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Clinical Practice Pearls
P R O B E
• V o l . L I I I • N o . 3 • A p r – J u n 2 0 1 4
From Other P ge
Jigsaw
I got my first stethoscope at age 5.
It had baby-blue rubber tubing with
yellow earpieces and came in a white
Fisher-Price box with handles. The box
was monogrammed “Doctor’s Bag”
in bright red script and for a time it
accompanied me everywhere. As often
as I could corner them, unwitting
friends and neighbors were subjected
to a complete physical, often resulting
in a diagnosis of strep throat, the bane
of my childhood existence and the
only malady I could name. Sometimes
during examinations “patients” would
ask if I was going to be a doctor when
I grew up. “No,” I would say. “I’m
going to be a ballerina.”
Two decades later I still have a blue
stethoscope, while in place of my
white box I now have a white coat.
It’s not monogrammed and the
short length proclaims me a medical
student, but for patients and their
families, none of that matters: my coat
screams “Doctor.” This is exhilarating
for the brief moment before reality
sets in. Most of the time, I am almost
unsure of what I am doing and
occasionally even where I am going.
As I walk through the staff-only
corridors in my coat, heels clicking
authoritatively and stethoscope draped
nonchalantly around my neck, all I
can do is wonder, behind this outward
show of confidence, how it is that one
human being can make a difference in
the life of another.
What occupies my mind are not
questions of pathophysiology or
pharmacology where the correlation
is simple: when you don’t know
something, you have to study until
you do. The lingering question
that haunts my thoughts is
different, beyond the intricacies of
arrhythmias or my repeated efforts
to see something, anything, with
an ophthalmoscope other than
the tearing eye of a patient I have
temporarily blinded in another
futile attempt to visualize the retina.
Harrison’s Principles of Internal
Medicine can explain the vagaries of
lupus or the presentations of coronary
heart disease. I want to put the pieces
together—the endless lectures, the
physical examination skills, the
challenge of taking a history that
means something—into a completed
puzzle that resembles the image of
the physician I am determined to
become. The illusion of the omniscient
healer has long since faded, a part
of the dream that died as medicine
became real and the weight of this
undertaking looked back at me
through the eyes of my very first
patient, a man dying of AIDS. What
remains is simultaneously less and
much, much more. The outcome and
the disease process are not ultimately
mine—or my mentors’—to control,
but the trust and the respect and the
experience of the person in the flimsy
gown of the patient are. And so, this
is what I ask myself, over and over and
over, as the days stretch one after the
other into a blur of metamorphosis:
are you making a difference in more
than your own experience?
In many ways the white coat is a
barrier even as it grants physicians,
or physicians-in-training, access to
patients. It sets us apart, creates a
hierarchy, and allows us to probe the
minds and bodies of people we have
never met in a way that would be
outrageous if it took place anywhere
other than the sacred sterility of the
clinic or hospital room. I watch the
physicians I admire—the resident
who makes a man losing his foot to
gangrene smile in the hours before he
is prepped for surgery or the thoracic
surgeon who is greeted by what seems
like every person he passes in the halls
of a very busy hospital—and begin to
see how one person can do something
extraordinary within a world of harsh
limitations. I can slowly and clumsily
try to incorporate their approach
into my own small place within
the medical world, and it is indeed
exhilarating when a patient thanks me
for talking to her. Yet in the end, it is
not until I find myself sitting on an
examination table and answering the
questions instead of asking them that
the pieces of this puzzle start to fall
into place.
Two weeks before starting my second
year of medical school, after 10
days of increasing fatigue, lethargy,
and malaise, I started coughing
up blood—hemoptysis, one of the
new additions to my vocabulary.
Shocked into speechlessness, I began
to unconsciously (albeit awkwardly)
evaluate the situation. After a year of
indoctrination I could construct a past
medical history, a history of present
illness, the pertinent positives in the
review of systems. Unfortunately,
