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I walk into the room Greet the patient She is happy, cheerful Much like me I sit down Still feeling like I’m playing dress-up "What brings you in today?" "Just here for a physical", she begins Run through the laundry lists in my head Location, quality, severity, timing, context Social history last We know all of this by heart now "Thank you for your time" Present to my preceptor We go in together Smiles all around Everyone is happy to be here, happy to help Happy to be part of my education The physical exam begins "How did the medical student do interviewing you?" Patient laughs "She did great", she says "But the question about abuse, she asked me if I had ever been abused I had to laugh at that That sort of thing doesn’t happen Not to people like me Not to people like her" I stand in the corner Trying to stay out of the way Pulse racing Smile faltering Mind darkening Straining against the clumsy stitches That no one can see In a room getting smaller and smaller Because it has It’s happened to me This patient a teacher As I step into those rooms As I shrug proudly into my white coat As I question my abilities and As I prove myself As I ask the tough questions As I learn what it means to be a physician Forever reminded You never know You would never know Looking at me I’m joyful confident present That I was once none of these things "Not to people like her" Words like bags of sand I’ll carry with me always My patient taught me Never, ever assume Because it’s happened to me.

- Anonymous, M1

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Her clear blue-green eyes sparkled as she played with the blocks, and for any other 21 month little girl, they would have been considered adorable and envy-inducing. For “Ana*”, however, her beautiful eyes were dwarfed by her profound cephalomegaly and as she walked around the room she seemed almost off-balance, as if she could tip at a moment’s notice. I met Ana for a simple ear check as part of her pre-operative clearance for placement of a ventriculoperitoneal shunt, and while her exam was easy to perform, digesting the rest of her short and complicated story was somewhat more difficult.

Throughout my third year I had met many patients whose stories lingered with me – from an old man who stoically digested his unexpected cancer diagnosis, to a young woman struggling with her psychiatric illness. I always enjoyed getting the chance to talk to those individuals, to hear precisely what was important to them and how they wanted to be treated. Children, on the other hand, especially ones who are not even two years old, cannot always tell you what happened, what they feel, or what they want. Therefore pediatricians must rely the parents can tell us what the problems are, but what happens when the parent is the problem?

Ana’s enlarged head was from subdural hygromas caused by subdural bleeds thought to be due to non-accidental trauma. There was a woman in the exam room, who gently held Ana’s head as I peered at her tympanic membranes, but this woman was her foster parent, not her birth mother. Although this woman had been assigned to Ana by CPS, the affection between the two was palpable and even as she squirmed on her lap, it was clear Ana felt comfortable. This was a therapeutic alliance that I could understand –clearly both of us had Ana’s health and wellbeing as our primary goal.  
What I struggled with was the appropriate way to interact with Ana’s biological father, who sat awkwardly on the other side of the room. This young man was alert, eagerly asking questions about her lab results, and clumsily held her tiny hands during the ophthalmoscopic examination. Without knowing the full details of the CPS report, how do you include a parent in a visit who has been judged unfit to take care of their own child? Even if you are privy to all the information, how do you respect parental rights when they have been stripped away? Clearly the child’s best interests are the priority, but what level of parental involvement with medical care when a child is in foster care is appropriate? With the possibility that Ana may one day be returned to her parents’ custody, physicians must keep a balance between not alienating the parents while also keeping them at an appropriate distance. We are trained to see the red flags of child abuse and how to sound the alarm, but I do not know much about the aftermath of child abuse as it relates to the family structure. While the technicalities of the process of rebuilding a safe parent-child relationship are not strictly within the physician’s domain but at the same time a pediatrician will take care of a child for nearly two decades and throughout that time can offer guidance as well as serve as a safe harbor.

*Not the patient’s real name.

- A, M4

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I can understand how outsiders might see what surgeons do as borderline barbaric—slicing into people’s bellies, opening up their skulls, taking out their organs—but to me it has never seemed that way. Even with a patient’s small intestines splayed out across their abdomen during an exploratory laparotomy, within the environment of the operating room somehow that process seems controlled and purposeful. On the table, under the halo of the OR lights, something as brutal as sowing someone’s flesh back together becomes an art of approximating skin flaps precisely so they line up – not too far apart, not too close together. This is the way I felt until I met Mr. Crow.* The first time I saw Mr. Crow was in the Emergency Department where his MS-ravaged body lay rigid on a gurney; his face was pale and sweaty with strained breathing despite a CPAP strapped to his face. His hemothorax on CT was obvious even to me, and combined his esophageal perforation, so was his need for emergency surgery. Despite the patient’s wincing, the most agonizing part wasn’t the physical discomfort of multiple IV sticks, or the struggle to breath. I saw the painful side of medicine as I stood in the corner and watched as the attending realigned Mr. Crow’s expectations with reality. Tracheostomy. Discharge to a SNF. A 50/50 chance, given his co-morbidities. “Not yet. Not yet.” He strained over the hum of the CPAP machine, referring to the tracheostomy, as his eyes frantically swept the room. Even in the OR, with ET tube in his throat, a chest tube between his ribs, and later a scalpel in his chest, I never felt his pain as acutely as that moment in the ED, as his eyes bulged and his wife sobbed in the background. The emotional pain that we inadvertently bring upon our patients is often overlooked in favor of treating the physical pain we have inflicted. Physicians bring people nose to nose with their own mortality and after a conversation of that magnitude people on both sides of the table need emotional support.
I believe the emotional distress associated with surgery, particularly in emergent cases, can be devastating. Trauma of that nature can be harder to reconcile with the spirit of medicine and more difficult for patient and provider alike. As a medical student, I couldn’t talk to him about his chances of surviving the operation. Nor did I have any experience to lend about inserting a chest tube. I could not alleviate his physical pain, but I did the one thing I could do – as they sedated him in preparation for intubation, I held his hand. *Not the patient’s real name.

- Anonymous, M4

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He mentioned it so matter-of-factly at the free medical clinic on that frigid January evening. "Are y'all from the U?" "We are" "My sister-in-law is there." "Oh...what does she study?" "No, she's at the university hospital. Burn unit. Her boyfriend murdered the kids and tried to kill her, too." "That's awful..." is all I know to say as I pull the blood pressure cuff snug.

- J, M4

Expressions of Love: One Medical Student's Perspective on the Beauty of Breastfeeding

Dusk is near, Your day of study at its end. We stand still, quiet. Our evening ritual begins. We take a long moment, Surveying one another with delight, Treasuring today. Suddenly, your famine overtakes you. You begin your ravenous search for nourishment. When you find it, you affix yourself with a determination that implies permanence. You claim your stake and glance my way to make it understood. As you devour your prize you become voracious, Your small hands grip me with strength that would not seem possible. We are enmeshed in battle, Your hands grasping my face, neck, hair with wild ferocity, Your feet maneuvering swiftly at the edge of our enclosure. And I am amazed you are still feasting. I begin to engage my forces. First, a small brush along your side. Next, a caress of your underarm. And you are smiling, laughing, All the while retaining control of your territory. We carry on this way. Eventually, I abandon my assail. Grateful, you initiate one final effort, Consuming with renewed vigor. But you are weary and worn. The campaign has taken its toll. Gradually, all fighting ceases. Your eyes are blanketed, no longer flashing around our encampment. Your breathing is deep, I can feel it overtaking your entirety. Your small hand rests heavy atop my bosom like a small white flag of surrender. I examine you one last time. I am awed by the expansiveness of your existence. How can a person so small fill my heart beyond measure? I softly lay you in your bunk. You barely perceive it. As I make my way to the exit, your eyes flicker open briefly. A final smile, your eyes close, and we part.

- Caitlin Regner, M4

Words Unexpected

Pre-pubescent body, bloodied and bruised Lifted from a husband four decades her elder Into sterile hands weathered by life and death Her presence made known by moans To women whose eyes speak of hunger Their words unexpected “Never question your husband” “Deserves to be beaten” Innocence drips from my eyes A puddle of sorrow

- Tyler Etheridge, M2

Watching

I watch on the monitor as your heart stops beating I watch as you walk down the hallway, knowing that you have ALS before you do I watch as the chest x-ray shows your cancer has spread It seems so unfair that I know these things before you do To me you are an “interesting case” to talk about over lunch, but to you this is everything What gives me this right to know how your life will turn out? I feel like I can't even help you, not yet.

- Anonymous, M4

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She closes the door behind her and says,
"It's the 5 year anniversary."
Huh? How can that explain/or excuse anything?
A belly so large and full of life,
yet already so dependent.
Suboxone needed like a gasp of air.
And it hits me,
and I try to walk a mile in her shoes,
but i can't even imagine a first step.

- Gabby, M2

Medicaid

15 pounds she carries.
15 extra pounds of fluid
she brings with her in her right arm.

No care covered.

A disfigured sack that grows larger each week,
and each month,
stealing health, job, home, and dignity.

No care covered.

Breast cancer stole a year of her life,
but without treatment she'll carry this baggage for a lifetime.

No care covered.

- Gina Phillips

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Educated, informed, and eloquent, 
but frozen by her fear.
She wants to change, knows how, can't.
Help me help myself, she says.
I'm stuck. I just want to do the things I used to.
She knows what's wrong,
but knowing still holds her back.
We begin together.

- Erin, M2

The Cost of Diagnosis

She lie in agony on the gurney, her cause of pain uncertain.
Beside her worried lover, 
her battered abdomen
concealing her broken heart.
Oh good doctor, 
would you risk irradiation of an unborn babe
to test your hypothesis?
Have you no other way
to mend her mind and body?
Alas, be not the crushing stallion?

- Orlin Serger, M1 

Affliction

Elderly, proper, so put together.
She awaits us with her daughter,
Holding the thumb that is bent and bruised.
We ask all the questions we were taught. 

I don't know,

 I don't know, 

I don't know.

She starts to cry.
The pain in her thumb a mere morsel
to the pain of losing her mind. 


- Caitlin Regner, M4

Time

She's been feeling ill for quite some time.
Bloody emesis
leads to a hospitalization, IVs, fluids, meds.
Next a scope and biopsy.
Doctor says it might be cancer.

Waiting,
waiting,
hours,
days...

Family gathers,
still no results.
Family can't breathe.
Results are back, rush them over.
No malignancy.
Her words, "You are my Angel."

- Anonymous, M4

Innocence Lost

"I'm scared to lose it"
On her own
So much fear, so many doubts
Worried for the growing life inside her
But what of her future?
Her growth will now be physical
I see her wonder at the miracle
"What is a uterus?"
I'm struck speechless by her innocence
Heartbroken by this last glimpse

- Anonymous

Family Doc

How does it look, Doc?

Hand hold,

Heads fold.

Cradle to Rock.

She is perfect, Doc.

Toddler gleams,

Mother beams.

Cradle to Rock.

It hurts badly, Doc.

Shoulder tweaks,

Syringe squeaks.

Cradle to Rock.

Is it time, Doc?

Crying baby,

Cooing lady.

Cradle to Rock.

There’s a spot on my back, Doc.

Biopsy punch,

Late for lunch.

Cradle to Rock.

What did you want to tell Doc?

Pregnant mother,

New big brother.

Cradle to Rock.

I’m feeling good today, Doc.

Breath sounds,

Heart pounds.

Cradle to Rock.

Is this goodbye, Doc?

Quiet room,

Glowing moon.

Cradle to Rock.

I am going to miss you, Doc.

Hang up stethoscope,

Put away white coat.

Cradle to Rock.

- Sarah Mortimer, M2

Labor, the Fountain of Youth

Born in 1913.

A farmer's daughter.

I married a farmer.

With whom I raised four children.

Hard-work was my mode of operation.

And still is.

With a failing heart,

and an aching body,

I continue to exercise, play, and laugh.

Join hospice? Okay, I suppose.

One hundred and two is a good time to go. 

- Anonymous