to judge others. But I now realize that my single realization that year was integral to my medical education and training as a person. Even when I knew nothing, I knew enough to be present. Any amount of knowledge is meaningless in my own absence, figuratively just as it is literally. When we disregard humanity, we may miss pathology and in doing so make our own. If disease is defined as a deviation from an accepted set point, then the disregard of humanity in medicine is itself, pathologic amongst our fellow man. In spite of everything I am and everything that I hope to become, I want to always remember the best and most important thing I can be is just another person in the room with the patient.