A PIECE OF MY MIND The Good Doctor A NYWHERE ELSE.THIS IS THE EXACT LOCATION OF WHERE you’d rather be when you’re a patient sitting in an oncologist’s office. Unfortunately, I was too famil- iar with such settings, having survived rhabdomyosar- coma once as a child and once as an adolescent. Now, here again I sat, 27 years old, living in New York, and planning to start medical school next fall. I had hoped not to find my- self on this side of the encounter again, but having learned, just before Christmas, that I had bilateral breast cancer, I had little choice. I was numb to the news. It was devastating, but unsur- prising, somehow. I knew the terrain of cancer and what struggles would come. I prayed the disease hadn’t metasta- sized, making cure impossible, shutting so many open doors on my path to becoming a physician. I waited nervously in the examination room with my boy- friend, swinging my legs and staring blankly. The oncol- ogy fellow entered, a woman around my age, animated, and lighthearted in her banter. We talked about medical school and my disease in equal parts. She connected with my fear of losing everything to cancer, losing my chance to be a phy- sician. I felt more at ease, laughing at her jokes and making some of my own. We moved to the office of the attending physician, an older woman whom I had become more relaxed about meeting, since I now anticipated a similar warmth and humor. My boyfriend and I sat across a wide desk from the clinical team, and the attending began dryly reciting the facts. “Our body is made of cells,” she started, as an entry to explain the ba- sic science of my cancers. I held up my hand and smiled. “I’m going to be a medical student in the fall. I know.” She didn’t smile back, or go on to ask about me, my support, my fears. She continued to describe a nodule found in my lung that would need to be biopsied, the drugs that I’d be on, and the uncertain prognosis in brief, unanimated terms. She then asked tersely if I had any questions. My mind was filled with silence, so I shook my head and declined. As she dismissed us, I went to an empty examination room alone and sat down, allowing the tears to come. A few minutes later, I saw her gingerly approach her assistant, who had in the meantime given me tissues and words of comfort, and ask in a whisper, “Why is she crying?” Six months later, I managed to emerge from the barrage of treatment. Months after a lobectomy and weeks after a bilateral mastectomy, I showed up for orientation, re- ceived my white coat, and began crossing into a new world. But the oncologist in New York still haunted me. After meet- ing her, I sought care in Boston, where I was now starting medical school. I thought of her often, wondering if she was the exception or the rule. Would my classmates and I, all seemingly kind and concerned human beings, be like her at the end of our training? When would it happen? Would we even realize it? From the first day of orientation, we’re taught that medi- cine is holistic and humanistic and should always be in- fused with genuine care for patients in addition to routine patient care. Perhaps predictably, this emphasis degrades. And, not slowly, as I expected, but rapidly, declining with a speed inversely proportional to the rise of basic and clini- cal sciences. In anatomy lab, in the name of efficiency, we move feverishly around and through the bodies of our do- nors, focusing on nerve, muscle, bone, attachment. Eulo- gizing takes words, and words take time. We are given only two hours a day over the course of six weeks to learn what we can of the whole human composition. “Flexor carpi ul- naris” is all that’s uttered when lifting the hand. A hand. Her hand. Nerve, muscle, bone, detachment. The same holds in lecture halls and tutorial rooms and at laboratory benches. We are overwhelmed with patho- gens, seduced by physiological mechanisms, intrigued by drug names. We begin to speak more and more cryptically, learning the incantations to unlock the approval of attend- ing physicians. “Cloudy white infiltrate” or “diaphrag- matic tenting” or “hyperinflation” all show that we’ve learned the correlates of shortness of breath. Writing “SOB” and not snickering means we are very advanced indeed. We are never taught to think about not being able to breathe, what it must be to have heavy lungs, gasping, pain, the searing sense of impending doom that accompanies what we now only call hypoxia. Our new attitudes and words hemorrhage into the spaces and territories once untouched by medicine. When a classmate is sick, we skip “How are you feeling?” and go straight to “What are your symptoms?” which he or she dutifully recites, having already tried at a rudimen- tary differential. When I hear of a family member diag- nosed with prostate cancer, or a friend’s baby with con- genital heart problems, I still feel the sick, sadness of any civilian. Yet my brain whirs and nags, paging through what I’ve learned about each disease. But what have I learned about each illness? How, I ask myself, do you combine the heartsickness of humanism with the mental acrobatics of medicine, when both are required to be a good doctor, but only one is reinforced? A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor. ©2011 American Medical Association. All rights reserved. JAMA, October 12, 2011—Vol 306, No. 14 1525 at Harvard University on October 28, 2011 jama.ama-assn.org Downloaded from