By Jaleesa Jackson, M.D.
At the end of medical school, I found myself seemingly on top of the world. I had just received my degree from one of the best medical schools in the country, and was well on my way to becoming a first-rate surgeon. However, beginning intern year became, in a word, a fall from grace. I was no longer the carefree confident fourth–year medical student. I was in a new hospital, with new colleagues, and struggled to find my way as a new doctor.
Medicine always intimidated yet fascinated me. No one in my family had ever attended college, let alone medical school. As a first-year medical student, I was surrounded by my classmates who hailed from schools such as Duke, Stanford, and Harvard. And there I sat, a black girl from a state school wondering the whole time if I was admitted just to fulfill enrollment quotas.
Being a medical student is an amazing experience. The institution is steeped in history. One step through the main door and I was surrounded by paintings of medical giants: Osler, Halsted, and Kelly, none of whom looked anything like me. I immediately felt as if my being accepted to this school was some cosmic joke. As my confidence faltered, so did my performance. I went from being the all-star student that I was in undergrad, to the insecure medical student just scraping by. After narrowly avoiding failing a test my first year, I knew I had to make a change. I surrounded myself with people who motivated me. I met with mentors and discussed my reservations and insecurities with them, and my performance began to improve dramatically. There is a course at my medical school called Clinical Foundations of Medicine. It is designed to teach medical students how to perform physical exams and how to communicate with patients effectively, compassionately, and knowledgeably. Although I had struggled with other courses, this I knew I would be good at. A predominant part of the course was just being able to communicate with patients – to let them know you acknowledged their suffering and would do your best to alleviate it. I still think back on those days, awkwardly holding a stethoscope and trying to hear the faint murmurs or altered breath sounds that some of our patients had. That part made sense to me. Of course I had to learn how to correctly perform a physical exam. It was a vital characteristic of any aspiring physician. But patient communication? Why did we need a whole course for that? Wasn’t that common sense and common decency? What was the need in spending hours learning how to talk to patients?
During my next three years in medical school, I was confronted with dying patients many times. On my internal medicine rotation, we had admitted a woman who had developed a bloodstream infection; she experienced severe mitral and tricuspid regurgitation. The infection was arising from her dialysis catheter; however, it couldn’t be removed, as she would not survive the procedure necessary to replace it. She had been evaluated by multiple teams and the goal transitioned to keeping her comfortable instead of focusing on surgeries and injections. However, she was still my patient and I presented her on rounds each morning. I would spend time every morning listening to her heart and trying to appreciate both murmurs. She would only groan or moan when I introduced myself, but each day at 5:00 a.m., I would place my stethoscope against her chest and just listen. One day, she began decompensating. Her heart rate increased and her blood pressure decreased. My resident called her family to come in, as we knew she only had hours left. Slowly, her heart rate began to fall, and I watched the monitor as her heart slowed then stopped. Her family was in tears, and my resident and I prayed with them, and then later returned to perform the death exam. For the first time, in two weeks of listening to her, I put my stethoscope on her chest and heard nothing.
Death comes in many forms. It comes slowly like it did for my internal medicine patient, or it comes suddenly, as it does for the hundreds of young black men and women who died in Baltimore due to gun violence. I watched as mothers broke down and cried after learning their child would never be coming home again. What struck me most was always mothers and grandmothers who then cried the soul-wrenching cry of heartbreak that became all too familiar to my ears. These were often teenagers –just children who grew up without social support and used illegal means to obtain money to help support their families. I would secretly head to the bathroom and cry with them. Cry for the youth stolen from their children, the lost potential, and for the other children in Baltimore who I knew would eventually suffer the same fate.
What struck me most was the difference in the ways my attendings and senior residents would tell family members about the loss of a loved one. Some would sit down and gently explain that a patient had died, and allow for the family members to grieve in their own way, whether that was to ask as many questions as they could, or cry, scream, or sometimes beg. Others would simply state the facts and head out to answer a page or return a cell phone call. I was determined that I would be the former, that I would be the saving grace that a patient could lean on in times of despair or worry. I was going to be the difference.
Surgical intern year is a physically, mentally, and emotionally demanding experience. As a new doctor, I identify one key word as “efficiency.” You are expected to write orders and notes, see consults, take care of patients you have already operated on, and perform excellently in the operating room on new patients. This proved a daunting task for me. Our rounds are, on average, 45 seconds per patient. We quickly go over vital signs, lab values, checking incisions, and making sure our patients aren’t in any excessive pain. We woke patients up out of deep sleep at 6:00 a.m. and they had one chance to ask all the questions they may have for the day. Afterwards, I placed necessary orders, wrote notes and headed to the pre-op area to see new patients for the day. As an intern, I, as part of my job, asked patients to sign a consent form for the procedure they will be having. In many cases, these are for major operations. I walked in to their rooms and could sometimes see the anxiety and apprehension on their faces. Part of me yearned to be there to assuage their fears and answer all their questions before proceeding to the OR. However, I know I have to see three more patients in the next 15 minutes, so I quickly hurried through the consent, wrote my initials on the side we will be operating, and headed to the next patient. Yes, I was efficient. But was I compassionate? Was I that ideal doctor that I was trained to be in CFM? The answer was absolutely not. Soon I found myself seeing a consult on a dying patient and ended my physical exam short after the patient requested no surgical intervention. A few weeks later, I asked myself: when did I become this callous person, who seemingly ignored a patient’s pain and suffering, and saw his questions as just another interruption to my day?
The question is: how do I improve? How do we as a medical community improve? The answer is not easy. The white coats and stethoscopes are a stark contrast to the hospital gowns we lift up to examine incisions or press on the bellies of our patients, sometimes even without their permission. I believe the key to retaining humanity as a physician is to help our patients keep their humanity and dignity. Treating them not just as a patient, but a fellow human with goals, dreams and aspirations who just happens to have a medical issue.
A few weeks before finishing my surgical intern year, I was wheeling a patient down the hall into the OR. Usually I looked straight ahead, ready to open the doors to the operating room so we may begin setup. That day I looked up briefly at the ceiling. I wanted to look at the same thing my patient was looking at as we headed to our destination. I wondered what he was thinking, an old man who just said goodbye to his family, and was now staring at the countless fluorescent lights passing overhead as we headed down the hall with hopes of repairing an aneurysm in his aorta. Was he coming to terms with his mortality? Was he thinking of the many loved ones he left behind in the holding room? Or was he simply trying to maintain a peaceful, positive outlook on his condition? It occurred to me at that moment that he was not another box to check on my daily list. He was another human being, just like me, hoping to make it from one day to the next.
Jaleesa Jackson, M.D., is a pain medicine physician at UAMS.