In the hospital, separated from your classmates, you wonder if you can do it. The academic rigors of the first two years were supposed to prepare you for this, but nothing can prepare you for this. The patients aren’t questions on exams anymore. Their suffering follows you on the wards, where you trek from service to service every few weeks, reporting to physicians who grill you and grade you.
This is your rite of passage. This is third year.
Yesterday he helped suction blood out of a woman whose aorta — a vessel that carries blood from the heart —was bleeding into her abdomen. The aortic walls were fragile, and the surgeon had to cut them to sew them up right. Blood pooled in her abdomen as fast as Norton could suction it. The sutures threatened to tear through the walls. But the surgeon kept working, snipping, slicing and sewing, fixing her.
During this rotation, another surgeon will tell Norton, “We’re the same as other doctors, except two days a week, we get to go to the playground.” Yesterday was one of those days, where life and death teetered like a seesaw.
A third-year medical student, Norton knows how to tie knots like the Eagle Scout he once was, place nasal gastric tubes and Foley catheters, even drive the little camera in laparoscopic surgery. But he still hasn’t managed to impress Dr. R. Matthew Walsh, a general surgeon who specializes in pancreatic surgery and the one in charge of him today.
During back-to-back gallbladder surgeries, Walsh pummeled Norton with questions about cholangitis, an inflammation of the bile ducts from which both patients suffered. He followed up Norton’s answers with, “Are you sure?” Again and again. “Are you sure?”
When Norton was wrong, a new line of questions followed. When he was right, a new line of questions followed.
Norton is among those medical students who ace most of their exams and pick up the physical part of being a physician easily. They’re used to smiles of appreciation from their instructors, who record their performance as “thorough” and them as “motivated” on evaluations. They thrive under the kinder, gentler instruction of the modern medical school.
But Walsh is not an instructor for the self-esteem junkies of Norton’s generation. If surgery is the playground, some see him as the bully. But is it bullying or conditioning? That depends on whether you can take it. ￼
When Walsh, a tall, elegant figure with a surgeon’s slight stoop, emerges from a patient room, Norton snaps his head. Walsh is indifferent to him, writing something.
“Mike, do you have something to do?” Walsh asks without looking up.
“I’m preparing to see Mrs. ----?”
Mrs. ----’s online chart says her condition is “not disclosed via Dr. [Toby] Cosgrove.”
“I should see her,” Walsh says at first. Cosgrove is president and CEO of the Cleveland Clinic. In Norton’s mind, the patient has VIP status, and he’s not surprised that Walsh doesn’t want to bother her with a med student.
Then Walsh changes his mind and tells Norton to see her first.
“I saw Dr. Cosgrove’s name and thought you might want to see her yourself ...”
Walsh waves him off as he walks down the hall.
Unlike the first two years of medical school, the third requires some weight-pulling in real clinical settings. Even though the students’ work is double-checked by doctors, they still have a place on the team. Expectations must be met beyond learning. Histories must be taken, physical exams given and presentations and assessments made. Above all else, medical students don’t want to look like idiots. Next they want to be useful.
This would be easier if the students spent more time in each service, getting familiar with the culture and the personalities. But at Case Western Reserve University, the third year is characterized by short stints in the major services: internal medicine, surgery, family medicine, pediatrics, obstetrics and gynecology, neurology and psychiatry. The students complete two 16-week blocks during which they do clinical work and one 16-week block during which they do research, which is a feature of the school’s new curriculum.
At CWRU, administrators have married the study of medicine with that of public health, hoping to graduate better doctors who are more community-minded. Norton’s class of 2009 has had the most clinical experience of any third-year class to date. But it doesn’t seem to make things easier for him.
He enters the room of the VIP patient. About a half hour later he comes out and starts pacing again, studying a notecard he has pulled from the bulging pockets of his white coat. He spots Walsh.
“I’m ready whenever you are,” Norton calls.
“You’re totally ready.”
Walsh’s answer is neither question nor statement. He disappears into another patient room, leaving Norton to obsess over his presentation for a few more minutes.
“It doesn’t matter how thorough I am,” he says quietly. “Walsh will be more so.”
The surgeon flips through a chart as Norton begins: “She plans her life around eating and going to the bathroom.” Walsh asks about her allergies, her meds, her history of gallbladder disease, whether her colon’s enlarged. He asks Norton to tell him everything causing her pain, if she has cirrhosis.
“If I take her gallbladder and she has cirrhosis, what’s the chance she could die?” Walsh asks.
“I don’t know.”
After more questions, Norton follows Walsh into the patient’s room, his forehead shiny with sweat. When he comes back out again 20 minutes later, Norton looks shaken.
Walsh leaves him standing there thinking about why he didn’t tell him about the C-section scar or the severe and persistent pain in the right upper quadrant of the patient’s abdomen.
Disappointment spreads across Norton’s face like a rash.
For almost 20 minutes, Franco conducts a completely average checkup. Ears are clear. Throat looks good. Reflexes perfect. She learns that Delia still likes dolls, hasn’t started her period yet and won’t wear her glasses because her friend told her they look ugly. Then Delia’s mother tells Franco that one of the girl’s prepubescent breasts hurts.
“How often does that happen?” she asks, suddenly concerned. “It may be a normal part of breast development. I’ll check.”
When she examines the girl’s chest, she notices the left nipple has what looks like a vein running through it. The nipple hurts when she touches it.
Franco excuses herself from the room and sits down at a computer in the hallway. She takes a sip of her soy coffee drink and looks up the Tanner Stages of Sexual Development. She’s comfortable at the Thomas F. McCafferty Health Center on Lorain Avenue in Cleveland, but there’s still so much she doesn’t know. Dr. Wendy Cicek greets her from the phone across the hall. She’s on hold with an insurance company trying to get a preauthorization. This is good use of physician time, she says sarcastically.
Some patients at McCafferty, a center affiliated with MetroHealth Medical Center, speak only Spanish and have trouble navigating the health care system. According to the Centers for Disease Control, Hispanics are more than 14 percent less likely than whites to seek and receive health care coverage, which may be why they have poorer health and higher rates of serious disability and death. Cultural barriers often get in the way, as do language problems.
That’s one reason Franco loves it here. Of all the clinical experiences she’s attended, this is the one that most fits her ideal: It serves a poor population — her population — or the population she was part of while growing up in Jamaica Plain, a Latino neighborhood near Boston. The doctors were good there, but they didn’t speak Spanish well, and, as a child, she became the spokesperson for her family’s health. At McCafferty, most doctors do speak Spanish, and the cultural disconnects seem to be fewer than at the Boston clinic. Once patients realize Franco is Dominican, they open up about all the home remedies. When one patient told her he uses Vicks VapoRub for everything, it didn’t surprise her. A member of her family did the same thing.
Franco writes notes from her visit and her research on a notecard, which she holds like a security blanket in front of Dr. Douglas Van Auken, the always-busy medical director. Presenting a case is still tough, though she’s gotten better at it since her surgery rotation, when there were times she couldn’t muster the courage to speak. She goes over her speech in her head and swallows hard. Once she begins, she tries not to stutter. Van Auken listens, most of the time without making eye contact.
“She has no issues whatsoever,” Franco says in closing. “Just breast tenderness.”
No medical issues, maybe, but Van Auken continues to bring up new subjects that could affect her well-being. What activities is she in? Is she reading much?
“It’s important to talk to her about strangers,” he adds. “Two girls about her age disappeared around here.”
He’s referring to Amanda Berry and Gina DeJesus, West Side girls who disappeared in 2003 and 2004, respectively. Neither have been found.
Franco didn’t know that. She adds “abduction” to the long list of things to bring up with this patient population, these younger versions of herself.
Later, in the patient room, Van Auken retraces all of Franco’s steps. He tells Delia’s mother not to worry about the breast soreness.
He tells Delia to be aware of her surroundings when she’s outside.
“If someone talks to you on a busy street, what do you do?” he asks.
“Run!” Delia answers.
“Good. What else?”
“That’s exactly right.”
This is Gentry’s second day with Dr. Richard Krasuski, an attending physician at “the nation’s No. 1 heart program,” and she needs to not blow it.
She found out recently that a doctor-instructor from second year gave her a negative evaluation. And she’s had other bad clinical experiences, one so uneventful she passed the time snoozing at the nurses’ station.
She knows she needs to work on her motivation, but she keeps dreaming of becoming a housewife.
Gentry does not want to be a “gunner,” a med-school star who tries to excel at everything. She wants to be good at what she will do one day, in her chosen medical field. She also wants a husband and kids, and she’s not been afraid to say so.
Still, she could have been more of a self-starter; she could have been more thoughtful with her words. She could have asked for more feedback earlier. In year three, Gentry is determined to turn things around and hopefully find her place in medicine in the process.
Today, she couldn’t have a better patient, a smart, talkative 31-year-old single woman who runs a few miles three days a week. She went to her local hospital after having chest pain that lasted all day, got better, then seemed to turn into bad upper gastrointestinal pain. Routine tests yielded nothing helpful. When they wanted to do a heart catheterization, an invasive procedure, she came here.
Yesterday, Gentry spent a long time with the patient and her parents. Today, the patient complained about being awakened six times during the night and giving the nurses what seemed like gallons of her blood. Gentry smiled sympathetically and listened to her heart. Sounded good to her, but she’s still learning to listen to heart sounds. One cardiologist told her you have to hear something hundreds of times to be sure what it is.
On the eleventh floor, Krasuski’s team gathers around a too-small table. Like Gentry, some have been there all night, handling patients who range from Gentry’s seemingly healthy young woman to a lifelong smoker. In their heads are stats and studies, social and physical histories and questions for Krasuski, a Harvard Medical School graduate with a gentle, mannerly way that belies a fierce intellect.
Members of the team take turns presenting. Krasuski, an expert in adult congenital heart disease, listens, questions and offers insight, usually in that order. He asks the most questions of Gentry, who maintains her calm demeanor that some have mistaken for aloofness, even when she admits she has no idea what answer he’s looking for.
“Oh, man,” she says in response to a drug-related question. “I’m blanking because I’m under stress.”
“You can ask for a consult from a pharmacist,” Krasuski offers.
And so it goes on like this, for more than two hours.
The willful infliction of humiliation on a medical student is called “pimping,” but Dr. Dan Wolpaw, a CWRU professor of medicine in charge of the clinical curriculum, explains that questioning is necessary to “diagnose the learner” — find out what a student knows and how to help her learn what she doesn’t. True pimping still happens, but not nearly as much as it used to, Wolpaw suspects.
At the end of the meeting, they still don’t have a diagnosis for Gentry’s patient. Every test she took was fine except one. It may be a false positive. But Krasuski says there’s a slim chance she could have acute coronary syndrome. He decides she needs one more test to rule it out.
For the rest of rounds, Gentry follows Krasuski in and out of patient rooms, observing his bedside manner, which is both pleasant and intense. “Can I have a quick listen?” is how he asks patients to let him listen to their chests. “I know you’ve already gone through a lot” is how he asks them for just one more test. Even though his phone rings every few minutes — he’s in charge of approving transfers to the hospital today — causing him to duck out of the room, he doesn’t forget Gentry. When he has a quick listen, he makes sure she does, too.
“Lead the way,” he tells her at one point. “You’re the doctor.”
In November, Franco finds herself standing before the attending physician in psychiatry at University Hospitals Case Medical Center, wanting to disagree with him. She hardly resembles the nervous third-year student she was, the one afraid to open her mouth in front of attendings. It helps that psychiatry has been one of her favorite rotations. Although it resembles the McCafferty Clinic very little — there are no cute kids getting checkups, no easy rapport with other native Spanish speakers — the inpatient psych ward is interesting and unpredictable. One minute she’s talking with a patient eating orange slices. The next she’s brushing them off her shoes.
The psych team asks her opinion on every patient. Most of the time she agrees with the attending physician, but not in the case of her most recent patient, a normally high-functioning bipolar woman. He wants her released. Is he sure, Franco asks, given the woman’s obviously speeded-up speech pattern?
Regardless of whether he ends up agreeing with her, Franco is glad she has enough confidence to challenge him. In June, she couldn’t get off her couch. She thought she was just exhausted from an incredibly tough first clinical block. It started with surgery, while she was still recovering from a strange illness that caused debilitating vertigo. Then, a surgeon pricked her hand with a scalpel in the operating room, necessitating AIDS and hepatitis tests. (Both were negative.) Throughout the rest of the 16-week clinical block, she rushed from service to service, never getting fully acclimated to any of them. When the block finally ground to a halt, so did she.
Days on the couch turned into weeks on the couch. She cried at every little thing. Her mother visited in August, and that cheered her up. But when she left, Franco cried more. She left her apartment only to get groceries. Once in a while, her boyfriend, a salsa instructor, got her to salsa night at downtown nightclub The View. She never stayed long.
Franco knew depression is common among medical students. According to a 2005New England Journal of Medicine report, “White Coat, Mood Indigo — Depression in Medical School,” medical students are more prone to depression than others their age because of the emotional and academic strain involved in becoming a doctor. They seem most at risk during the third and fourth years, when they are separated from their peers and frequently moved into new situations with unfamiliar physicians. Often these experiences include the students’ first encounters with illness and death and “may unmask psychological vulnerabilities.”
Even though student doctors can often diagnose depression in others, many don’t seek treatment themselves. Like Franco, who even hid her symptoms from her friends and family, they fear a depression diagnosis could limit career opportunities. One study showed residency directors were less likely to ask a candidate to interview if he or she had a history of counseling, theJournal pointed out.
Franco was supposed to spend the summer interviewing low-income women about the human papillomavirus vaccine. Instead, she spent it watching daytime television. In September, people at the school contacted her friends, who contacted her family.
The phone tree of concern helped her snap out of her funk, as did the realization that she was risking her future. She had pursued her dream of becoming a doctor all the way from the hospital where her mother worked as a nurse in the Dominican Republic to Jamaica Plain to Brown University to medical school, and she wasn’t going to stop pursuing it in her third year. She suspects the idleness of the research block contributed to her problem, and she decided against taking time off from school. She changed the order of her coursework, first doing her electives and delaying the research block. She started seeing a counselor.
One doctor who became depressed in med school warned Franco about the psych rotation, but it’s only made her more empathetic. She’s seen so many professionals, so many “normal” people with “normal” lives. Psychiatric diseases don’t discriminate.
As if on cue, the patient Franco wants to keep in the hospital starts talking really fast, as if someone pressed the fast-forward button on a tape recorder.
Witnessing this, the attending decides Franco was right about the patient acting too manic to be released.
At the end of the rotation, he asks Franco if she’d consider becoming a psychiatrist.
When the fourth year of medical school begins in the spring, Marleny Franco still wants to be a pediatrician, though she’s not sure about the specialty. She regrets not completing her research on time, but it did give her one advantage: She took her electives, which are part of the fourth-year curriculum, early. After one in pediatric gastrointestinal medicine and one in adolescent medicine, she’s sure she wants to work with sick kids — a diverse population of sick kids.
“I want to work in the inner city,” she says. “I feel it’s my duty. If I’m not going to do it and I come from there, then who’s going to do it? And I want to do it.”
Norton and Gentry have changed their minds about the sort of doctors they’ll become.
Dr. Walsh was the toughest instructor Norton ever had. He taught Norton a lot about surgery and identified what may be Norton’s biggest problem: his compulsiveness, which Norton thinks may be a side effect of his attention deficit hyperactivity disorder.
The surgeon advised him to stop looking for a clean clinical picture, the kind Norton can always figure out on exams. Real people are more complex; they have a variety of ailments. Sometimes they don’t tell you what you need to know; sometimes they lie.
“He is bright and has a very good fund of knowledge,” Walsh wrote in his evaluation of Norton. “Overall, his performance has been quite good and he may consider a career in surgery.”
For most of his third year, Norton planned to become a surgeon. But then he took an anesthesiology elective in April. He watched an anesthesia team quickly and safely sedate a man with a life-threatening postoperative hemorrhage, so the surgeons could cut him open again. Even though the specialty isn’t as sexy as surgery — the man’s family is more likely to remember the surgeons who saved his life than the anesthesiologists who made him comfortable — Norton thinks he’ll like it.
Anesthesiology offers plenty of intellectual stimulation, and the lifestyle will afford him mor
12:00 AM EST
July 23, 2008