Physician by Number

It's an inflated title:
“Student Doctor.”
More accurate might be
“Recent college graduate
who spends her days buried in books.”
Without her fancy white coat,
would you expose
intimate details
to this stranger?
Would you surrender
every nook
to foreign hands?
Would you submit
your vulnerabilities
to a novice?

Or would you balk at the youth
standing at the foot of your bed?
Would you question the girl with curly locks
while she feigns a professional façade?
The girl recently mistaken for a teenager
when she ordered a glass of wine?
The girl who giggles when she sees a cute guy?
The girl who still cherishes her stuffed animals?
The girl who has lived a comfortable life
and may not appreciate where you're coming from,
even though she listens intently
and desperately wants to understand your world?
What gives her the right
to invade your privacy?
to subject you to such indignities?

These thoughts flood my mind when I enter a patient's room. I take the history and perform the physical examination, but it's more for me than for the patient. I go through the motions for practice, but I lack the ability to discern subtle differences in my findings. It's a performance: a didactic routine with precise directions to guide the end result—reminiscent of the paint-by-number kits I loved as a child.

I’ve upgraded since childhood. Now my “doctor kit” contains the following: a checklist for eliciting the history; a script of questions for particularly sensitive topics; a review-of-systems laundry list to salvage the encounter if necessary; a second checklist detailing each step of the physical examination; a template for the write-up; and a blueprint to guide my oral presentation.

This kit proved useful in completing a clinical skills assessment during my second year in medical school. I met an actor posing as a patient. She had memorized a standardized patient script, just as I had memorized my doctor script. Script versus script, it was my job to unravel the “patient’s” chronicle of events. Under the watchful eye of a video camera, I elicited the patient's mock chief complaint, listened to her mock history, proceeded through the mock physical examination, wrote up her mock case, and presented the mock patient story. I was a good pretend doctor, and I passed with ease.

But I’m still unprepared as a real physician. The first time I was unleashed to do a real patient's full history and physical in the hospital, the scripts and templates fled my mind.

I liked my real patient; she was sweet with a gentle, warm disposition. Her tiny frame blended into her bed—wisps of matted blonde hair emerged from her pillow. I leaned in close to hear her story. She could barely speak. Each string of words triggered labored breaths and bouts of coughing. Her pale face could muster only the strength for understated expressions. Still, she punctuated her brief, whispered clauses with a friendly smile. She apologized for the interrupted communication; ten days prior, she had undergone a tracheostomy. It still required some adjustment.

Her story unfolded. She developed diabetes in childhood, and complications led to end-stage renal disease. She had hoped to be eligible for kidney transplant, but her congestive heart failure disqualified her. Instead, she subsisted on hemodialysis. Now, just shy of 35, she presented with shortness of breath. Her physicians found throat cancer obstructing her airway; hence the tracheostomy.

I hated that she was in pain. I hated that her young body had betrayed her time and time again. But as a second-year medical student, I was not formally a member of her health care team. So we both knew there was nothing I could do for her. I was there just to listen and learn.

Meanwhile, her elaborate list of physician visits and diagnoses left me stunned. This lovely woman had spent the better part of her short life surviving a messy string of bodily failures. I felt myself deviate from the doctor role. I was emotionally attached.

We chatted about her life. I learned that she had married the man sitting by her side on Valentine's Day 13 years earlier. He held her hand adoringly while she described his unwavering support through each medical obstacle she had endured.

She revealed that she was most anxious about cleaning her tracheostomy tube herself, because she had cataracts and could barely see. I tried to imagine the terror of cleaning my only airway without proper eyesight for guidance. That must be something like repairing scuba gear while diving below 80 feet of water—without a mask. I shuddered. Her fear struck me as well founded.

After showering her with questions for over an hour, I shifted to the physical examination. I awkwardly avoided the tubes emerging from various portals of her body. I cringed with guilt each time she shifted positions to facilitate my exam. I winced at the idea of causing her any additional pain with my touch. It was all for my benefit—just so I could practice.

And because previously I had practiced my examination skills only on healthy classmates, omitting components near the surgical site on her neck threw me off my routine. I forgot the choreography necessary to perform the dance of the doctor.

I was relieved once I was done—done making her speak, done causing her pain. I thanked her and her husband for their time, for sharing with me, for helping me learn. She must have sensed that I had lost the purpose of my presence—not quite a physician, but not just friendly company. She smiled and offered parting encouragement: “You did great—just like a real doctor.” I let the corners of my lips curl up to acknowledge her compliment as I sheepishly avoided her gaze.

I had asked enough right questions and performed sufficient physical maneuvers to convince the patient I had fulfilled my role. And I suppose there was some utility in my time with her. I had an hour and a half to absorb every minute detail of her story. The shock of her experiences was fresh to me, an unseasoned student with little exposure to the complications of diabetes and cancer. What she had endured wouldn't flee my memory when I left her room. And she knew it. She knew her barely audible voice had been heard.

But I still felt like a little girl who had struggled to complete her paint-by-number project. And now, looking at the finished product, I recognized it for what it was: an artless, cookie-cutter piece, devoid of creativity or finesse. I suffered the frustration of appreciating what the art of medicine should look like, but being completely incapable of painting it on my own.

Real physicians graduate from the paint-by-number model. Instead, differential diagnoses inform their questions; clinical judgments dictate their physical examinations. They masterfully navigate awkward interactions, instill confidence, and balance investigator with healer. Their art makes them worthy of entry into a patient's world.

One day, I hope to paint my own creations. But until then, I will offer my attentive ears.