Boonshoft Blogs

The Road through Residency
The Looming Terror of the Classifieds
Jason Faber, M.D. ’08
March 11, 2011

As graduation approaches you can see the apprehension in many of the third-year resident’s eyes. After three years of caring for patients in the hospital and clinic, having placed tubes into the throat, and catheters into every conceivable vein in the body, there comes a more daunting task. It isn’t the looming board examination in Internal medicine or the application process to obtain a license, although those are both frightening endeavors. Instead, the graduates, months clicking down until they finish their residency, face their most difficult challenge yet: finding a job.

“A lot of fellows nowadays have a B.A., M.D., or Ph.D. Unfortunately, they don’t have a J.O.B."
— “Fats” Domino

I page through the back of one of the many medical journals littering my desk, perusing the classifieds section. I see “hospitalist needed in Poughkeepsie, New York; nocturnist wanted in Little Rock, Arkansas; general internist position available in Rock Springs, Wyoming.”  The internal medicine and hospitalist sections of the classifieds are the most extensive sections in the entire journal. Unfortunately, few of them look interesting to me, so I put down the journal and jump online. I find similar want ads about positions and job openings throughout the search engines. There are rural positions and academic hospital openings, permanent position offerings and locum tenens (a temp position), and generalist or more specialized hospitalist jobs. Feeling like I am drowning in this flood of choice and opportunity, I turn to my most trusted resource, my fellow colleagues and ask them a complex, yet pointed, question, “So whadda ya up to next year?”

We’re not really trained to assess the business aspect of applying for a job in internal medicine, and although there is some consolation in the amount of options, you still feel overwhelmed by the extensive research that comes with looking into business contracts. A few clauses here, addendums there, and you feel more lost. So you hit up the closest consultant to you, an attending you trust. I start to pursue this research by finding some of the younger internists I know and asking them what to do about this and that while looking for a job. The responses are, shall we say, mixed. I remember sitting down with a more senior attending physician who would carefully lay out what questions I would want to ask about vacation, call schedule, ancillary support, health benefits, and incentive packages. Another younger attending gave me very clear advice, “Get a lawyer to look at it.”

The experience underscores the maze of the ‘hidden curriculum’ that exists in the training to become a physician. There are no lectures, textbooks, or journal articles that cover this aspect of the practicing physician, and yet we still must learn it. As I page through another medical newspaper for further classifieds, a fellow senior resident sits down next to me in the lounge. “Looking for a job?” he asks.

“Just looking for now,” I reply. The statement strikes me as the same as someone whose clunker is about to give out paging through the car ads.

“I just finished my third interview,” he says.

I sit up and listen intently, “So what was it like, did they talk about salary, incentives, vacation and stuff?”

“Well, let’s put it this way…I liked it better when I was a resident.”

The Road through Residency
Follow-up as Needed
Jason Faber, M.D. ’08
January 15, 2011

The stacks of charts on the desk begin to resemble an art deco building, twisting in so many levels upon levels. The nurse passes by and plunks another chart down on the stack that is accumulating in front of me.

Now my view over the edge of the desk is obscured, effectively locking me into this prison of paperwork — each chart carrying a story, each level unique unto itself. A fax of skilled nursing orders on the ground floor gives rise to a couple of medication refills on the second, followed by a request for handicap placard on the third.

Filling the hours between the patient bedside and intense study is the sea of paperwork across which I must navigate. It often seems like a daunting and fearful task, but today I am reveling in the paperwork, hiding behind this wall of parchment to avoid doing what I have to. My citadel of manuscripts is not enough to hide me forever, and before long, the nurse again passes by and slides a chart directly into my view.

“Your next patient,” she said.

The handle of the door seems cold as I grasp it, and I glance down at the collection of studies and tests in manila folders and beige files, cloistered together by a thick rubber-band. As I open the door slowly I stop for a slight moment before continuing, angry at myself that I had forgotten to knock on the door. This simple pleasantry and etiquette, drilled so hard into my brain as a medical student, has long been forgotten in the heat of the moment.

As I enter the room, the slight frame of a woman greets me, her eyes bright, her cheeks sunken and sallow. I sit down at the desk with the computer jutting out at me from the wall, demanding my attention. I shake her and her daughter’s hands, and sit down on the swivel chair, pulling the computer in between us, like a gate closing between two old friends.

Electronic medical records are the wave of the future. They are supposed to make documentation, billing and patient data, readily accessible and easily portable. They can streamline the history and physical to a point-and-click parade. They can increase productivity and decrease cost, all in a package that opens with the click of a mouse.

At least that’s what I have learned from various articles in the newspaper, medical journals, and from the technological faithful. It reminds of those news reels and cliffhanger serials of the 1950s.
I remember watching re-runs of Commando Cody on TV as a child, thinking how wonderful the future would be with flying suits, rocket ships and flying cars. Today I suppose I harbor a little resentment that I still don’t have that flying car. Now, as EMRs are thrust upon us, I wonder about how I’ll feel a decade from now about these “flying machines.”

Maybe they will bring a world of streamlined health care, and easily accessible medical records from across the globe, but today all I can see is a computer screen where my patient’s face should be.
I ask her how she’s feeling. She says she feels fine. I ask her about pain. No pain. I ask her about chest pain, shortness of breath, fever, chills, abdominal pain, bleeding. No, no, no, no, no and no, she said. I don’t feel very useful at the moment. Her daughter relates that no more chemotherapy is planned, and they are considering hospice.

Slowly, the once-vibrant lady that I saw three years back is now withering away from the mass in her pancreas that has invaded beyond the borders of a normal organ.

At the sound of her daughter saying hospice, my heart sinks. Not so much because I don’t feel this is a good decision. she would be comfortable in their care, but because I feel the unfairness of this situation more so than usual.

So many patients we see are quite ill from poor choices in life, angry at the world, themselves and us. And here this kindly lady, surrounded by a family who sings her praises as she walks through the hallways, is simply one of the sickest patients I have had the privilege of caring for. There is a saying I hear muttered throughout the hallways of the hospital, “Bad things always happen to nice people.”
I excuse myself to speak with the attending physician. There is nothing to discuss, but I present the patient to the attending physician from the beginning. I try to be thorough, feeling that treating her like a complex medical case is in some way being respectful. There is nothing complex about this, really. There simply is nothing more to offer at this point, except for supportive care, a synonym for everything else that doesn’t solve the problem.

I go back to the room and talk with the patient for a while and reminisce about our time together. I have seen her extensively over the past few years and have enjoyed our meetings. She smiles, shakes my hand, and walks out of the office with her daughter, who is calling to make arrangements for hospice at home. I hope to see her again, but I know deep down I probably won’t. I move back to the computer screen and type my note for the day, a simple note:

“Patient, 75-year-old with pancreatic cancer. Met today to discuss plans with patient and daughter. Plan for hospice at this time. No further invasive interventions. Follow-up as needed.”

The Road through Residency
Sleepless in Dayton
Jason Faber, M.D. ’08
November 2, 2010

The crisp white coat I'm wearing belies the coffee stains that have spattered my button-up shirt beneath it. The past 30 hours while I have been on call have left the white oxford littered with brown discolorations — a splash of Sumatra here, a few drops of Arabica there. I pull my glasses off as I set the coffee cup down gently on the counter, careful not to splatter my only clean white coat. One of the young interns comes up to query me before the attending is upon us.

"Mrs. B's white count is up," he says with a hint of regret. His face carries a feeling of shame, as if every patient must make a speedy and complete recovery before he releases them back into the wild.

"Why do you think that is?" I ask, prodding. I have already seen Mrs. B's white count, examined her, and figured out why her labs are slightly abnormal. But I know that if I tell him, he won't learn. Teach a man to fish ... you know the proverb.

"I'm not sure. It could be infectious, a urinary tract infection." He sits down and hangs his head in his hands. He has been up all night too. Looking at his fatigue, so obvious upon his face in rings and circles, I stop my Socratic questioning and tell him.

"Steroids. We started steroids, remember?"

"That's right! I forgot."

"It's fine," I say. "The good news is she can probably go home."

"You know, I just can't think after a night on call," he explains. He heads off to finish up before rounds.

I look at my watch to gauge how much time we'll have to round on patients, if we'll have enough, and whether I should take a few minutes to discuss a topic for the interns and medical students. As I'm running the list through my mind and sipping my coffee, our medical student arrives. Her eyes are bright and well-rested, and she is showered, smelling of lilac perfume and Dove soap. At this time in the morning after a night on call, you would sell your soul for a shower and a pillow.

"You look a little tired, Dr. Faber," she says.

"Jason," I correct her. "And yes, I am a little tired. But you get used to it."

"How many hours do you have to stay up?"

"Depends," I say. "Sometimes it's all night, sometimes you get two to three hours of sleep or more. But the experience is important, and it teaches you your limitations."

"Well I hope I can get several hours of sleep when I'm on call," she says.

"Conceivably, you might never have to worry about that." I proceed to tell her about the changes coming.

Throughout medical training, long in-hospital calls have been commonplace. Although many programs now have shift work - with interns and residents to handle the night shift - many still have interns stay overnight while on call every fourth day. The hope is that this experience, under the watchful eye of a resident, will give the newly minted physician a taste of long hours, which are common in the real world. I remember my time in the hospital as an intern, staying 30 hours and watching patients and their progressing or worsening state. Managing sick patients over the first 24 hours can be an exceptional, valuable learning experience.

Starting next July, the Accreditation Council for Graduate Medical Education, the accrediting body for residency programs, has stipulated that interns be on call for no longer than 16 hours at a time. This could result in physicians never having to spend more than 16 hours in the hospital during their entire training. I fondly remember those long days on call, while young physicians years from now will shake their heads and say, "Nobody ever stays longer than 16 hours."

"So," the medical student asks, "do you think that means I won't get enough training?"

"I don't know if this change is good or bad," I tell her. "But I think my days of sleepless nights have made me more resilient, and ready for what the future has to bring."

The Road through Residency
Jason Faber, M.D. ’08
May 8, 2010

"It doesn't change. It always just hangs there in the sky."

I ignore the patient's comment for a moment as I look down at my notes, making sure I haven't forgotten any important questions. Beyond the wide windows before us, trees sway back and forth, and I wonder how many lives they have witnessed come to an end as they continue to reach toward the sky.

“You could not step twice into the same river; for other waters are ever flowing on to you.
— “Heraclitus, (c. 535 – 475 B.C.E.)

"Do you have any history of diabetes, high blood pressure, COPD, cancer, heart failure—"

It is only after he interrupts me that I realize my fingers are counting the possible flaws brought upon him by time, lifestyle, or genetics, like so many bullet points on a checklist.

"No," he says. "Been healthy all my life."

"Until now?"


He looks back outside toward the sky, his eyes fixed upon a point far from his predicament. A single star, clearly visible, twinkles back at him. He has told many of us at the hospital that he feels strangely at ease with his fate, knowing that these burning fires-running on helium and hydrogen, light years away, untouchable, unchangeable-will continue without him.

"That's the three sisters," he points out. "They're part of-"

"Orion's belt," I say.

"So you know a little astronomy?"

"I grew up in the country," I answer without looking up. "I would take my telescope out into the fields and try to find my way from one side of the horizon to the other, each constellation leading to the next."

"How often do you go now?" he asks.

"Oh, wow," I say, flipping through the chart, checking a box here, writing an order there. "I haven't been out in over a decade. Just lost interest, I guess."

He turns grim now, looking outside again.

"You should get back into it. Things change down here. Wars end, nations fall, but the stars, they're always there."

"Yes, they're very lovely," I say, finally looking up. "Now, how long have you been on chemotherapy?"

The weeks pass, and his fever starts subtly, a small spike here or there. We react aggressively, but despite our efforts, his condition slowly deteriorates. I come to visit after I've ended my rotation one night. He is in isolation for his low blood cell count. I don the mask, gown, and gloves, thinking how ironic that the closer to death he comes, the more impersonal we have to become. Upon his bedside table are books of Hubble telescope pictures, astronomy reference manuals, and a laptop whose screen shows the Pleiades, a young, open star cluster in the Taurus constellation, which is visible to the naked eye on a clear night. He is gaunt and sallow, his eyes still staring out into the night sky.

"Been out enjoying the spring view?" he asks.

"No, mostly working. I haven't had a chance," I answer.

"Well, not much to see in the city. Too much light. I wish I could get out into a dark sky, take in the view."

"Hopefully you'll be able to soon," I answer, but I know it is unlikely.

As I say goodbye, he scribbles down the titles of a couple of books on astronomy and astrophysics that he says I'll enjoy. His pen runs out of ink during the last title. He swears, and I reach into my coat pocket for another. I walk out of the room with the completed list and muse about the pen. As much writing as I do, I've always wondered which pen will be my last. When I buy a pack of pens, I wonder if I'll run out of time before one of them runs out of ink. With that in mind, I never get angry over a dying pen; I'm thankful that I've outlasted another one.

Three days later, he passes away at home. Sometime after that, perhaps two or three months later, one of the nurses mentions him and his infatuation with the stars.

"He was always saying how they never change," she says. "I guess that's a good thing to hang onto."

I look up from my chart.

"Unfortunately, they do." I tell her. "The Pleiades star cluster he kept referring to is supposed to disperse in another 250 million years. What we see in the sky today is not necessarily what our descendants will see long from now."

She looks down to the floor. "That's really sad. It seems like there's nothing constant to hold onto in the universe, then."

"Well, sure there is," I say. "The constant is change. How boring would life be if nothing changed, and how meaningful is each moment because it does."

The Road through Residency
Silent Companion
Jason Faber, M.D. ’08
March 8, 2010

Snow dances across the road as the old maroon Plymouth hurtles down the barren stretch of highway. The thin, pale man inside breathes deeply but rapidly as he grinds at the window crank on the door. With one hand on the wheel, he uses his other painful, arthritic hand to roll down the window for one last enjoyment before reaching his destination. The crank sticks but finally gives way, and cold winter air permeates the Plymouth. The driver smirks, looking down at the crank, admiring the old relic, which needs a little elbow grease but still works just fine. In the back of his mind, he wishes someone would think the same of him. From his coat pocket, he produces a pack of cigarettes, fondles one into his mouth and clicks his lighter into flame. A few puffs, and he blows smoke from his mouth, past his yellow-stained, patchy beard. He hasn't eaten for two days but has run through three packs of cigarettes in the same time. His bloodshot, age-worn eyes look up at the off ramp sign, and he exits the highway for the last time, along with his silent companion.

He finds a handicapped spot at the far end of the first row. After placing his oxygen tube around his face, he slings the small tank upon his shoulder, kicks open the door and with all his strength pulls himself to his feet. Immediately, he feels his sixty-seven years upon his back, weighing down on him. His blue lips huff and puff in the February air as he staggers into the emergency room. Still panting, he rests his hands on the check-in desk and he declares his purpose: "I'm… short… of breath."

Hours pass in the noisy arena as he lies on a stretcher. A small line in the back of his hand slowly feeds saline into him. Salt water, he thinks. Ten years on the sea, working my back into spasms, finally running as far as I could from that sour liquid, and here I am getting it pumped into my veins. He smirks again, and looks up to see a young man walking through the curtains. The doctor is short, his face covered with stubble, and his white coat is littered with coffee and ink stains. The youth in his eyes doesn't offset the dark circles under them, each ring representing another lesson learned, another hard night. The man answers his questions about weight loss, shortness of breath, medical history. Then the physical begins.

"You're going to do what?" asks the thin man.

"Sir, it's very important that I do this rectal exam. We have to make sure that you don't have any bleeding anywhere," the young doctor states.

"I'm not letting any boy-doctor… You know I came here because of my breathing. What does my rear end have to do with my lungs?"

"I'm just trying to exclude-" the boy-doctor starts.

"You can exclude this exam, because I ain't doin' it!"

His arms are folded in front of him, his intentions clear. I consider explaining what a rectal exam has to do with the lungs, but give up when it becomes clear my attempts at reason are more entertaining than enlightening. I complete the exam as best I can. On his lung exam I hear crackles throughout his entire chest. In his mouth I find thrush. He is thin, emaciated, and dying. I carefully broach the subject of HIV testing, but he is adamant against it, though his chest X-ray suggests a type of pneumonia seen almost exclusively in HIV patients. Over the next few days, I discuss with him my suspicion, my concerns. His condition deteriorates, and eventually we diagnose the silent companion that has accompanied him so long. He makes his wishes clear: no intubation, no mechanical ventilation. He wants to be comfortable. Throughout this process, I admire his ownership over his own existence, something so often cast aside in the immediacy of illness. His Plymouth sits in the parking lot for a short time, motionless, cold and dying. It has given one last ride for its owner, one last hurrah for the relic.

Three weeks later, I wake up to the sound of my beeper and answer a page about a new admission. I make my way to the restroom in the resident lounge and splash water on my face. As I look into the mirror, I see the rings under my eyes and notice that a new one has emerged.

The Road through Residency
Hope, Happiness and Quiet Conversation
Jason Faber, M.D. ’08
January 12, 2010

The cold air penetrates, knife-like, into the spaces my gloves can’t cover. I pull my coat together at the bottom of my neck as the wind whips across my face. I look up and see that only a few more feet remain to the door of the restaurant.

The sight of that door fills me with the same feelings, perhaps, that a small island would give a weary sailor, tired from months of floating across the sea. I pull the door open with my free hand, noting the bells clanging, reminding me I am knee-deep in the season of cheer and goodwill toward man.

The hostess looks up and asks, “Reservation?”

“No. Meeting someone. Will just sit at the bar,” I say as I pass by.

Few people are here this evening. I see a few couples, eyes locked together while bags of presents sit at their feet. An older gentleman sits at the end of the bar, his eyes turned towards the televisions.
It is unbearably evident he has nowhere else to be.

I find several seats standing lonely in the middle of the bar. Taking off my coat, scarf and gloves, I seat myself on a stool and order a beer. Months of call and long hours at the clinic and hospital have begun to take their toll.

It has been some time since I’ve sat down with my friend for a chat. It has also been a long time since I’ve had time to reflect on anything that has happened over the past several years.

Taking a drink, I look up from the glass and notice my friend coming in from the chill air of this bleak winter night.

After an hour of catching up, watching a game on the TV sitting high above the bar, and poking fun at each other, he asks me what’s bothering me.

“Just tired, I guess.”

“Marathon runners are tired,” he says. “You look depressed.”

“Maybe just a little. You have these expectations of how it’s supposed to be, treating patients,” I confess. “Things just aren’t what I thought they would be.”

“Things never are.”

“What I thought was this homogenous population of experts is more like a hodgepodge of educated tailors, each one with a different talent, each one with a different amount of ability and knowledge.”

“Well,” my friend says, “a doctorate does not a smart person make. Intelligent, maybe, but not necessarily smart.”

“And the politics,” I continue. “It always feels like a losing battle.”

“Well, your humanity still appears intact. You know, everyone faces cold and horrible situations with no honorable outcome. The compassionate person meets these, while the selfish person runs from them. You knew that when you started wearing that albatross around your neck years ago.”

“When you’re young,” I tell him, “you feel like it’s a phase, that at some point the storm will let up and you’ll be in calmer waters. Sometimes it feels like the storm will never end.”

“Life isn’t simple,” he says. “It’s not supposed to be. If you go through your whole life following one set of rules, you’re living as if you were following a large truck through snow on a forgotten country road. Eventually you need to either pass or pull over.”

“Or crash.” I smile at him. “I think I’m hopeful. I just don’t think I’m happy, I guess.”

“Well, I gotta get home.” My friend stands and puts on his coat, scarf, and gloves. “I’ll get this, okay?” He pays quickly.

As my friend makes his way to the end of the bar and the door of the restaurant, before going into the deep cold of the December night, he turns back toward me.

“I would rather be hopeful than happy, and I would rather be content than hopeful.”

He smiles and walks out the door. After he leaves I stare into the glass in front of me for a long while before I smile back at my reflection. I finish my drink, put my coat, scarf, and gloves on.

The bartender walks by and comments, “That’s a pretty good quote.”

“What quote?”

“You know. About hope, and happiness and whatnot.”

“I know. It’s one of my friend’s favorites,” I say, gesturing to the door.

The bartender, looking puzzled, asks, “What friend?”

I stop for a moment. Staring at the bar in front of me, I notice only one glass. From a look of confusion, I break a slight smile and pay the bill.

“Happy New Year,” says the bartender as I make my way toward the door.

“I hope so,” I say, and I break out through the door and into the cold night, smiling.

The Road through Residency
Habit and Apathy
Jason Faber, M.D. ’08
December 8, 2009

We're taught in medical school and residency that our responsibility to our patients often supersedes all others in times of crisis, but "crisis" is a vague term. In reality, crisis tends to be defined by those moving through an experience. A young asthmatic needing intubation will very likely recover, although family members may well believe they're facing a terminal situation. An elderly grandfather hospitalized multiple times in several months for the same worsening heart failure may have few good options for treatment, despite his family shrugging off another of grandpa's "episodes." We are creatures of habit, and habit breeds apathy.

It's fifteen hours since I've slept or eaten. The on-call period is long and arduous but a great teacher. The two pagers on my hip start beeping at the same time. I call one number, and a nurse says that a 67-year-old woman admitted for diabetic ulcer is complaining of heartburn. At the second number, I'm told a 40-year-old has a sudden onset of shortness of breath following orthopedic surgery. I go to see him first.

The patient, his left leg bandaged at the knee, is breathing deeply. My heart sinks, and I fear he has a pulmonary embolus. His vitals are more concerning: tachycardia, tachypnea. When I speak to the patient, he tells me he has severe anxiety, and "No one's giving me my anxiety pill." I order a chest CAT scan with contrast. Thirty minutes later, the patient is back in his room complaining about how small the CAT scan machine was, and he is very claustrophobic. I'm sitting at the computer screen checking the scan. The final read: no pulmonary embolism, normal lung. I give the patient some Ativan, his shortness of breath subsides, and he sleeps comfortably for the rest of the night.

I then move on to the 67-year-old with heartburn. The patient looks my grandmother, and countertransference occurs-I can't help but feel an immediate emotional connection.

"My heartburn is acting up really bad," she says.

"What does it feel like?" I ask.

"An elephant sitting on my chest-"


Thirty minutes later, I'm calling the cardiologist about what I suspect to be a myocardial infarction. The patient goes to heart catheterization, does well, and eventually goes home. Despite this good outcome, I don't feel well. I can't sleep. Tonight, I chose the wrong patient to see first. What if other calls had suddenly occurred? What if she hadn't described her symptom so perfectly? What if the outcome had been poor? We can live our whole lives wondering "What if?" but put simply and succinctly, medicine is not perfect. Like everyone else in life, physicians try, but we do not always succeed. Even the most seasoned attending in any specialty makes mistakes sometimes, and if we don't remember that, we won't be able to function.

Calls about heartburn happen often, and habit breeds apathy.

I sign out and give my summary of the night to the senior resident. After noon conference, I walk down to my car and climb in. I'm so very tired, but I couldn't sleep even if I were lying on a California king. The drive home is long and full of more stoplights than I feel entitled to. Coming home fatigued and sleep deprived has become a routine, a habit. In our apartment, my wife Sarah turns to me and smiles, our son in her arms.

"Daddy's home," she says.

I pick up my son and hold him close. He looks at me, his face blank, and then, as if by magic, he smiles. He doesn't need any words. That smile says more than words ever could. I kiss my wife and excuse myself to get some rest, as I always do after a night on call.

"I thought we could get a Christmas tree on your day off," she says.

"OK," I say, moving to the bedroom. I think, I hope I never get used to this habit.

"And we still need to get a Christmas present for…"

She walks into our bedroom, but I'm already passed out on the bed. She closes the door, and so I sleep deeply.

The Road through Residency
Cursed Enlightenment
Jason Faber, M.D. ’08
September 15, 2009

The scrubs I’m wearing are hanging damp and heavy. My limp hand is starting to go numb from the squeeze my wife is placing upon it.

The obstetrician, her forehead drenched in sweat, yells for more light and to for my wife to push harder. The monitor starts to show the baby’s heart rate falling more frequently into gullies and canyons, dropping off.

My wife’s blood pressure suddenly surges, her eyes roll back into her head, and she starts seizing. My mind races with the possibilities.

“Oh God,” I think, “it’s eclampsia.”

Her neck stiffens, and I fear aneurysmal rupture. The obstetrician calls for the nurses to start rolling her into the operating room. As we move down the hall, my hand is now squeezing hers, which hangs limp, lifeless.

Tears stream down my face, and a nurse stops me as they take my wife into the OR.

“We’ll do everything we can,” she said. “Please stay here.”

My mind reels. My hopes surge for the best outcome, but the physician in my mind whispers to me, “They’re gone.”

I sit up, and my head falls into my hands as I reorient after the nightmare. My eyes move to the baby monitor on the bedside table. The red lights jump with each of my son’s cries. He’s been teething for three days now, each ivory challenge presenting itself at night. At least, that’s what I hope it is, and not something sinister.

My wife moans, “Can you get him tonight?”

I get up from the bed, my back aching. “This is what happens when you turn 30,” I mutter.

I climb toward the nursery. Standing there in the crib, my son has tears streaming down his face. He sees me towering over him and outstretches his arms. I pick him up, and he buries his face into my neck, breathes deep and stops crying. I rub his back gently as we rock.

Earlier, my wife had asked me about giving him some ibuprofen. I refused, fearful of an allergic reaction, something I have had the unpleasant experience of seeing firsthand. Now, sitting there with him at 3 a.m., I think I might have been too hasty.

Over a year ago, I remember a visit to the obstetrician at 30-something weeks. I sat there while he asked my wife all the regular questions about swelling, nausea and weight gain. Afterward, he turned to me and spoke the only four words he said to me that day: “Don’t treat your wife.”

I appreciated his advice but never thought much of it.

Our pregnancy and delivery went as smoothly as any other. When we got home from the hospital, however, the worry began and never left. Every cough or sneeze became a rare, incurable condition in my mind.

At six months, my son developed mucus and blood in the stool. I feared the worst. After a visit to the pediatrician, we cut out dairy from his and (much to her chagrin) my wife’s diet, and his symptoms resolved. Just a milk allergy. Since starting a family, I have seen how this knowledge of all that can go wrong, all the terrifying diagnoses sneak into your mind with each symptom. These “zebras” are driven into our minds to make us into vigilant diagnosticians, but this enlightenment becomes a curse. The fear of horrible diseases befalling those you love is always in the back of your mind.

My son is sleeping now. I stand, move quietly to his crib, and lay him down amongst the soft liner with images of farm animals. The sound of rain outside lulls him asleep. I rub his back for a few moments and realize how vulnerable life can be. Then I tiptoe down the stairs and crawl into bed.

But my ears stay turned towards the monitor with the perpetual vigilance of a parent, made worse by the knowledge of a physician.

The Road through Residency
Hopes and Dreams
Jason Faber, M.D. ’08
July 13, 2009

As the Greek myth goes, once Pandora had lifted the lid of the jar, every manner of evil escaped to torture and punish man. She quickly covered the jar back up, as the last evil escaped. Wondering what was left in the jar, she peered inside and found the only thing remaining was Hope.

As a metaphor, the myth shows that in the most trying times we are often reduced to the core virtues we inherit by being human. In medicine, we sometimes stand on a precipice, below which the cold, dark sea beats against the rocks. There comes a decision then, whether to carry Hope away from this cliff or allow to it drop into the rocky chasm below.

I'm standing outside the hospital room with the family as the patient's chest rises and falls easily. The ventilator beeps occasionally during the conversation, distracting the patient's adult children. Their gazes dart into the room as an alarm sounds, but it is only the blood pressure monitor, because the cuff is off the patient as the nurses clean and organize the bed. Their looks are composed of love for their dying father, confusion over all that is taking place, judgment upon the care we provide, and fear of facing their own mortality at some time in the not-too-distant future.

"But I, being poor, have only my dreams; I have spread my dreams under your feet; tread softly because you tread on my dreams."
—W.B. Yeats

I'm discussing the code status with the family. In Ohio, the law in all its ignorance and politics, has decreed the setting of three different levels of care during a cardiac arrest, although two of these levels overlap enough to render them useless. The law is yet another attempt by a rigid, arbitrary system to impose categorization, an organizational approach, as a blanket solution to a situation that is anything but homogenous. I attempt to explain the differences among a Full Code, DNRCC, and DNRCCA. They're convoluted and difficult for the family to understand, and-I have to be honest-not easy for me to grasp either. I go over what would happen in a cardiac arrest, or a respiratory arrest, and reassure them that at no time will any care be withdrawn that isn't already in play. The patient's wife, who has been looking down at the ground as I speak in such cold, technical terms, looks up at me. Her gray eyes wet, her age-worn hands folded in a prayer-like frame, she asks, "What are his chances?"

The stethoscope hangs around physicians' necks throughout the day. Over time though it often starts to feel like an albatross, worn not to remind us of the transgressions against man, God, and Earth that we have already made, but of those we have yet to commit. It warns us of the mistakes we will make, the people we will fail, the inability we have yet to face. Throughout many patient rounds, I have often seen older physicians throw out percentages, estimations, ideas of what the prognosis likely will be. What I came to realize over time is that these are really, in most cases, guesses. Yes Virginia, miracles do happen, but rarely.

So here I am, standing in front of this elderly woman, who longs for the man she has loved for greater than a half-century to get up and dance with her one last time, and the family wants me to guess what his chances are. I could say what I truly think: that he is critically ill and has very little likelihood of survival. That even under the best circumstances, in the healthiest people, cardiac arrest is 50/50. That I don't think he'll see out the night. I squeeze the stethoscope in my hand as if I could strangle the albatross I'm forced to wear. I look at the family, their eyes full of expectation.

I answer honestly: "I don't know what his chances are… but I'm hopeful." They nod and go to the bedside. The patient remains a Full Code, and, despite our interventions, overnight he passes on. Over time, the conclusion I've come to is that it is best to be honest, but not at the expense of dashing someone's hope. It is all we have, in the end, and it is not for us-or anyone else-to tread on.

The Road through Residency
Jason Faber, M.D. ’08
May 8, 2009

The warm air kicks up dust from underneath the wooden giant standing before me. Metal rails guide the patrons from the beginning of the line to the small covered house at the end. I suddenly hear a loud whirling, and a rush of air blows past my face. I look up, too slow to catch a good look at the speedy demon, which is only a red flash at the edge of my vision. Clenching the metal rails tightly, heart racing, I wind through the maze and stand waiting at the end of the line. It's quiet in the covered house with no walls, where attendants wait with 'you-must-be-this-tall' hard plastic tubes in hand.

Suddenly, the ground shakes, and the red flash bursts into the house and slows to a halt. The riders get out of their harnesses, ladies with their long hair frizzy, and several young teenagers missing baseball caps or sunglasses. They look exhilarated. I move into a seat and pull the harness over me. The coaster juts out of the house, and I hear the tick-tick-ticking of the chain, pulling us up to the top of the hill. My heart races, hair stands on end, sweat begins to flow, and I look out over the rest of the park before I stare down into what seemed, when I was eight years old, like certain death. I close my eyes and put my hands up.

I open my eyes to reveal another exhilarating sight. The patient on the stretcher in the hallway is retching into an emesis basin. Another lies on his side, holding his left flank. Still another sits puffing through pursed lips turned a pretty hue of purple, laboring to push air into her lungs. I've come full circle now, having left the emergency room as a technician and returned a physician. I remember what I had forgotten; how such a small, enclosed space in the hospital can hold the majority of the drama and excitement.

I snap out of my reminiscing and grab the next chart in the bin. A 78-year-old female, post-fall onto the face. I make my way into the room while darting this way and that to avoid the barrage of nurses, family members, patients and physicians parading through the hall, minds focused, concentration on edge. The patient lies on the stretcher, a cervical collar around her neck, her hands shaking.

"Miss what happened today?"

"I'm nauseous. My head really hurts."

"Did you pass out when you fell? Did you trip over something?"

"I'm nause-"

She turns towards me and vomits onto the floor and my left shoe.

"It's okay." I keep my hand on her neck, stabilizing it until her nausea abates.

"I'm sorry."

"Nothing to be sorry about. I didn't like these shoes anyway."

My exam doesn't show anything too concerning. Her pupils are a little sluggish but equal, and there are no focal deficits. I order a CT scan of the head and some pain and nausea medication. I make my way to my attending and give him my presentation on the run, while he paces quickly, getting work done.

"Sounds like a good plan," he says. "We'll keep a close eye on her."

I move on to my next patient, a 45-year-old female who wants to throw herself in front a train. As I walk into the room, the patient breaks out into tears about her boyfriend, finances and how all she thinks about are exotic ways to end her life. I sit, listening, nodding, holding her hand. As I leave to close the door, she asks for a warm blanket, a Vicodin, and a ham sandwich, no cheese.

Later, I sit down at the computer and bring up the CT scan for my elderly patient with the fall. Staring back at me are two subdural hemorrhages. I quickly walk back to the radiology department. The patient is lying on her stretcher in the hallway. She is still neurologically intact, and I start pushing her back to her room, explaining what we've found. I ask the unit coordinator to page the neurosurgeon immediately. As she does, another patient grasping his chest wheels through the door of the emergency department on a stretcher. I close my eyes and feel myself winding up and down the tracks of the rollercoaster, through loop-the -loops and corkscrews, before bursting back into the small covered shed and coasting to a sudden stop. I open my eyes and realize the only difference is the excitement of the rollercoaster lasts less than two minutes, but I still have eight hours left in my ER shift.

The Road through Residency
And None at All...
Jason Faber, M.D. ’08
March 8, 2009

The soft glow of the monitor displays a bright red and green light across the patient's face. The slender endotracheal tube juts forth, sideways from the mouth, winding down and then upward into the mechanical ventilator. The chest rises and falls. On the other side of the bed, tubes full of blood run down from the patient and into a machine. The rolling apparatus, moving steadily like a metronome, pushes the blood through the machine and back down into tubes that return it to the patient. For this patient, the lungs no longer pull in air from the room, and the kidneys refuse to strain out natural toxins from the blood. Long ago, these organs were working well, during decades when a president was shot, or when a war raged in Vietnam. Earlier, on a beach somewhere in Europe, the diaphragm was able to contract tightly, drawing in deep breaths of sea air. Going farther back, the kidneys were doing great when this patient first had a beer. But years of life have taken their toll on what was once a pristine chemical machine, leaving it an organic ruin. Now, all that keeps this flask churning and burbling are machines and electricity.

The ICU is a netherworld. It's quiet and almost serene late at night. The nursing staff sit, twisting side to side in their rolling chairs, watching… waiting. Every once in a while the quiet is broken by the annoying, computerized tune of an alarm going off. Apnea alarm, bradycardia, oxygen saturation dropping: ding-dong-ding. Buttons are pressed, the pulse oximeter wrapped around the finger is changed, and the ICU once again falls silent. As I sit there, watching… waiting, it dawns on me that it is perhaps only with expectations that we become disappointed.

A new patient from the emergency room is brought up to the ICU. Old lungs and a worn heart have left little to drive him forward, and years of smoking have further weakened his lungs and given him cancer. This is his tenth admission in the past year. Each time, he is tuned up and sent back out into the world, always a little sicker than when he last came in. His family, hearts full of hope, sit outside while we transfer him. We place him on the monitor and the ventilator and open the bag of saline. I go out to talk to the family about his code status. "Do everything. Anything you need to," they say. I smile, nod, and walk back into the ICU, but deep inside, I know that all we can do will never be enough.

It is five o'clock when the heart first stops. Slowly, it makes its declaration of intent, the pulse coming down, the blood pressure ebbing. Then the pulse ceases. In the movies, this is when heroes and heroines spring into action, desperately grabbing for paddles and needles, and they usually win, beating back the inevitable for one more day. In the real world, very little is in our hands to change. I cannot give the patient a new heart, new lungs, new kidneys. I can't erase 70 or 80 years of life. In some situations, you simply know that you are not there to try to save someone, but just to be his witness at the end.

Multiple times the heart stops, and multiple times we restart it, not knowing how much damage has been done. I speak with the family many times and paint the picture of what is happening 20 feet away, and they eventually decide to stop intervening. The patient passes in the next hour. The tubes are removed, and the family comes to say their goodbyes. The ICU again is quiet and I sit there watching… waiting. To paraphrase Arthur Young, there is a great difference between a good physician and a bad one, but in certain circumstances, often no difference between a good physician and none at all.

The Road through Residency
The Novice
Jason Faber, M.D. ’08
November 8, 2008

Plato is credited with saying that before a man dies, he should plant a tree, write a book, build a house, and father a son. It is interesting that all but one of the items on his to-do-list for life have finite endings. Becoming a father is more akin to a lifelong tenure that doesn't pay as well as many think it should. I'm learning that being a new father isn't very different than being a young physician. There are many times when your patients can't tell you exactly what's wrong, just as a baby can't explain why he won't stop crying despite interventions such as a long feeding, a good burping, and an eventful diaper change. Patients sometimes become disgruntled at your lack of ability to fully give them relief or explain their symptoms, much like a baby wondering why you can't just walk around with him in your arms all night long. And, of course, you always have a little fear in the back of your mind while your patients are tucked in at night, a nagging worry that they might suddenly stop breathing or throw an embolism into their lungs from an occult clot in their leg. This is similar to pestering a pediatrician, despite sympathizing as a fellow medical professional, to evaluate the little cough your son has to the fullest extent. Being a new father is as daunting as being a new physician. The only difference is that as a physician, I'm only on call every fourth night.

It didn't take long for me to start worrying, even before we came home from the hospital…

I sit rocking in the oversized recliner in our post-partum room. My wife is asleep in the hospital bed, serene and exhausted. Twenty-four hours ago, we were pregnant. Now we've been parents for four hours and fifty-seven minutes. My little son lies asleep in the cradle in front of the bed. I hear him squirm, moan, and then fall asleep again. Despite the moon being at its zenith in the night sky, my eyes are wide, and my ears prick up at every groan, whimper, or cry. As someone who recently graduated from medical school, it's hard not to worry. All the horrible pediatric diseases I can remember flash through my mind every time he makes the slightest noise. Suddenly the prospect of being a father, a possibility I have excitedly awaited for thirty-eight weeks, is very frightening. I wish I didn't know everything that could go wrong. I wish I didn't have the mindset of trying to find things that are wrong. I wish I could just go to sleep and wake up when he's twenty-two and graduating from college. No matter how much I know about pediatrics, I am a mere novice when it comes to what lies before me.

"He's a little yellow," says the nurse during a visit later.

"I know. It's probably just physiologic. Nothing to be worried about." I'm saying this for my own sake. They take him out to the nursery, and I sit down, my knees rocking up and down. I look over at my wife, and she gives me that look.

"You need to settle down. He's fine."

On the ride home, I drive as if my insurance agent is in the front seat and a Department of Motor Vehicles representative and State Trooper are in the back.

A month later I'm rocking my son against my shoulder. His jaundice is all but gone. He squirms and cries. Slowly, with each little bounce, he calms down. He's almost twelve pounds now, and he's changing and growing every day. I'm starting to get the hang of this. I can tell when he's hungry and when he's just being fussy. I can tell when his diaper needs changing and when to grab a towel or duck as the cold air hits him. At work, something similar is happening. I can often tell when a patient is having more severe pain, or when a physical exam doesn't fit with the history, and I can see the potential complications of our interventions before they happen. So I guess being a father is a lot like being a new physician: there's a lot of on-the-job training.

The Road through Residency
Jason Faber, M.D. ’08
September 8, 2008

It's a scary thing when people look directly at you when someone is dying. While the face can lie about its emotions, the neck never can. The pulsating carotid bulge, the contraction of the sternocleidomastoid, cannot be calmed in a moment of fear. Many years ago, when I worked in the emergency room as a technician, even the most seasoned attending physicians, with their poker faces practiced over a lifetime of medicine, were betrayed by this muscular tightening of the neck.

One of the greatest modern physicians, Sir William Osler himself, described the quality of resolve in the face of great and certain adversity, which he considered essential to the modern physician, as imperturbability. In his address Aequanimitas (a Latin conjunction meaning "even mind"), he relates, "Imperturbability means coolness and presence of mind under all circumstances… immobility, impassiveness, or, to use an old and expressive word, phlegm."

A few hours into the first of many call nights I will experience as a resident, the pager on my hip goes off and a voice comes over the address system: "Code blue, room…" I've had anxious dreams exactly like this for months, but this time, the situation is undeniably real. Flying up the stairs and into the room, I try to take control over a situation that actually seems fairly stable without my intervention. I don't necessarily feel overwhelmed. I follow the algorithm that has been beaten into my mind. I try to think out of the box, I examine, I watch, and I analyze. There really is nothing more I can do. The chest compressions are sustaining an excellent femoral pulse. The carotid pulse bounds with each push into the chest. The rhythm on the monitor jumps and falls. The cycle continues: shock, drug, shock, drug. It's almost like a dance, where each step is delineated. An anti-arrythmic drug here, a dose of magnesium there. Suddenly, I realize that I'm no longer treating the patient. I'm treating the family outside the doorway.

Osler wasn't a cold, aloof physician bent upon making robots out of medical students. The "firmness and courage" essential for physicians should never come, he insisted, at the cost of "hardening 'the human heart by which we live.'" Nowadays, physicians seem to fear our patients more than a failure of our own courage. We are much more worried about harming the patient than afraid that some disease will take them from us. Writing down an order for medication or treatment has a sense of finality to it. There is no going back.

"Do everything you have to," the patient's son tells me. I take his words to heart and assure him we are doing all we can. I wouldn't look so confident in my response if my senior resident weren't standing behind me. When you're being pushed to the edge of your comfort, it's nice to have someone back you up. I return to the scene, still filled with a deep-seated fear that I'm forgetting something, that I may do something wrong, in the incorrect order, or without some vital piece of information. But there's no time to stop and second-guess. I keep watching the monitor, my fingers on the femoral pulse, repeating the algorithm in my mind like a prayer.

The truth is that physicians make mistakes. We're only human. No matter how many checks and balances exist in the hospital system, errors will seep in. At the end of the day, you have to accept this, or you'll never be able to keep out the fear that can freeze you in your tracks. I suppose the mistakes we make, we can ultimately live with, as long as they are in good faith. These are the mistakes made from ignorance beyond medical knowledge, from the excessive complexity of a situation, not because we faltered in our resolve.

In his farewell address, Osler admitted, "I have made mistakes, but they have been mistakes of the head, not of the heart. I can truly say, and I take upon myself to witness, that in my sojourn among you: 'I have loved no darkness / Sophisticated no truth / Nursed no delusion / Allowed no fear.'"

At the beginning of what I hope will be a long and fulfilling career as a physician, I can only hope I will someday be able to look back and say the same.

Notes from a Medical Student
Deja vu
Jason Faber, M.D. ’08
May 16, 2008

There's a feeling of déjà vu as I walk through the sliding double doors. The sounds, smells, and sights remind me of times long past. Nurses and medical technicians move past me quickly carrying IV equipment, EKG machines, monitors, blood, and paperwork. I see the small rooms, some curtained, others not. As I look to my left an older gentleman lays on the stretcher, his Sunday best on, clutching at his heart. On the right, a thirty something female lays holding her right upper abdomen. I hear the moaning, calls for nurses, orders being yelled across the room, and the constant 'beep' of a monitor somewhere. In this sea of chaotic order, I feel strangely at home.

I had two decades on this earth the first time I laid my eyes upon the emergency room. I was still in college, studying Greek, Latin, and Philosophy when a friend told me about a job he was applying for at the local emergency room in Cincinnati. It paid well, sounded fun, and already I was thinking how cool it would be to say I worked in an ER. Of course, this was at the height of the TV show. The job was as a medical assistant, patient care assistant, whatever you'd like to call it. I would basically be a jack-of-all-trades. The first day we met the nursing supervisor, interviewed, and then left for a tour of the ER. The double doors swung open and suddenly I was immersed in the chaos. Physicians running quickly past me, nurses kneeling with needles in their arms, and clerks answering phones with rapidity while cross checking paperwork in front of them. I remember thinking that I would never get the hang of this, that this might be too much for me. Four years later I started medical school, leaving the ER which had given me my baptism of fire into medicine and my niche in both library and laboratory for two years.

Now I'm back. Not to the same ER, but nevertheless it feels the same. Oddly, despite the whirl of movement and work, I'm calm, a feeling of satisfaction moves over me as I stroll into my first patient's room for the day. Then the difference strikes me. Instead of running to get an EKG machine, getting paperwork ready, or grabbing an IV starter kit, I'm standing here, white coat on, trying to figure out what's going on with this thirty something female holding her right side. I run the differential. Cholecystitis obviously, but I'm also considering hepatitis, pneumonia, and ulcer. My thoughts run over the pointed questions to ask.

"Have you had any nausea or vomiting?" I start. "Yes a little, I vomited yesterday twice and, OUCH." The IV finds the vein quickly, I watch for the flash of blood, and quickly fluids are running. Vomiting, nausea, right upper quadrant pain, some increased severity to food intake. I'm confident in my differential. As I start to walk out the room, she mentions suddenly, "I've had some discharge and lower belly pain too." I stop… suddenly everything's changed. This is what I learned after years in the ER. Just a slight phrase, a word can change the way you see a patient, the picture, the process. It's what keeps you on your feet. Because beneath all that obvious history and physical exam, sometimes something very sinister and unsuspected is waiting to declare itself. By then you might be too late.

Before the night is over, we have a lull. These are transient, and must be appreciated for as long as they can be, because the storm is always coming. As we sit back and enjoy it, the doors open swing from waiting room. An older gentleman sits in a wheelchair, clutching his chest, sweating. As we lay him down I start moving quickly, grabbing an IV, cleaning the arm, and finding the vein. Retract needle, place lock, draw blood, secure with tegaderm, and flush. I do it without thinking, without pause as he starts to tell me about that elephant sitting on his chest. Later, the nurse pays me a compliment on my rapidity with the IV. "I've had a little practice with it before," I answer.

Notes from a Medical Student
Jason Faber, M.D. ’08
March 16, 2008

We all face it. We face it from the moment we realize its consequence, finality, and heaviness. Maybe it comes when our pet parakeet flies away, never to be seen again, or when an uncle dies unexpectedly from some sneak-thief arterial block. We are left to confront the greatest and oldest adversary of medicine. It focuses the mind on questions of God, reality, being, soul, and eternity. Beyond its frightening awe and inspiring intricacy, it is as simple for the adventurer into its depths as for those who witness it.

At times, the physician plays little more than a witness. For me, the close, sudden thunderclap of death's arrival brought back those college days when life is so wide and wonderful, and you believe you can't die, you question everything your senses and mind tell you, hoping that you'll have some glimpse of the truth that has evaded capture since our ancestors first asked, "Why?"
48 hours--I sit gazing longingly into my computer like a gypsy peers into a crystal ball, but I find no answers. So instead I pick up my stethoscope as if it were a divining rod and move down the hall toward Mr. M's room. For several days, he has been facing his cancer. There he lies making conversation to ease in my heart. He speaks of seeing his family, his son, his wife. There is hope in his voice and kindness in his words. He manifests all that I hope any man or women could when confronted with such a grim prognosis. He is courageous and calm; goodness incarnate, perhaps. Yet, he lies before me, dying. Oh, not immediately mind you. cancer is a slow mover at times. After all, how could the end come so soon to a man who is so elegant in his speech today?

24 hours--"It's been a pleasure Mr. M," I say, feeling good about what little I've done. His hand reaches into mine and we shake, with warm, strong grasps, containing pride for what one has done and what one has endured. As a medical student you suggest, never order, but feel, as the brand-new intern does, that you've done some good when it comes down to the end of the day. Mr. M will be transferred to another wing of the hospital for palliative care. The wheelchair comes, a tank of oxygen, and off Mr. M. goes. His hand rises and waves as he rounds the corner. I hope he has at least six months left. Six months to ride his motorcycle, to feel the wind in his hair, to feel the wonder of simply existing. I hope and pray his discharge comes quickly, before chemotherapy takes its toll. I tell myself, he is a strong man, and I do the Hollywood double take, almost to reassure some invisible audience, as Mr. M rounds the corner, that all will be well.

The next day--The doors swing open, and I come in out of the cool morning air. I'm tired. Not enough sleep last night compounded by a long ride in this morning. I put my coffee down on the table and go to see a few patients. I talk with them, make sure they are improving in some form or fashion and make my way to the work area to start my notes. As I enter, the resident turns to me and says, "Mr. M died yesterday." At first, it doesn't faze me. Then, I am saddened. "Oh no. That's horrible. He was such a good man." I hang my head for a few moments and then go back to typing my SOAP notes.

On the long drive back home, the reality of it all hits me. As I reach my exit, I pull into the gas station and start to fill up. I flick the clip into position and sit down in the driver seat, with the door ajar. I sit there, my head in my hands, and I think. Not about Mr. M, I'm sorry to say. When I think back on it all now, I feel ashamed. I should have thought of him, his family. But instead I was filled with that awful realization that I too will shuffle off the mortal coil someday. I hold my head in my hands and cry… for myself… for my patient… for my species. I realize at that moment that my circle has widened and I stand up, wiser. Suddenly the latch clicks and the tank is full. I snap the cover and start the car. I pull out and onto the road.

So many years of philosophical training, and I still have no clue how close I am to any answers. The questions that deal with what it means to be human: Who am I? Why are we here? What is reality? What does it all mean? What other questions are there? And how often have you asked them yourself? After so many years, I feel part of becoming a physician lies in the ability to understand what it is to be human.

I look out the passenger window, a field of corn blowing in the breeze, high and green. I smell burning wood, and hear a brass band playing in some small town. And so, I take solace that somewhere, as Ms. Teasdale says, there will come soft rains.

Notes from a Medical Student
Summer Sun and Morning Rounds
Jason Faber, M.D. ’08
January 16, 2008

The radiance of the summer sun is quite a spectacle in mid-morning rounds. The light shines brightly into the hospital room of the upper floors, bathing the patient, medical staff, and myself in its glow. I squint my eyes out at the outside world. Try as I might, my eyes don't adjust to the glow, a consequence of walling myself in this citadel of the sick for so many hours. I move my gaze back to the patient, a kindly looking elderly gentleman, all smiles despite the odds. He is staring directly at me while I was looking out the window, and in a reflex response I smile back at him. He smiles and turns back to my attending physician who is talking softly and with compassion as the plan is put forth in simple terms. The patient nods his approval and looks back out the window, perhaps trying to see what I was looking at. We move back into the hallway…I field a couple of questions from the residents and the attending physician. Some I get, some I don't...and we move on down the hall to the next beam of light shining.

The crux and keystone of the practice, art, or science of medicine is the basics of Internal Medicine. A vast library of knowledge supplants this specialty and gives credence to Hippocrates' description, "The life so short, the craft so long to learn." So as my third year of medical school draws to a close, I finish on the specialty which allows me to use all that I've learned to this point. It is by far the biggest world of medicine I've come into contact with. The differentials are long and the possibilities endless.

So I start where I began so many years ago, with some simple reason to derive a common theme or two from this ocean of knowledge and practice. Up to this point, I've derived three qualities I find I cannot do without if I hope to be worth my weight in salt as doctor.

Of course, the most obvious is a love of knowledge. The curiosity has to be there or this long course of learning can't continue. Now the verve for this learning can wax and wane, with the circadian rhythms of the day or the trials and tribulations of any life, but eventually the deep entrenched curiosity of what is wrong and how to effect change must come flooding back. When the possibility of an uncommon ailment or the hoof beats sound more like a zebra than a horse, I detect the eyes of the physicians around me shining a little brighter with interest and intrigue. After all, part of being human is being humbled by not only that which we do not understand, but that which we do not commonly see. This leads to the second quality.

Einstein himself related "No amount of experimentation can ever prove me right; a single experiment can prove me wrong." Without humility, curiosity would never be strong enough to be considerate of every patient. So humility is indispensable, because without it you can run the risk of diagnosing the patient before seeing them. I've walked out of a patient's room and believed that I had the diagnosis nailed down, only to discover I was so far off as to be embarrassing. Those times in particular, I saw what I wanted to see instead of seeing what is simply there. So instead I've tried to walk into a room as Tabula Rosa, allowing the patient to paint the entire picture while I'll simply add the framing.

However, humility and a love of knowledge cannot exist without simple compassion. It's a quality that is simply human but not the simplest of emotions for humans to control. Without simple compassion I am already categorizing them without humility and often without sufficient curiosity. After four years in an inner city ER, compassion isn't the easiest of emotions to turn on or off. Nor should it be so pliable, but with anything takes practice and I haven't mastered it yet.

The patient in the next bright room is doing well, or at least much better than last night. When I saw him at admission the night before he was severely hypotensive without tachycardia. Fluids were started and antibiotics as well. As I laid in the on-call room, I tossed and turned over it. Finally, I got up and made my way to his room and sat there for some time. I don't know if he was aware of my presence--he didn't have to be. As time passed, he became normotensive, and I made my way back to the resident lounge. Today, the light is reflecting off the monitor in his room, and his lucidity has improved. The attending physician is doing his examination and his vitals are looking good. I look back out the window. An elderly woman is walking up the path to the hospital, a large green lawn stretches out into the distance, and I swear I can smell fresh cut grass.

Notes from a Medical Student
Jason Faber, M.D. ’08
November 16, 2007

St. Francis de Sales is credited with saying "Have patience with all things..." In my clerkship rotations so far, I've found this to be an important and indispensable piece of advice. A significant part of medicine is often spent waiting. Allowing for the tincture of time to set in often remedies the most painful of problems. Waiting for a culture, a lab value, or a patient to be ready for an interview requires the physician to have this virtue in spades. I've found this quality of character no more useful than in pediatrics.

As I walk into the exam room, I'm confronted with patient who cannot talk, cannot walk, and cannot communicate in such a way that I can understand. Despite these circumstances, nothing is wrong with this patient. She's only 9 months old. Here for a well-child check-up, I introduce myself to her translator. Mom sits the infant in her lap and I start the run of questions: bottle-fed, breast-fed, cereal, other foods, stool, diapers, babbling, stranger anxiety, etc. Mom has no questions or concerns. Everything with this little one is good. So I start the exam. I swivel on my rolling stool over to mom and spend a couple moments playing peek-a-boo. I slide the little one down, intending to listen to the heart and lungs when I'm faced with my first challenge: the Onesie. It's this little bodysuit for infants which buttons with three snaps at the bottom. At this point you can guess I have no children of my own and have virtually no experience with human beings of this length and weight. I fumble at the snaps, hoping Mom won't notice and think, "Who is this kid, think he is, examining my baby?!?" I breathe slowly, and with a little patience, it comes apart and I slide my stethoscope up underneath onto the chest. I start to listen, then look down. She's looking back up at me with a dazed look. I smile. She smiles. I get lost for a moment and then move my stethoscope. As I continue to listen to the lungs, I realize that while I was lost in her smile, I hadn't really been listening to her heart at all. I move the stethoscope back and listen again, this time with my eyes closed. I slide her down then, squeeze her belly, feel for femoral pulses, and attempt the Barlowe and Ortolani maneuver. As I squeeze and jostle her, I'm amazed with how strong this little one is as she extends her legs and pushes back on me, almost moving both me and the rolling stool that I'm sitting on. I feel the back, look in the mouth, and finally the ears. As I finish the exam, I hold the infant in my arms for few moments to get a feeling for movements and strength. I turn her on her belly in my hand and fly her towards mom; back and forth, away from mom's face and then towards her. She laughs and moves her arms, clapping her hands together, while mom's face goes from relaxed and smiling to wide eyes and puckered lips. It is in this moment, that I forget all the things I might be forgetting and suddenly this all feels a lot like simple fun. I set her down in mom's arms, thank them, and leave the room. I start worrying as the door closes, my face drops from its smile. I'm not worrying because of something I found in the history or physical exam. I'm worrying because I don't know what's normal, and without that important feature in my arsenal of medicine, learning the disease state becomes even more challenging.

Two hours later, I find myself standing outside the same exam room. As the physician whom I'm following asks if I can start, I can hear several voices, some loud, some soft, issuing forth from the room. As I enter the room, I see three children, one about 9 months sitting in mom's arms, another around 2 years of age running around the room, and finally a 5 year olds sitting in a chair giving me an interesting look. Mom looks at me and says, "Do you have any kids?" I shake my head no and smile. She smiles back, "Well this will certainly be a learning experience for you." Each of these children are here for the same complaint: cough. So, I start at the beginning, with the five year old. She sits still on her chair but clearly doesn't want to have anything to do with me. Next I move to the 2 year old, which at the beginning seems like an act of futility. I point to pictures on the wall, distract him with lights and my stethoscope, and have him hold a tongue depressor trying anything to obtain 15 straight seconds of stillness. Finally, I move to the 9 month old, who starts screaming the second I roll towards her and mom. I play peek-a-boo, move around the stethoscope on her siblings to show her there's nothing to fear, and bop the otoscope on my nose to be funny. The latter only causes her to scream more and turn her head toward mom. I try my best to listen to her lungs. She sounds clear through the screaming; at least she is definitely moving air well. Finally, I end with the ear exam. After I simply mention the exam, mom already assumes the position, holding the little one's head against her chest. I press my fingers against the head so I can move with her as she shifts her head one way and then the other. I never got near seeing the Tympanic membrane. I walk out of the room, feeling inefficient, and admit to my attending that I couldn't visualize the Tympanic membrane. Not because of earwax or discharge. I just couldn't get her to stay still enough. My attending smiles and walks in the room, within minutes, the 9 month old is laughing, and the exam is done within seconds.

Patience is really all it takes. Patience in learning the baseline of all things. Patience in learning what makes children distracted. Patience in seeing an ear infection in all of the other siblings and what settled them down after a good cry. Francis de Sales quote holds true, and as the rest of it goes, "Have patience with all things, but chiefly have patience with yourself."

Notes from a Medical Student
The Doctor’s Knock
Jason Faber, M.D. ’08
September 16, 2007

I've often thought that the doctor's knock, that tap-tap-tap on the door immediately before entering the exam room, was always a great metaphor for the remaining graces and manners of office medicine. In a way, a knock on the door is usually equated, at least in my mind, as a request: "May I come into your home?" or "Will you be so kind as to let me in?" Interestingly it almost implies the invasion of one's abode by another for a philanthropic, benign cause. Yet in this day and age, where privacy is quickly becoming public domain, it still stands as a testament to a level of courtesy and respect that stands firm at the center of being a physician. This is not without irony however, because the knock-knock usually is immediately followed by a turn of the knob because, well at least in my mind, I can't hear anyone through these thick doors.

The reason I mention this little metaphor is that I've come to a realization over the past month in Family Medicine that the end is nearer than I think. I move with a little more confidence now and feel more relaxed when I counsel on giving up those Ultralights or trying for that extra thirty minutes on the treadmill each week. I feel more confident because the explanations and choices that I have to give are starting to flow out of me. I don't find myself reaching into the recesses of my mind trying to remember what antibiotic is first-line for Streptococcal pharyngitis, or what a reasonable asthma regimen might be. So with this confidence comes the questions about what the future entails and asking myself should I let the world shape me or should I shape the world. I remember almost half a year ago that I was shutting my eyes tightly trying to remember an ‘on the spot’ question, whereas now I knee-jerk the response and expect the next two to three questions as follow-up. The mantra has been knowledge before speed. So I thank my time here in Family Medicine for allowing me to slow down and truly ponder what are the choices I can give, what are the red flags I'm looking for, what canI do to develop more of a rapport. In a sense that is what this entire month in Family Medicine has been for me…a lesson in rapport.

Tap-tap…knob turns…door opens, and there sitting in a small chair is the patient. His face brightens up when he looks up at the attending physician I'm following. "How are you doing?" Simple words, but they will result in all the information you might need to help. I watch as the two, the patient and the physician, shake hands and sit down. They chat…asking how's this and that. If you would remove the white coat and gown from this picture you couldn't tell that this was a conversation between physician and patient. The attending physician leans over to me and says, "I've seen Mr. H for…oh what has it been now?" "Ten years," says Mr. H. I smile and realize that I know very few friends whom I've kept in contact with longer than ten years.

I think of all the yearly physical exams, the heartburn and sick kids, getting them through cancer and off cigarettes…this conglomeration of attempts to help mold a person's life in some manner to increase both quality and quantity. It dawns on me then that a physician's job is more akin to that of a blacksmith. Today, the patient simply has a physical. The visit ends and they both go their ways, happy to see each other. I don't believe rapport can get much better than that.

Not to say that all relationships are that friendly. I've noticed over the past month that these long time relationships often take on the form of other long term relationships: the younger and older brother, the father and son, the squabbling old married couple that never agree. But through it all, the good news and bad, the function is often the same: to remind the patient that they are as much a part of this congregation of homo sapiens today as they were on the day they were born. As for myself, with this new confidence and lesson in rapport, I move closer and closer to the end of third year and the beginning of my final year of medical school. At this point it seems so far away…and yet in a way not far enough.

Notes from a Medical Student
Obstetrics Training
Jason Faber, M.D. ’08
July 16, 2007

As the sun sets behind the Dayton skyline, I come in from the chilly fall air and begin my next 12 hours on Labor and Delivery. As I follow around the interns, I try my best to follow the logic that leads one from evidence to action. Learning to span this gap is the purpose of these two clerkship years. Unfortunately it isn't so easy, because from my eyes this movement is almost instinctual to residents, making me wonder if it ever will be so for me. So I do what every good medical student does in the meantime…I wait…read…study…get some coffee…read again…check back. The life of a medical student in the clerkship years is spent mostly in limbo. You begin to feel like you're waiting at a train station that has no scheduled stops. Hoping and squinting off into the distance so that you can catch just one train. You get excited when a whistle blows, but realize that there is no train, or that the train just isn't stopping for you. This is very true of a rotation in Ob/Gyn, where I sit waiting to hear that whistle.

Then, in the late evening, they page me for a delivery. I shake off the daze I was in and move quickly to the room. Despite how it appears on this end, mom is doing quite fine on the other. So I find my place holding a leg here, grabbing things there, or simply watching and keeping my eyes and ears open. The delivery goes smoothly, with the normal progression of hair giving way to a head, to a neck, a body next, and feet at the end. Excitement, humility, joy, concern, satisfaction, and relief fill the room in a heavy, humid air. But the work goes on. Still two beings to care for, only now they are separated by several feet, instead of nothing at all.

As the night wears on, a young mother-to-be and her unborn begin to stride into uncomfortable areas. Heart rates go down, and quickly the decision is made for a C-section. My past rotation in surgery has prepared me for work in the OR well, so I now don the cap, gown, and boots with ease, and scrub my hands with a sense of confidence that no microbe will be left. However, after spending a month of 3-4 hour surgeries in the OR, I'm surprised by the relative quickness and rapidity of the procedure. Through the belly, into the uterus, delivery, and closing takes less than an hour.

Morning comes, and I pay a visit to the Neonatal Intensive Care Unit to check on a preterm infant of one of the mothers I'm looking after. The careful design and technology of this place awes me. It stands in my mind as a testament to the edge of reason and science that can truly change the natural pathways of life. The infant is stable, breathing well, and kicking both arms and legs, covered in soft hair, yet still so small and fragile.

I make my way back to the Rotunda in the Berry building and stand watching over the people coming and going two floors down. I watch as a young woman, baby in her arms pushes through the revolving doors and disappears. At the same time, another woman enters the building through the same revolving doors. This young woman is pregnant and looks term from where I'm standing. This is the cycle that I have to learn to live in while I'm here. But perhaps the most pressing question that I have been unable to answer is how much of all this should I let in. How much am I unable to stop from getting inside? I don't know the answers to these questions, and of course they really have no answer. So, like everything else, I'll learn by trial and error.

Suddenly, the pager on my hip beeps. The train is whistling, and I head off down the hall to Labor and Delivery.

Notes from a Medical Student
Perhaps It Was Divine Intervention
Jason Faber, M.D. ’08
May 16, 2007

There's a story I know. Don't ask me how or why I know it….and don't assume that the story is about me. It may be true or it may not. It doesn't have any moral undertone; it isn't a proverb. It just shows one of the worst days in the life of a medical student in the second year. For this story I'm going to exercise a little literary license and tell it in the first person.

The white wire mesh holding up my clothes in the walk-in closet of the apartment crashed to the ground. My eyes flew open and the subconscious took over. I quickly looked over at the alarm clock: 7:15. I panicked. Flying off the bed, I ran to the dresser and began frantically throwing on shirt, jeans, shoes, and hooded sweatshirt. I glanced at the wire mesh dangling from the wall. "That's for later," I thought, and dashed out the door grabbing the keys, cell phone, and wallet off of the table as I ran past.

I hit the back roads, which are usually much more light at this time of the morning. I stayed within 5 mph over the speed limit. I drove carefully and reviewed the information for this morning's test in my head. I ran through the neuroanatomy and then onto the pharmacological aspects. I realized I had not reviewed pediatrics as deeply as I had wanted to. I threw up my hands and said "Oh well" and continued on the country highway.

As I drive the traffic slows down to a crawl and I begin to wonder where I can find my professor's number so I can profusely apologize for my absence. The traffic begins to pick up and I pass the accident that caused it. The car is a small compact, resembling the small Yugos of the 1980s. It's completely flipped over onto its top at the edge of the road. There are no police but there is a tow truck. The only people are an older looking man, leaning against the car as if leaning against a bar, talking to the man who obviously owns the tow truck. The two of them laugh and then I see the older man throw up his arms as he looks toward the car. I immediately understand exactly how he feels.

It was as I was turning onto Fairfield Road that I felt it. It started as a twinge in my stomach and quickly began to engulf my whole body. All the adrenalin that had been running in my veins was catching up with me, and I began to feel sick. Worse yet, I got stuck in traffic again. When you are stuck in traffic, you watch the clock carefully, trying to make sure that every second is counted, and possibly trying to use your sheer willpower to slow time. Time, however, is stubborn and it kept on clicking by at the usual rate. Finally I reach the college and jump out of my car and into the building, knowing I'm just a minute late and that they don't always start on time. I slow down to a stroll as I enter the room and grab the sheet of paper and sit down. I breathe in and out and smile, knowing I barely made it on time. Unfortunately, for the rest of the test the adrenalin rush made my stomach churn, and I began to lose my concentration.

I was on autopilot during most of the test, which I don't really remember too well. The drive home is somewhat of a blur as the descent back down from my rush got worse. I walked into the apartment and went straight for the bed. As I passed the closet I looked at the white wire mesh hanger. There was little sign of how or why it had fallen. The hooks were still screwed tightly into the wall. I shrugged and promised myself I would clean it up later. As I passed the alarm clock, I picked it up and dropped it into the garbage bin and then promptly fell onto the bed face first. The last thing I remember thinking was, "Wow…someone really wanted me to take that test."

As I said, this story has little purpose than to show one of the worst days in a particular medical student's second year. It may be true or it might not be. At any rate, I passed.

Notes from a Medical Student
This is Medicine
Jason Faber, M.D. ’08
March 16, 2007

The voice of the resident in the far corner begins to fade out. His white coat begins to blur along with everything else in my visual field. As this happens, I explain it to myself in medical terms; the blur is the result of my eyes converging due to the movement of my ocular muscles, which I'm losing control over due to my fatigue. At this point I'm only catching little phrases from the presentation.

"55 year old male…" "History of CAD and hypertension.." "Sodium 135, Potassium 2.0…" "Chest X-ray shows bilateral…"

Then, like two stage curtains, my eyelids begin to droop and I can feel my head falling forward. Suddenly, the fail-safe alarm in my subconscious comes on, rattling me back into consciousness. My head pitches back, my eyes fly open, and my hand comes up to my mouth to make me look like I'm deep in thought about what exactly is ailing this 55-year old man. It's the second week after my first-year finals, and I'm sitting in morning report at seven in the morning. I look around to make sure no one saw my descent into REM. Everyone's eyes are fixed on the overhead projection of the chest X-ray. My eyes dart toward the X-ray I look at it sternly, but I am thinking in the back of my head, "Are the lungs normal…I think so…is this pneumonia….I'm not sure…wait, is this Situs Inversus…no the X-ray is backwards." I strain my mind to remember my anatomy class and the radiographs I studied intensely. Then the X-ray begins to blur.

I wouldn't be tired if it wasn't for the fact that I have been staying up late reading my pathology book to get a head start on second year in med school. In the first class we get three weeks to read 600 plus pages from the pathology book and a pharmacology book. This then, culminated with the fact that I have to drive to Miami Valley Hospital in Dayton from Cincinnati every morning, results in one fatigued student. Sitting in morning report, I know this, but I keep telling myself the same thing I've been telling myself all year, "This is medicine…this is medicine."

As morning report draws to a close, I team up with a resident and we begin to see patients. After spending four years in the hectic pace of an ER, I expected family practice to be more lax and slower paced. I was wrong. The residents darted from room to room as patients remembered more complaints. The residents swiftly scan through test results and old medical records. They write prescriptions and medical notes quickly, with the penmanship paying the price for speed. As time goes on, I'm amazed with how much I remember about patients I've seen from a few days ago or even last week. The names of patients I've seen previously don't ring a bell, but give me a chief complaint or a medical history and I can tell you what that patient ate for breakfast on the day I saw them.

Despite the fatigue, I listen closely with each patient, desperately trying to recognize a constellation of symptoms that I can categorize or thinking about what would be in my differential diagnosis. Here is a five-year-old with diarrhea for the past two days. So I think, "What could it be…probably Rotavirus…or could be Vibrio Cholera…no, no this isn't a third world country…but could it be? Is it Salmonella….no no…there's no blood in the stool…wait, was there blood in the stool?

Lunch comes and goes, and although they are nice enough to provide me and other students with a free lunch, it comes with a side of a Conference on Obstetrics, and the dessert is Medical Journal Club. The afternoon is filled with the same, but this time more patients. Then, the resident and I go in with a patient who is scheduled for a fifteen-minute appointment, but unloads on the resident a multitude of complaints, some of which are personal and emotional. We leave the room forty minutes later, far behind the schedule. Despite the surprises and new complaints, somehow we're done just about when we should be.

I drive off toward Cincinnati and back home where I can relax for a few minutes before moving back to the books. I'm tired but awake. I treasure this long drive because I feel good about myself and about what little I've done to help these people, these patients. I arrive home feeling rejuvenated and hungry for more. As midnight rolls around, I realize I've been reading the same page for the past fifteen minutes. It's about edema due to lymphatic obstruction. I read over and over again but it doesn't quite stick. The pages begin to blur and the stage curtain begins to drop. My head pitches forward and I keep telling myself, "This is medicine..."

Notes from a Medical Student
The Greatest Gift
Jason Faber, M.D. ’08
January 16, 2007

As I stood there in my white lab coat, I felt intimidated. In a way, I felt that I shouldn't be. For four years, before I was accepted at Wright State University School of Medicine I spent some sixty hours a week in an inner-city emergency center. I remember the gunshot victims rolling in on stretchers and the packed waiting room, swelling with the suffering and the impatient. I worked third shift during those four years, staying up late into the night to watch the sick and suffering of Cincinnati. It was a wake-up call for this twenty-year old Classics major at the time--a brief glimpse into the atrocities that bug and man can create. It was my trial by fire and an experience that would either solidify my desire to practice medicine or destroy it entirely. As fate had it, my desire to become a physician grew, and I found myself increasing my hours after graduation. The masochist in me began to take hold, and I became convinced that if I can survive this, then I just might make a good physician.

There were scenes and experiences that I took part in that have been engraved in my memory. I remember a homeless patient who had scabies over his entire body. I remember an HIV-positive woman who rolled into the emergency room at the height of a rush of trauma patients. She had cut her hand severely, and a large bandage and mass of clotted blood clumped together where her index finger used to be. As I stood before this woman, I felt concern and worry for her, yet at the same time I felt fear for myself. I remember the first patient who I did CPR on, but despite our intervention, died. His name was Marcus.

I have seen and experienced situations other first-year medical students have not and perhaps will not see for another year to come. However, despite all these experiences, I still stood there back in September of last year, and was humbled and fearful. Before me, lay my greatest teacher. The white sheet covering him hung there like a stage curtain waiting to open. The class was Human Anatomy, and this was the donor upon which I would learn firsthand the intricate design of the human body.

It's a strange feeling to be given an experience such as this. You feel like an astronaut on his or her first trip to the stars. So I steeled myself and drew back the covering to begin my examination of this donor and my career as a physician. At first, I had a great doubt in my mind. How would I ever learn all this? I looked from head to toe over this brave donor lying before me. Every intricacy of this design lay before me. Then I felt elated. I realized that however one sees the human body, by God's or evolution's design, doesn't take away from the fact that you stand in awe of this complex and highly adaptable design. So many anatomists and healers have come before us and mastered an intimate understanding of us as flesh and blood beings. Where they have gone we, too, must follow.

As time wore on in the class, the amount of information increased. It was overwhelming, and there were times when it felt like too much, and at one point your mind would suddenly shut-off, like the click of the nozzle when you've filled the gas tank to full. In the end, what kept me going was awe and fascination. You can't help but be drawn to the information, to learn what makes us lift our arms, allows us to smile, or even take five steps towards the door.

All this I learned from my donor, a man who lived a lifetime before I was even born. Throughout that lifetime, he had been overseas and traveled. He had suffered, rejoiced, hated, and loved. I'd like to believe that the vast spectrums of human emotions are experienced by all of us. Throughout all our experiences, our bodies are there with us, up to the end. In only nine weeks, we had soaked up a vast amount of information about the human body at the gross level. The final exam came and went. I answered the last questions on my donor and then bid him farewell. I never saw and will never see him again, but I can never forget. It almost feels like he was some supernatural being who appeared suddenly one day to teach me all about the human body and then disappeared just as mysteriously. I often think it's very ironic that the greatest contribution to raising physicians is giving over oneself. As for me, I passed the class, but more importantly, I can't forget it.

Notes from a Medical Student
Deep Breaths
Jason Faber, M.D. ’08
December 16, 2006

With my eyes closed, I take a deep breath. I review the flow of the material I need to remember and quickly recall the most important points. My hand goes up against the door and knocks. The voice on the other side says "Come-in," and I think how simple that phrase is for something so complicated. I grab the knob, turn, and walk in, exhaling with a smile and an exuberant, "Hello."

For the past two years I've been reading. Well, mostly. Medical school demands that you master the pages before touching the patients. Well, for the most part. The growing trend now is to start the clinical training earlier. When I say this I mean to say that it's not only important for me to know what pneumonia is, but what it could sound like when I listen to the lungs, what an S1 heart sound is like, and what I should be looking for on a neurological exam. So, for the first two years of medical school, I have studied the aspects of disease, the etiology, pathogenesis, and everything in between. But almost every Friday, we are trained in the technical skills of a clinician, because of course medical science alone, does not a physician make. So here I am this Friday afternoon, learning one of the more intricate techniques of the clinician: the female exam.

Am I nervous? Of course, I'm nervous. In the real world, many aspects of the physical exam would legally be considered battery. Listening to the lungs, the heart, and the abdomen are one thing. You can easily get over the invasion of privacy because you're pretty much examining a patient in something similar to their underwear or a swimsuit. This exam however, is a completely different ballpark. It is the first exam that really shocks me and makes me think, "This is what real doctors do."

Technically, I shouldn't be nervous. For the several years that I worked in an emergency room, I assisted and chaperoned in perhaps hundreds of female or pelvic exams. Holding the tube of preservative or getting the patient comfortable with the most sought after commodity for any patient in a hospital gown: a warm blanket. Several hundred times I've stepped in there and several hundred times I've not thought twice about it. Now I realize, standing in front of the door, I've gone from passive observer to active participant. Now whatever happens is pretty much my fault.

So we start where any relationships starts, with a "Hello." I should explain that the woman guiding me through this exam isn't a real patient. For the first two years of medical school, simulated patients, actors of clinical presentation and thespians of the body, train us. This exam, however, is as real as it gets. And to tell you the truth, aside from the fact that I've never done this before, the fact that I'm male doesn't seem to bode well for me.

So my reaction is the same as any other male medical student's reaction should be…sheer anxiety. Before I even grabbed the knob on the door, my hands were dripping with sweat and the hallway was spinning. A deep breath later and I'm in the room with the door closed thinking, "I forgot the order….what was the order of the exam?!?!"

Despite the fact I know I look nervous, my simulated patient, my guide through the world of the female exam, calms me immediately. She is relaxed and takes me through the motions of the exam easily. As my hands stop dripping sweat and my brow dries, I remember the order of the exam and move calmly through it making sure to ask as often as I remember, "How are you doing?"

I leave the room, beaming, and feeling like I just bought a time-share on Cloud 9. But the anxiety still churns my stomach. After worrying for the entire week about the last hour I sit back and relax. Still, I think, it's better than biochemistry.

Notes from a Medical Student
With Cold Steel
Jason Faber, M.D. ’08
October 16, 2006

The water runs down my arms and onto the floor as my back goes against the door, pushes open, and I enter. Don't touch anything, don't knock anything, just don't do anything stupid, I tell myself. The gown then comes over my arms and my hands dive into the plastic gloves.

Under the watchful eye of the surgeon, the first cut is too shallow, and so I have to make another. The abscess I'm cutting into has an induration thicker than three of my fingers. The bacterial cocktail bursts forth, and the cleaning and packing follow. I pull the gown off, strip the gloves off, and realize how bad my heels hurt, something I hadn't even noticed for the past hour. The resident sits down and starts writing orders. I assist in the dressing and finally the transport of the patient into post-op. As I leave I see the scalpel sitting on the tray with just a drop of blood on it. "The way to heal is with cold steel."

You see, that's just one of the sayings you'll hear. "A chance to cut is a chance to cure…Surgeons separate their patients from disease." All types of physicians are proud of what they do…surgeons are no different. So you start to pick up the quirks of the resident you're following; you're doing what they do because you have no idea what to do. You watch, you do, you teach…or so the teaching model goes.

Transition from the first two years to the last two years isn't as smooth as I'd like it though. Surgery is well known as the boot camp of 3rd year clerkships and so I've been hitting myself on the head wondering what possessed me to choose it as my first rotation. To tell you the truth I have no idea, no real rhyme or reason. Now, as I transition from 10 hours of steady study to 14 hours of constant surgery, I find myself lost again. So most 3rd years, in my opinion, have to get used to the idea that you are starting over again. Despite coming so far in the last two years, you open the door into the wards and realize there's an entire world of knowledge you haven't even touched yet.

As the scrub brush darts back and forth on my arm, I keep counting as best I can. I rinse and push my back on the door. Don't touch anything, don't knock anything, don't do anything stupid, as my mantra goes. So it begins, a bypass and transposition of several vessels in a nice lady's chest. It's a fascinating clinical presentation and an intricate story, with exciting twists and turns. For this procedure, however, I'll do nothing but watch, all gowned up and nowhere to go.

So I stand there watching, hands in front of me folded. I feel like an altar boy again, giving homage to whoever invented the electrocautery or the Metzenbaum scissors. As I stand there, the resident turns and asks me an anatomy question. "What's this…what's that?" It's a form of questioning called "pimping." So you try to know as much as you can before you even pick up a scrub brush. Problem is, for every right answer, the ante goes up. The questions get more and more complicated until you pretty much have no idea what they are even talking about. But it sticks…well most of the time.

At 4 a.m. I start to feel the burn in my feet from being upright all this time. My back is in spasms and I've been holding this retractor in the same position for the past 20 minutes. The young man in front of me, lying down with a tube in every natural and man-made orifice, had a scuffle which ended in two things: a police report and a hole in his back. The attending physician points out the anatomy to me as we go through. We trace the path of the bullet, through the liver and into the peritoneal cavity. Suction, look, suction, look, suction…you get the idea. As we close him, the attending allows me to staple the incision shut. Whenever a medical student does such a procedure, we get very excited and very nervous at about the same time. However, at this time of the night, I'm mostly excited about anything that has a flat surface on which to lie down.

A week later I'm rounding with the residents and seeing how the patients are doing. It's during this time that I've learned one immutable fact: the body can take more abuse than you think. It can be, as I've heard it so aptly described, "forgiving." So as I walk into the patients' room to ask them how they are doing today, I'm smiling for two reasons. First, I'm actually starting to understand some of this; I'm actually getting the hang of it. And, secondly, just like the Dr. Scholl commercial, "I'm gellin."