White Coats - Part 2

From the moment they put on this garment, tomorrow's doctors face a gauntlet of germs, gut-checks and gross anatomy.  A look inside the lives of three first-year medical students at Case Western Reserve University.  

When you wear the short white coat of a medical student, you are neither patient nor doctor. You are a tourist exploring the doctor side of the doctor-patient relationship. You follow someone else’s map, never knowing who you’ll encounter in the next patient room or what will be expected of you. Take this blood pressure. Start this physical. Help deliver this baby.
You don’t know.
You just hope that you can do it.
You start learning what you’re capable of.
And you find out how many frontiers you still have to cross.

The Pediatrician’s Office

In the MetroHealth Medical Center office of Dr. Mark Feingold, Marleny Franco sees a young mother wearing tight jeans, a sparkly top and an expression far too sad for a 17-year-old face. She avoids eye contact, looking instead at the baby who squirms in her arms and sucks at her hand.

As a pediatrician, Feingold is understated and serious. But the pockets of his white coat are filled with fun. Along with a prescription pad and tongue depressors, he carries a kazoo and two rubber balls, good for distracting young patients long enough for him to feel a tummy or look into an ear.

He starts the 7-week-old’s checkup by typing notes on the computer, turning around to question the mother and offer information, such as, “Your baby’s old enough for shots.”

When he inquires about the baby’s father, the girl begins to cry silently.

He was shot and killed in late May, she tells him, three months before her baby’s birth.

Franco studies the floor and worries she might start crying too.

It’s October, and she’s been shadowing doctors for a month already. In the past, first-year students had the option of following a woman through her pregnancy and delivery. But matching students with willing patients wasn’t easy. This year, administrators decided to expose students to the entire life cycle. It’s a feature of Case’s ambitious new curriculum, which merges the studies of medicine and public health.

In the two-and-a-half-month-long Rotating Apprenticeships in Medical Practice (RAMP), students observe doctors working in labor and delivery, pediatrics, emergency medicine, mental health, adult medicine and end-of-life care. After completing RAMP, each student will visit the same clinical setting weekly in the Community Primary Care Preceptorship program.

Ultimately, Franco’s class will have more clinical experiences than any first-year class in the medical school’s history, says Dr. Daniel Wolpaw, chairman of the Clinical Curriculum Council.

The apprenticeships are the first time patients see the students in their white coats. The educational quality of the sessions depends on the doctor (called a “preceptor”), the patients and the students’ luck. On a busy night in an emergency room, for instance, Mike Norton probes the failing liver of a former drug addict with Hepatitis C. On a slow night on a labor-and-delivery floor, Millie Gentry passes the time leafing through a baby-name book. The rest of her apprenticeships are similarly frustrating, while Norton’s and Franco’s vary.

Franco watches Feingold hand the crying girl a paper towel so she can wipe away her tears.

The girl tells him she’s OK when he asks. Really.

They start talking about the baby, her eating, her sleeping, her pooping.

“Hello,” Feingold says to the infant as he takes her from her mother. He checks out the rash on the baby’s head. It’s “cradle cap,” a common skin condition that causes the scalp to flake or scale.

He shows the rash to Franco and another medical student before going back to typing patient notes. Then he swivels around to face the girl again.

“I don’t usually do this,” he says. He tells her he knows a little about what she’s going through. His father died when he was 3 months old, and his mother had to work. It’s really tough, he says. And it’s OK if she needs some help. She can call him anytime. He assures her his answering service will deliver the message.

She nods, then he turns around to type some more. She opens her mouth and a question tumbles out, very quietly: When her daughter cries, why doesn’t she see tears?

Feingold doesn’t hear her. Franco repeats the question so it’s audible.

Yes, that’s normal, he says. Babies that age don’t have a lot of tears.

The girl looks relieved. When Feingold tells her the baby is a bit heavier than average, she even smiles. Franco gives her a look that says, You’re doing a good job feeding her!

After the baby’s checkup, Franco follows Feingold to other appointments. She hears him give advice on everything from how to prevent diaper rash (apply Desitin cream) to how to keep jean snaps from irritating eczema (paint them with clear nail polish).

He gives a free book to each child.

Franco marvels at the ease with which patients and their parents talk to Feingold, at his ability to be both straightforward and reassuring. In three hours, she never sees him take a break.

Although Franco likes pediatrics, she doesn’t want to be a general practitioner. Ever since she worked with seriously ill children at a summer camp in Connecticut, she’s wanted to help really sick kids.

She doesn’t get overly saddened by them, like some people do. She’s seen the happiness on a wheelchair-bound kid’s face when he climbs into a hot-air balloon, and really, there’s nothing like it.

More than keeping healthy kids healthy, she likes to help sick kids feel normal. So instead of pediatrics, she’s considering pediatric oncology.

Gross Anatomy
Exam: Limbs and Back

During the introduction to Anatomy in October, subject committee chair Barbara Freeman gave the students some advice: “Anatomy is not difficult,” she said. “But never underestimate the volume of the terminology.”

During one lab, an anatomist joins Franco and Norton’s group, sliding his hand under the trapezius muscle and lifting it to show them the rhomboid major and rhomboid minor.

When Franco asks him something, using the word “upper,” he cuts her off.

“You need to use terms like ‘superior,’ ‘inferior,’ ‘major’ and ‘minor,’ not ‘upper’ and ‘lower,’ ” he says.

Anatomy is a new language. If you want to learn it well, you need to do more than read and attend lectures and labs. Gentry draws “stories,” including one of the brachial plexus, a network of nerves in the armpit, featuring “dudes” and “girls.” Norton learns by studying images. He finds the material really sticks when he tries to teach it to someone else. Franco studies with upperclassmen. She also uses flash cards and mnemonics. The students have made some up themselves. Some have been passed down. All are raunchy.

“Steven Tyler likes sex and pot,” for the branches of an artery, for instance. And for bones of the wrist: “Scared lovers try positions that they cannot handle.”

It is, in effect, an end-justifies-the-means sort of endeavor. How do they learn the anatomy? Any way they can.

The studying lasts into the early morning of exam day. Franco, wearing a sweatshirt and pajama bottoms, works in groups and alone at her desk through the night, sleeping for just 45 minutes on a couch on the fourth-floor lounge. Everyone is stressed. One student actually pulls out strands of her hair.

At the practical part of the exam, the students travel from station to station in the lab, trying to identify structures tagged with colored flag pins. The cadavers, most on their stomachs and dissected in some places down to the bone, look like real human pin cushions, pierced across their backs and arms. The joints are waxy and dull, like things a dog would enjoy chewing. The limbs are elevated on blocks, the fingernails and toenails often long and jagged. Some still have polish on them.

In the lab, Norton seems deflated in his green scrubs, as if the sharp tip of the pencil sticking out from behind his ear just punctured his frame. Two days ago he woke up with a debilitating migraine, the kind with double images and colored spots. He was better yesterday. If this were college, he could just cram. But he can’t cram Anatomy. There’s just too much to learn.

He didn’t follow the schedule he needs to keep it all manageable — and to keep his ADHD in check. His medication, Dexedrine, a stimulant, helps control the symptoms, but it isn’t ideal. He thinks it causes the migraines. And he has to take the drug early in the morning because he’s likely to be up for the next 10 hours. It makes him really tired in the late afternoon, often causing him to fall asleep while studying in the scoop-shaped chair in his bedroom. (After his nap, though, he can study for another eight hours.)

Routine is the answer. Routine in studying — reading before class, highlighting, underlining and boxing important information. And routine in the rest of his life — cleaning, reading Scripture, family time happening regularly, every day.

But since becoming a father, routine is as elusive as sleep with a 6-week-old who drifts off only when she’s held. To complicate things, baby Megan has a cold. And Norton just caught it.

A bell rings, and Norton, congested and miserable, moves to a cadaver with a pin sticking out of its chest. He bends down to study it, then scribbles the answer on his clipboard.

“That one was easy,” he whispers, relieved. Then he moves to a station with a pin sticking out of a thumb. Question: “What spinal segment supplies the skin pierced by the red flag pin?”

With exactly 75 seconds before the bell rings again telling him to move to the next station, the look on his face is not so certain.

A cadaver on which he has to identify structures is the one his group is dissecting. It was the body of a 94-year-old woman who died of multiple organ failure. The cadaver is twisted, as if the woman died just as she was trying to get up off of the floor.

Norton walks out of the lab after visiting all 25 stations; he’s sweating.

“Sixty-five percent is passing,” he says. “If I blew it, then oh, well. I’ll just have to work harder.”
A friend, who will take the practical exam with the next group, passes him in the hall.

“How’d it go?” he asks.

“What the hell, man,” Norton says. After the friend passes, Norton adds, “Sometimes, unless you spend 900 hours studying it, you’re not going to know.”

He worries he failed. And for someone who hasn’t gotten a “C” since seventh grade, that’s hard to take. What’s worse, he feels he’s letting everyone down — his wife, his parents, God, his teachers, all his future patients. Sometimes the weight of their expectations is harder to carry than the burden of ADHD, which he’s shouldered since he was a child. At least he’s used to that. But he wears his new white coat like a promise. I’m up to the task, it says. I deserve to be here more than all the people who didn’t get in because I did.

Norton stays in the mostly empty lecture hall until all the groups have taken the exam. Then he walks through the test with the committee chair, who goes through the answers. Norton realizes he didn’t do as poorly as he thought and thinks he may not have failed after all.

About a week later, he finds out he passed.

He always worries too much about exams. He’d stop that if he could. He just can’t.

The Heart

Over time, the students’ relationships to the cadavers change.

Norton finds himself increasingly desensitized. The first day, he felt “creepy” cutting into dead human flesh. A few weeks later, he reaches in and separates the connective tissue with his fingers without thinking about it. Gentry sometimes rests a book on her cadaver’s bag-encased head or leans on him.

Franco feels the pull of desensitization, too, and fights it.

“I’m surprised that I don’t remember that she was human sometimes,” she says. “I just think, I’ve got muscles to learn.”

Sometimes, the hair sticking out from the head covering reminds Franco that blood once flowed through the body’s flattened arteries and life once warmed its death-washed skin.

A few weeks into Anatomy, while working in the lab with a third-year student, Franco wants to see the face. Dissection of the head and neck happens during the second year, so students tend to keep the face covered until then. But Franco wonders if she can handle it. Better to find out now with an understanding third-year student than with a lab full of her classmates, she thinks.

When the third-year student pulls up the bag, Franco sees an old woman’s face ringed with hair that is both dark and gray. The pained expression surprises her. Aren’t people supposed to look peaceful when they die? Franco runs her gloved fingers over the ashen cheeks, wondering if she had anyone who loved her and what her last days were like. Did she die alone? Could she even get out of bed?

As much as the face saddens Franco, it’s the still lifelike hands that unsettle her.
And it’s the heart that moves her.

During Cardiology, she uses an electric saw to cut through the ribs so the whole breast area can be lifted off like a lid. The smell of shorn human bone is distinct from that of the embalming fluid — organic and strong, like the way a chicken bone smells when it’s chewed. Franco cuts the heart out of its cavity and holds it in her hand, thinking, Oh, my God!

And she’s not the only one.

“I’m holding a human heart,” Norton says. “This is cool.”

On heart-dissection day, the energy level, which has been waning, suddenly spikes. The students go about the dissection with thinly veiled amazement, taking turns holding the disembodied hearts, gingerly washing them off in the sink and comparing them.

“His heart is super big,” determines Gentry, blinking from either disbelief or the fumes or both.

She needs two hands to hold it steady.

But her cadaver’s heart isn’t the biggest in the room.

There’s something in the grocery store produce aisle to match the size of every one of these hearts. The largest, padded with fat, is nearly cabbage-size. Another looks as big as a cantaloupe. Franco and Norton’s cadaver’s heart resembles a small Thanksgiving gourd in shape, but even it has too much fat on it.

“This is bad diet,” says the physical anthropologist helping them with the dissection. “You shouldn’t have too much fat on the heart.”

There’s no limit to the ways in which med school is a wake-up call. How would their hearts look in someone’s hands?

Continuous Quality Improvement

The small group starts at 8 a.m. in a cramped room with bookcases, a step ladder, even a minifridge.

Franco is there. Norton is not.

In the last Science of Clinical Practice meeting before winter break, they won’t be debating any intractable societal or medical problems. Unlike when the topic is the inequitable health-care system or the epidemic of medical mistakes or the drawbacks of prenatal testing, each student will have to carry some of the conversational burden today.

Their Continuous Quality Improvement projects are due. Over the past several months, they all have tried to improve something about themselves. First, they came up with a plan. Then they collected and analyzed the data. Today, they will report on the success or failure of their experiments.

One student, who wants to read more for class, studies whether getting more sleep helps her achieve that goal. Another tries to increase the amount of vegetables in his diet by keeping frozen vegetables in his freezer. Still another, concerned about the appearance of his acne-prone skin, analyzes how certain activities affect it.

Franco wants to go to the gym more. She put her entire presentation together last night.

Wearing glasses, khakis and a blue “Case Med” sweatshirt that reads “Is there a doctor in the house?” on the back, Franco turns her computer around to face the group.

She explains that her gym-going has decreased from three to four times per week before medical school to two to three times per week in August to about one time per week in September.

She thought finding a gym buddy who plays racquetball might help her reverse the trend.

She points to the graph she made on her computer screen. There were more trips with a buddy than alone, but she’s still not up to her pre-medical school workout regimen. So she has joined the intramural volleyball team, she says.

The end.

One of the facilitators notes that her presentation was “all anecdotal.” He mentions something about needing “outcome measures.”

Norton arrives. He says his ride never showed, so he had to walk to school.

“I should have chosen getting on time to SCP as my project over exercising,” Franco chimes slyly. “I’ve been good at that.”

Before the facilitators dismiss the group, the true goal of “Touchy-feely Tuesdays” is reinforced. It isn’t about busywork and guilt trips. It’s about making future doctors want to live up to even higher standards than society has set for them.

“Rarely will you ever be assessed by anyone in medicine who knows more about yourself than you do,” says Dr. Ted Parran, SCP’s co-director and an associate professor of internal medicine.

“Patients won’t be able to tell if you’re good at all. They’ll be able to tell if you’re friendly, affable, available. But they won’t be able to tell you if you’re able.

“My chief of medicine can’t tell if I’m worth a rat’s you-know-what as an internist. Only I can tell.”

Failing

Coming from a small undergraduate college where students receive a great deal of one-on-one attention, Gentry feels more isolated from the faculty at Case. She even ended up hating Anatomy, which seemed so promising in the beginning. (She felt Neuroanatomy, taught by Anatomy chair Barbara Freeman, was an “awesome” exception.) There were so many different instructors that she didn’t know who would be able to answer her questions. The residents, who were helpful in the muscular-skeletal committee, didn’t come into the lab for the other committees.

In Science of Clinical Practice, instead of just talking about the poor, Gentry wishes the students were made to go out and encounter them. She’s heard of similar courses at other medical schools where students learn about the medical needs of certain groups through firsthand experiences, such as wearing a blindfold to experience blindness.

Through November, Gentry continues to pursue a life outside of medical school. On weekend nights, she goes dancing at Spy Bar and enjoys vodka sodas at The Boneyard. She cooks. She shops. She runs. She skips classes. She spends an entire day baking holiday cookies for her friends and puts them in their mailboxes at school. When she starts feeling guilty about not studying enough, she thinks about what doctors have told them about the importance of making time for yourself.

Then she fails the Cardiology exam by two questions.

“I’m not used to being the stupid girl,” she says.

Granted, she only studied a little for that exam, one of four given on the same day. She focused her attention on the Pulmonary exam and the Anatomy practical instead.

She didn’t really study Histology either, but she aced that test. She always does well in Histology, the study of tissue. If she wanted to be a pathologist, she’d feel encouraged right now.

“I’m like the idiot savant of pathology,” she says.

But she doesn’t want to search for disease in tissue samples. Gentry likes kids, and she would consider pediatrics if she thought she could earn enough to support the standard of living she wants and pay back all her school loans, which will total more than $224,000 when she graduates, not counting interest. But pediatricians are among the lowest compensated doctors, earning between $150,000 to $170,000 on average, according to recent surveys. And they’re on call a lot.

Gentry is considering dermatology, which pays better and has better hours. It also happens to be one of the four most coveted fields in medicine, the “D” in the “ROAD” that also includes radiology, ophthalmology and anesthesiology. U.S. News and World Report recently noted that salaries for some of those specialties range from $250,000 to more than $600,000. Also, those specialists tend to have more time for themselves than other well-paid specialists, such as surgeons. But you have to be good. Really good, because residencies in dermatology are incredibly competitive.

And failing a committee is a definite ROADblock.

“I still don’t know how I’m going to be a doctor,” she says.

Franco expressed similar doubts after failing Biochemistry back in September. For the more recent exams, she got mired in studying for Cardiology, which she passed. When she finds out she failed Pulmonology, she cries all afternoon. Then she goes home and sleeps. When she awakens, she cries some more before deciding, I don’t have time to cry.

If a student fails one committee, she has to meet with her society dean and the committee chair and take another test (or some other assessment determined by the committee chair). If she fails two committees in a three or four-month block, she has to take the Mastery Exam, a cumulative test that covers every subject learned during that block — even those she passed.

If she fails the Mastery Exam, she’ll have to go before a faculty committee, which will determine what happens next. The committee can require a student to take a leave of absence, repeat the year or leave the school altogether.

As the first-year students break for winter, Franco flies home to Boston for a week. The Mastery Exam she’ll take Jan. 6 crowds most everything else out of her mind. But she doesn’t tell her parents about it. Every time her proud mother calls her “my beautiful genius,” she wants to climb out of her skin. She does confide in her mentor, a doctor with whom she did childhood asthma research, but downplays the test as a mere annoyance. He and his wife hold a gathering in her honor at their Providence, R.I., home. They serve baked chicken and sweet potatoes, two of her favorite foods. She smiles and schmoozes with the head of the lab where she used to work, one of her recommenders for the Jack Kent Cooke scholarship, now providing her with up to $50,000 a year for Case.

“I felt like the biggest fake,” she says.

Franco worries about jeopardizing her scholarship. That, for her, would be the hardest thing to bear. She has exceeded people’s expectations her whole life. Many kids who started where she did still live in the ghetto. But she has proved that a poor Latino girl can get an Ivy League education and win a prestigious scholarship to medical school. For her, flunking out is unimaginable.

She flies back on Christmas Day and retreats to her deserted third-floor apartment on Hampshire Road, where she studies by herself for a solid week.

Other students are taking the Mastery Exam, but she doesn’t know who. So she lets word get around that she is taking it. And one by one, the others contact her. A few days before the test, they form a study group she dubs “The Breakfast Club,” after the 1985 movie about an unlikely group of high-school students who bond over weekend detention.

As the exam approaches, Franco’s resolve grows: They’re not getting rid of me. The night before the test, she actually sleeps. The next morning her stomach is settled and her mind clear.

About half of the test is essay and half is multiple choice. It’s supposed to last four hours. But Franco’s computer crashes three times during the exam, erasing the longest essay she wrote three times. She has tears in her eyes when the professor tells her they have an extra hour to finish.

Four long days later, she finds out she passed.

Her confidence is out of intensive care and well on the way to recovery.

Anatomy Ends

In late January, the students are wrapping up the gastrointestinal part of Anatomy. After that, they’ll have a six-week break to study Biological Basis of Disease. Then they’ll study the pelvis. And it will be over. They will have dissected an entire human body below the neck.

Emptied of nearly everything, the chests of the cadavers are just hollow cavities. It’s easy to tell the good dissections — the flaps of skin are neatly tucked back like candy wrappers. And you don’t have to look too hard to find things.

“This is probably the best dissection I’ve seen,” says one student while peering into the cadaver of Gentry’s group. “Amazing” is the way another student describes it.

“Tell my group that,” says fellow student Tom Ladas, whose hands are the ones I most often see in the cadaver. Gentry calls him “SuperTom.” She even wrote “Tom + Anatomy Forever” inside a heart she drew on the chalkboard near their station.

He points out the adrenal glands and starts to remove the cyst-riddled kidney. In addition to having lung cancer, the man suffered from polycystic kidney disease.

“We have to chop it open, right?” another group member asks.

The answer is yes. The kidneys will end up with the other dissected organs the students keep in a bag on a cafeteria tray.

Then the subject turns to lunch.

Gentry arrives late, wearing scrub pants and a long-sleeved blue-and-orange shirt. She carries a drawing she did of the superior mesenteric artery.

“Five books did not list the colic artery,” she laments. “Five!”

She’s in a good mood. Two questions were thrown out on the Cardiology test she failed by two questions. She won’t have to remediate now.

Love and Med School

The first lecture of Valentine’s Day is on Chlamydia, followed by lectures on other sexually transmitted diseases, including HIV. The students aren’t complaining much about Biological Basis of Disease. It keeps them out of the lab for a while. And in spite of the heavy sex-equals-illness tone of their lectures this February, many students are looking for love.

At the orientation in August, society dean Steven Ricanati said, “At the end of four years, 10 percent of you will marry one another.” Ricanati, a Case Med grad who married his Physical Diagnosis partner, makes that prediction (or some variation) each year — not because he expects 10 percent of the students to follow his lead, but because it’s an uplifting spin on what first-year students used to hear at orientation: “At the end of four years,” one dean of admissions used to say, “20 percent of you will no longer be here.”

There have been no Class of 2009 marriages yet. But hookups have occurred, as well as some full-scale relationships.

Franco had a fling with another first-year student in the fall. After that, she went on several dates with an older Dominican man she calls The Banker. Gentry has brushed off the attention of sever-
al medical students. One invites himself to a potluck at Franco’s with the hope that Gentry will be there.

“I’m the last girl on the market,” she insists, around the time of the Hippocrates Ball, a medical school formal that resembles the high school prom.

Gentry invites a girlfriend, who comes all the way from Minnesota, just so she wouldn’t have to go to the ball alone. Franco brings a friend too.

“Instead of being stressed about school, we were stressed about getting manicures and pedicures and getting dressed up, and that was a break,” Franco says over brunch one Sunday in early March.

The reality that Franco and Gentry will be doctors one day is still setting in. Franco sometimes catches a glimpse of her white coat hanging on the back of her desk chair and thinks, A doctor lives here? When a patient calls Gentry “Doctor” during one of her apprenticeships, she laughs out loud. She can’t help it.

The 21st Annual Doc Opera

Doc Opera is Case Med’s annual variety show, completely student-orchestrated, uncensored and PG-13 for sexual content. It’s song. It’s dance. It’s the one opportunity students get to relieve stress by poking fun at the school, the profession and themselves while raising money for charity.

Inspired by sex, drugs and rock ’n’ roll — and a few show tunes, country ditties and hip-hop rhymes — Doc Opera comes of age at Lakewood Civic Auditorium on March 25, two months before the school year ends. Mary Poppins would not approve of“Chlamygonnoherpesyphillexpialidocious,” though the Blues Brothers would enjoy “Hole Man” as much as the gastroenterologists in the audience. The documentary-style commercial for “CaseMed and CaseMed Apartments: Come. Stay. Live. Learn,” features real footage of med students sleeping in class.

In “Free Pen,” Dean Ralph Horwitz shoos away pharmaceutical representatives waving airline tickets to the tune of Edgar Winter’s “Free Ride.”

Come on and take a free trip
Think of me when you write your script
Come on and take a free trip
Come on

Gentry dances in the show to “Send Him to Psych,” with musical inspiration provided by Billy Joel’s “You May Be Right.” Franco dances too, wearing less clothing in “Giving You Meds So You Don’t Feel” (En Vogue’s “Giving Him Something He Can Feel”).