Learning Patiently

by Shira Fischer, UMMS 2012

Honorable Mention 2007 Gerald F. Berlin Creative Writing Award

For our Physical Diagnosis course, we medical students play doctor – and patient.

I was upset when I first heard this, as I had no interest in being anyone’s guinea pig. I signed up to learn to be a doctor, not to have a friend learn how to use an otoscope by poking around my ear. Our school hires “standardized patients” who sign up to act as patients and are remunerated accordingly. But for this preliminary training in normal physical findings, each of us was required to find a partner from among our classmates. We were to practice taking her blood pressure, examining her eyes, percussing her chest, and ausculating her heart and lungs. And we were supposed to let her do the same to us. We weren’t at the point where we could identify anything abnormal, but the idea was to learn the motions, the tools, the normal sounds and sensations. In response to my skepticism, friends and family told me they thought it would be a great experience for a future doctor to practice being a patient: I could learn what is comfortable and what is not and help my partner do the same. I was not convinced that it was necessary. And I was right that I did not need the practice experience, as I soon became a real patient.

The week we started the course, right after winter break, I felt a lump on the right side of my neck. I ignored it at first, reasoning that everyone is a bit asymmetrical, and surely a slight aberration was no cause for concern. But it didn’t go away. As the second week approached and we went over the “head and neck” examination, I began to wonder. Monday morning, I left a message with my doctor. That night, as a volunteer at a free clinic, I cornered a young intern when the patients were gone. She kindly suggested that it would be a good idea to see my doctor. And so on Tuesday, when my message had still not been returned, I simply went down to her office in the hospital adjacent to the medical school. We scheduled blood work and a radiology appointment to figure out what was growing in what I now knew to be my thyroid. While I waited for the ultrasound and then for the next appointment, medical school went on. At night, I would lie awake wondering what was happening to me, and in the morning I would dutifully attend class. Except Wednesdays – on those days, in the morning I would shadow an internal medicine doctor and an evening attend my Physical Diagnosis class.

I began to see everything from both sides. As a medical student, I wrap my stethoscope around my neck and pretend I know what I’m doing when I interview my patients. I understand that doctor appointments take time, and that the waiting room is, by necessity, often a place of long waiting. After all, a doctor needs to write follow-up notes from each visit. In the interest of time, she often needs to use the time when one patient is dressing or undressing to examine another. It’s a good use of her time, but it often leaves patients waiting a while for her to return. Sometimes, in a teaching hospital, a doctor will even make patients wait so she can explain what she is doing to students like me. From outside of the examination room, it makes perfect sense.

But when it’s me, the patient, inside the room, staring at the clock, waiting, I’m incensed. I have been sitting in this office for hours, I fume. The nurse who took my blood pressure left 15 minutes ago and no doctor has shown up to see me yet. I glance at the sign on the wall that says, “Please let us know if you are waiting for more than 15 minutes.” I know that the doctors think these new signs were an important courtesy to patients, an indication that they are concerned about punctuality. But as I wait I realize that planning for a 15-minute wait does not feel courteous at all.

The doctor I shadow works in internal medicine, on the first floor. The doctor who is attending to my care works in family practice, on the first floor. The distance from patient to doctor-in-training is the walk across the waiting room. It’s the exact same waiting room, but walking in feels completely different, depending on which doctor I am going to see. When I put on my white coat and come to shadow and interview, it’s a place of adventure and curiosity – who will I meet today? Will I remember to ask all the right questions, be empathetic, take good notes? What will I learn? But when I’m the patient, I’m nervous, waiting for my name to be called out, hoping that there is no bad news and I won’t have to learn anything at all. Even though I’m on the same floor of the same building, I might as well be in standing in a snowstorm naked in Siberia. There is no best situation as a patient – I want not to be here at all. I feel vulnerable, ignorant, alone. Visits to the doctor wouldn’t exist in my ideal world, and that weighs on me each time I embark on one.

As a medical student, I of course try to be friendly, cheerful, and kind to all the patients who come in. But I definitely like the happy ones better. Who wants to talk to someone with lots of complaints and anxieties and questions? And yet when I come in as a patient, I have no interest in being nice. I’ve done my part by showing up. How can they expect more from me? Besides, I am scared and unclear about what will happen next, how serious this is, what it all means. It’s my appointment. I’m the customer, and the customer is always right. I have no obligation to be nice or friendly. All I want is to have my problems solved and to go home.

Later that same week, I was sitting in a small classroom learning “how to give bad news.” It was my turn to interview the standardized patient, and I had prepared more than usual. Like everyone else, I was surprised to discover that the patient had only diabetes, what seemed to be a relatively minor illness. We expected to be telling him he had something terminal: cancer, for example. But our discussion helped us all realize that while to doctors who might hear about various diseases all the time, “only” diabetes or “only” amputation of a few toes might not seem “serious,” it does matter if it’s your diet or your toes.

So I did my best. I told my “patient” directly, as we were taught to, that the results indicated diabetes, and I tried to listen to his response as he attempted to understand what his diagnosis meant. I learned that he would not be able to absorb too many details about the disease at this point, so that I should focus on both the reality of the risks of this disease and the high potential for its management. My classmates told me I’d done a good job, that I’d used silences well and that I sounded supportive.

Wednesday again, two weeks since the first doctor’s visit about this lump on my neck. Playing doctor on the first floor. In the evening, physical diagnosis class again (this time, abdomen). But in between, in the late afternoon, I am back on the first floor. I am a real patient with a real appointment to hear the results of a real biopsy.

I arrive before she is ready to see me. I first sit in the waiting room, impatiently fidgeting, and then finally she appears. I follow her around the halls of her clinic as she looks for a room where we can talk. I feel my heart racing. She could just tell me right now that I am fine and resolve the excruciating suspense a few seconds sooner, couldn’t she? But then I tell myself that she just wants to maintain my privacy and will tell me as soon as we get into the room that everything was fine. Everything fine.

Finally, an empty room.

An “It’s not cancer,” is all I want, but instead I get, “How was class?”

How was class??? I couldn’t take it any longer and begged, “Can you just tell me?”

I watched from the outside and from the inside. Part of me was in that little seminar room, watching how gracefully she would break the news. Would she be sensitive to my response? Would she tell me too much or not enough? How best to phrase it? The other part of me hung on her every word.

“It is cancer.”

She slowly told me a little more and answered my questions patiently. My awareness was piercing – I even said to her, “I may need to ask you these questions again as I’m not sure I’m really absorbing everything.” She responded, “I know. That’s okay.” It was almost like a script that I was playing out unwittingly: like my standardized patient who was upset to hear he had diabetes, I first challenged the results. “That’s not the cytopathologist who was supposed to read my sample. Maybe it was mixed up?” I then became directed, rushing to talk about what was next, what tomorrow would look like, when I would meet with the specialist. Only at the end did I let myself start to cry.

Before she left, my doctor did what I needed her to, though I don’t know if she learned it in medical school. She gave me a hug.

The office emptied out, but I wasn’t quite ready to leave. I stood in the waiting room, facing the clinic where my doctor worked. Where I was a patient. Where I was told I had cancer. I turned around, facing the clinic where that very morning, I had interviewed patients, listened to heartbeats, and counseled people on smoking cessation. The vulnerable me versus the confident me. The ignorant versus the learned. The patient versus the doctor. I stood alone, right in the middle of the vacant waiting room, turning around and around. And then I called my mom.

I spoke to her for a while and then called my closest friend, allowing things to slowly sink in as I spoke to the people I love. As I ended the conversation, a kindly middle-aged woman who seemed to appear out of nowhere apologized for eavesdropping.

“You’re going to be okay. I have two friends who had thyroid cancer and they are fine. My son has gone through so much medical care, so I know it’s hard, but a positive attitude really helps.”

I wiped away some tears as she went on, “Sometimes it helps to have a stranger tell you this.”

She was right. I decided not to go home to my mother or to curl up in a ball and cry, though I know that would have been okay. Instead, I picked up my bags and headed downstairs to class to learn how to do a physical exam of the abdomen. We were all just students, but we took turns playing patient.