“Man
is descended from a hairy, tailed quadruped probably arboreal in its habits,”
said the famous Charles Darwin. On the contrary, a medical student has
descended from highly motivated, persistent, intellectually curious do-gooders.
It takes a long shift on the internal medicine service to create the being
Darwin referenced, hairy and crawling on all fours.
The
evolution of a medical student is a beautiful one, at least in retrospect. Just
as the iconic photo, The March of Progress, depicts man growing taller, walking
erect with a sense of confidence and professionalism, medical school causes a
similar progression of growth and poise. The March of Progress shows man evolving
over a period of 25 million years. Medical school on the other hand is only
four years- four short years to devote to the roughest part of medical education
and four short years to develop into that strong and confident doctor walking upright
with pride. That was hardly fair.
Somewhere
around the second week of July (you think I’d have the date memorized or that
it would be beautifully engraved on some silver frame, but no), I began the
process of evolution. All I remember is that my summer had been cut short in
the year 2010 and it was likely the last time I didn’t complain about the
interruption, because I had waited for this day for so long. I started medical
school along with one hundred equally eager students- we began the journey that
we had spent at least the last two to four years polishing our resumes for. We
walked onto north campus like a bunch of Neanderthals, bright-eyed, bushy-tailed
with no grasp of the technical language, no sense of how to use the tools of
medicine, and definitely no understanding of how to properly interact with our
co-occurring species- the patient.
Anatomy
lab was a moment to reveal the weaknesses, which needed speedy improvement; a
moment to embrace the beauties of the human body; and a moment to evolve even
more rapidly than the peppered moth, which sprouted a pair of pure black wings,
as opposed to black spots on a white base in order to camouflage more
appropriately on the soot covered trees during the Industrial Revolution. This
scientific phenomenon had defied the widely believed perception of evolutionary
time, the idea that it is a painfully sluggish process that slowly progresses
through multiple millenniums, dozens of successive generations. And there we
were challenging the belief yet again.
It
took a class like Anatomy to serve as the point in which students evolve or
lose everything. Do or die. Anatomy became our Industrial Revolution, our
pollution gone haywire. The stress, the tests, the hours, the trials- they all
forced an un-natural selection and so we began to become a rare species,
doctors. We ever so slightly became more knowledgeable, but continued to hold a
dangerously small amount of information. Much of these details later proved to
be useless like the fact that the seemingly important bone, the hyoid, is the
only bone not attached to another bone, yet a fact that’s fair game for Dr. E’s
extra credit question. We learned everything then, because we had no idea what
would be important now.
What
took billions of years to evolve followed by nine months of in utero
development, just over a dozen years to mature, and a lifetime to age and
destroy had been laid out in ten weeks of lectures, learning groups, exam
questions, lab sessions, tutorials, virtual microscopy, and study sessions. The
beautifully intricate and perfectly created structure of the human body, as
well as the story of its creation from an embryonic ball of nothing to
carefully placed muscles, tendons, organs, and bones had been crammed into one
ten week block. It wasn’t until after that rapid two and half months that I
realized I had learned to think differently. I had more details to occupy my
mind, more information, more perspective. I recognized how flawlessly each
piece fits in its respective position. I tactilely confirmed it all- ran my
fingers between muscles that once flexed and relaxed with perfect timing to
allow for graceful movement and along arteries that at one time warmly coursed
with supple red blood cells. I held organs in my hands, while examining every
crevice and hole, memorizing their not-so-helpful eponyms. I had even taken a
human brain and stared at it for what seemed like days in order to identify
each thin and winding nerve, each sunken gyrus. Our peppered wings slowly
became less peppered and slightly more solid. Just as the peppered moth refused
to become prey to insectivorous birds among stained trees, we refused to lose
this opportunity.
I
spent most of my time with Spike, a generous donor with a frail body and knobby
knees. His naked and stiff body had initially been encased in a white plastic
bag no different than the couple of dozen other ones that lay atop newly
purchased steel tables with gutters to drain the spilled and oozing guts and
goo (a word not adequately replaceable with medical jargon). He lied among many
who had selflessly donated to this step in our growth as physicians and he was
the first person, I’d like to thank for contributing to my education.
Not
only had anatomy made us intimately familiar with the human body, but we began
to recognize that this vessel carries health and disease alike, emotionally,
physically and mentally. The object of
our obsession had unveiled well and sick lungs. The normally marbled pinkish-purple
lungs that were kept behind the protective rib cage sometimes exposed years of
smoke exposure. I squished Spike’s relatively healthy lungs with a single
gloved finger and they slowly and smoothly resumed their original shape, a
testament to the lifetime purpose of inflating and deflating with ease,
automatically and on command. Many of the blackish-purple lungs had lost their squishiness
like an old, soiled, overused TempurPedic mattress. We witnessed the
consumption of bodies by diseases we would later learn to prevent, diagnose,
and treat. Spike’s abdominal cavity was infested with cancer. It was sobering
as I stared into his belly and watched the cancer polyps adhere to any space sufficient
enough for a pedunculated tail to anchor on to. The malignant globs of
unorganized tissue lined the walls like bushels of small pale grapes with a
hint of black, but these were deadly and poisonous grapes that were learning to
out-evolve us.
Aside
from anatomy, we slowly dove into the basics of doctoring- this was the stuff
we learned and still mostly cherish, unlike the hyoid bone. After hours in
lecture and lab, we took additional courses that provided an introduction to
the patient history and physical, or rather the irreplaceable means of
attaining the necessary pieces to the puzzle. The H&P is equal to gold.
It’s equivalent to the discovery of fire or the invention of the wheel, all
tools that made life easier. And so a nugget at a time, we learned maneuver
after maneuver, which questions we should rattle off like beers on draft, and
tactical approaches to extracting the most sensitive of secrets.
Darwin,
a self-proclaimed workaholic, was also known for saying, “A man who dares to
waste one hour of time has not discovered the value of life.” What he meant was
“A man who dares to waste one hour not studying has not discovered success,” or
at least that’s what it felt like for most of medical school. The learning
curve had disobeyed the rules of a curve and had assumed the shape of a right
angle. I spent at least a couple of hours studying every single day and triple
on weekends. I relied on the company of my classmates, fellow study zombies who
are also deserving an enormous thank you. The circumstance in which we selected
for ourselves had caused a chain reaction of changes that led to our inevitable
growth. The hours spent studying filled our brains with the information and
mannerisms necessary to pass tests and move on. It’s like that expression: “When
we long for a life without difficulties, remind us that oaks grow strong in
contrary winds and diamonds are made under pressure.” We endured this to be
what we came to be- successful.
Following
this whirlwind of a block, we continued through genetics, immunology,
gastroenterology, nutrition, CV-pulm-renal, epidemiology, biostatistics,
ethics, and every other necessary subject. The first two years were a whole lot
of memorization, a whole lot of staged patient interactions with only brief splatters
of flustered, anxiety-inducing real patient encounters, and a whole lot of
tests.
Not
only had we learned to enjoy coffee for more than just the taste and aroma, we began
to realize how all these carefully intertwined systems perfectly came together.
The story, which had been painted onto a nearly blank canvas, had grown
beautiful with color and some detail. It still looked like a blurred piece of
art with areas smudged together and some spots unintentionally left bare only
to beam brightly with nothingness, but nonetheless it was a picture, decently
recognizable. We had become a unique breed of doctor impersonators, kind of
like the stage where man sort of walked on two feet, but didn’t do it well. We
were only 50% awkward with patients and our knowledge was there, but lacked any
in-the-field-practice. We knew which medication to give for what disease, but god
forbid someone asked about a dose, because those weren’t covered in lectures,
the book or Step 1, for that matter.
How
could I forget? Step 1. That one enormous little obstacle that sat in our way
of continuing the process of evolution. The step where you either act like a
giraffe and grow a longer neck to eat the plump nutritious leaves at the top of
the unevenly distributed tree, or you grow hungry, then weak, then die off, or
move somewhere else where the trees are shorter- usually not med school. My neck lengthened, most
of ours did, some more than others, so we moved on to Phase II. The peppered
moth evolved. It could have migrated away and occupied a more livable forest,
but it chose to stay and change (maybe unconsciously, because who knows how
much those little moth brains are capable of). We wanted to be doctors in the
midst of change, so we also stuck around to also change.
There
we were again, trekking up an unusually steep learning curve, fighting tooth
and nail like aloof cave men trying to stay alive. We couldn’t possibly let the
evolution train leave without us, because we had come so far and our loans had
grown so big. So we devoted nearly all of our free time between the 60 hour
work week to studying for the SHELF exams, which tie up the end of every block-
internal medicine, family medicine, neurology, psychiatry, pediatrics, ob/gyn,
and surgery. We moved along with the guidance of kind teachers, residents,
attending, and mentors who are also deserving of our gratitude.
Way
back when, the evolution of man from some hairy quadruped to graceful,
well-mannered, tool-using biped, involved the tripling of brain size. I’d like
to think that our very own evolutionary process involved some tripling of brain
size, or at least usable brain space, but our genetic information (with the
exception of maybe those subtle changes in methylated DNA) had not actually
changed so as to be inherited by our offspring (they might still be dumb, which
totally negates my theory, so forget I mentioned it). But the information and the
facts that flickered through our minds while encountering patients and their
misfortune had tripled if not hundripled. We could actually think up doctor
things and we often surprised ourselves.
As
newbies to every rotation, every case was a new case, even the routine ones. A
patient with the common diagnosis of Diabetes could be our first Diabetic. And
the second one would be so different from the first that it would be like
another new case for us. We saw all these diseases from Robins Pathology book,
but now they were attached to patients, their faces and their families. They
were real stories and we slowly gained context, but we also learned that our
patients weren’t cookie cutter examples like the books had taught.
We
learned the stages of grief in psych lectures, but we hadn’t learned to counsel
the grieving grandmother whose ex-daughter-in-law divorced her son and took her
two grandkids, which she babysat daily, half way across the county. This wasn’t
a case where someone had actually died. We also learned how to conduct
motivational interviewing and which addictions could be treated with anti-abuse
medications, but what about the young narcotic-addicted pregnant woman who was
getting ready to give birth only to begin her sentence in prison for illegal
possession of weapons. The soon-to-be-mothers I worked with taught me more than
any book. Addiction is pervasive and follows no
rules and as an outsider looking in, we will be helpless and angry, but
somewhere behind that mask of drug-addicted bewilderment is a person who
depends on us. The power to yield change
will never be as simple as the book teaches, but as physicians we need to try
anyway.
The case
that best demonstrated the novelty of our experiences was the old cleaning lady
who spent life on her knees and feet cleaning up after people. Her face was warped
with deep crevices haphazardly strewn about. She appeared much older than her
stated age, but she had the energy of young woman. She was bold and eagerly
shared her torments of being a cleaning lady for hotels along Central. She had
told me about the various dead bodies she had discovered and the eerily unique
positions she had found these once living people. She was jaded and my eyes
were opened to the realities that our patient’s face, the darkness that fills
their lives, and the things I could never comprehend. I had hundreds of hours of
lecture and not a single one had prepared me to counsel a woman who saw the
things this lady saw. If I reached back into the most distant of memories, I
could not recall that lecture entitled "The Struggles of a
Housekeeper on Central Ave." Ill prepared? Possibly, but surely the
medical school curriculum committee could not have anticipated such a scenario.
Textbooks
are supposed to be invaluable sources of knowledge, and they can be. But lives
have infinite opportunities for exploration, leading to infinite opportunities
for distinct outcomes. We could go to a century worth of lectures and still be untrained
for the challenges of patients. So in order to evolve into a doctor, we used
these experiences as a lesson that learning should continue each and every day,
because we will never know enough.
Third
year was a true test. We all went our separate ways, now strong enough to roam
the open land, hunt and gather, or settle and cultivate. We could disperse
freely into our rotations only to reunite on rare occasions. But we were all
doing more or less the same thing- adapting for fear of becoming an obsolete
species like Paranthropus which was
included in The March of Progress, but later discovered to be “an evolutionary
dead end,” not having led up to the creation of Homo sapiens. We adapted quickly, because we only had two months to
learn each entirely new field of medicine, and only a day or two at most to get
into the rhythm of the routine before it changed the next week or before a new
team came on service or because it changed and no one thought to tell the med
student.
We
were the med student, never really
remembered for our given name because we came and went so quickly. We were
expected to jump right into things when in reality everything was completely
new. We were expected to excel in patient care and development of differential
diagnoses, but we had no idea where to meet in the morning, or where to find
information in the nebulous EMR. And there was rounds! There were times on
rounds where I wished I could have fully camouflaged as nicely as those
completely evolved peppered moths, because it could become terrifying…
sometimes attending or chiefs wanted all the lab values, while some just wanted
the abnormal values, some wanted just the plan, others wanted 60 seconds, some
wanted the longer version, some wanted the whole physical exam to see what was
done and others wanted pertinent negatives and positives. Despite being pulled
in several different directions and despite continuously changing expectations,
we not only survived, we evolved.
I
recall a moment after third year. It was our final year, so my schedule was
much more accommodating of volunteer activities. I had signed up to work at the
local homeless shelter and was paired with a first year medical student. Our
second case was a hypomanic male, a veteran, or at least his fully camouflaged
gear suggested that. He complained of a cough that had persisted for just over
two weeks. The first year student had observed the first patient encounter, so
I urged her to take the reins the second time around. She was awkward,
flustered and had no natural flow to her physical exam, jumping from the mouth
to the lungs and back to the head again. Her patient presentation also lacked a
pattern. It was the pattern our very own evolution had engrained into our head-
subjective, objective (always starting with vital signs, moving to the physical
exam findings and ending with labs or other studies), assessment (a single
sentence compiling the pertinent negatives and positives followed by a
differential diagnosis), and a plan. Her differential diagnosis was a good
array of guesses, but not in any particular order and with no detail. Pneumonia
was pneumonia and her quizzical look when the attending asked “what type of
pneumonia” proved that I had in fact evolved into a different species. My mind
quickly scrolled with a more comprehensive differential for pneumonia. Viral
was most common, secondary to strep
pneumo, but the duration pointed to an atypical, perhaps mycobacterium. I
stood there staring at a younger version of the being that leads up to our
species. Lighter colors of peppered moths were still born for several years after
the trees were soot colored. The two variations of species, typica and carbonaria, co-existed, as we did in this small makeshift clinic,
as we would as long as the world needed doctors.
After
an adventurous third year, we were equivalent to the varying mockingbirds that
inhabited the different Galapagos Islands. We had all started as a similar
species but adapted to fit our niche. We
identified interests, gravitated towards our people, the people with shared
personalities and goals. We decided if we liked little people or big people,
women or men, cutting or talking, brains or bellies.
Now
here we are- all with striking differences, very different differences, but all
graduating from the same school with the same degree. All walking on two feet.
For now at least. It’s astonishing that we are the same creatures that share
over 98% of our DNA with chimpanzees, and yet were being released into the
world of medicine to observe, to unravel, to discover, and to conclude. We have
all earned our beautiful, completely black wings, the ones that will make us
more fit for survival in the field of medicine.
It
wasn’t a beautifully linear sequence of evolution so neatly depicted in the
iconic picture, but if you squinted your eyes, it was beautiful. Many people
met soulmates, best friends, future business partners, mentors. Through these
relationships we can continue to measure the worth of this journey.
“A
moral being is one who is capable of reflecting on his past actions and their
motives- of approving of some and disapproving of others,” again, words of the
gifted mind of Darwin. From here, we will part, many of us to different parts
of the countries and many will stay at our home school. And I hope that we will
continue to evolve, continue to embrace the opportunity to change and grow. Homo sapiens is Latin for wise man. It
can be such an undeserving title, but a title that captivates our potential.
Evolve on, Class of 2014, and spread your beautiful black wings. You earned
them.
