An Immodest Proposal

[Warning: PG-13 material. Actually, let’s be honest, they would never cover this stuff in a movie.]

In what I’m sure will be my most celebrated blog post yet, I will now turn my attention to the recent opportunity (and by recent I mean, in November. I recognize it’s been a dry spell for the blogosphere. My apologies) medical school provided us with – learning the genitourinary exam. To lay the groundwork for this experience: we’ve been learning the physical exam in pieces every week with our Clinical Foundations of Medicine exam (same small 5-student group of pancreatic cancer/Sharon-induced tears previously addressed). Each week we’re responsible for reading about and learning a portion of the complete physical exam, to include the pulmonary, cardiovascular, neurological, musculoskeletal, etc. We then meet in our groups in the Simulation Center in “fake” exam rooms and practice….on each other. It’s actually not as uncomfortable as it sounds and the males in the group are “voluntold” that they’ll be the guinea pigs for the abdominal, cardio, and pulmonary exams, thus eliminating the potential awkwardness of female students taking their shirts off….

As weird as practicing on each other sounded when we were first told about, I actually think it’s a great idea. And understand why a survey at the University of Minnesota medical school revealed that 95% of students also thought it was a great idea. From a learning perspective, you get the dual experience of both practicing on your classmates and getting practiced on, which only enhances your understanding. From a learning environment perspective, it’s pretty easy to quickly understand how practicing on your classmates is actually much more comfortable than practicing on “real people.” Practice is the way to eliminate the fumbling awkwardness of putting your hands all over someone else’s body; you are very fumbling and awkward when you haven’t figured out where on someone’s chest to listen for a S1-S2 split or how to use the otoscope without slapping someone in the face with the cord. Practicing on another medical student, who understands this learning curve and is patient with your fumbles, is much better than practicing on someone else. Additionally, medical students are a very healthy (and thin!) group of individuals. While any group of young adults is probably riddled with body image issues and I assume the first year medical school class is no different, the fact that basically no one is overweight (and many are probably underweight) relieves what could likely be the most uncomfortable issue. (However, it did not prepare me for my grossly overweight GU exam, but more on that to come. )

Obviously, however, practicing the GU exam on a fellow medical student would be vastly inappropriate. And uncomfortable. And so, the medical school gods, in their infinite wisdom, have created a solution – the GUTA.

GUTA stands for Genitourinary Teaching Associate; these are individuals who have been trained in the GU exam. They then teach medical students the exam…by demonstrating on themselves. And allowing us to practice on them. How you get into such a job…or would want some novice medical students touch you in all the most personal of places…. is beyond my wildest imagination. It surely must take a special individual. Or a crazy one..but again, more on that later.

So there we were – 24 intrepid medical students, sitting around the Simulation Center one morning, ready to spend the better part of our Saturday shoving metal pieces into vaginal canals and testing cremaster reflexes. Sounds delightful, right? It was probably not helped by the fact that the day before had been an exam day and, instead of catching up on the sleep lost to cramming, most of the first year class hit the town the night before. Needless to say, everyone was looking a little rough at 8:30am.

I was fortunate enough to be paired up with two friends of mine, both of whom have been out of college for a few years and who I assumed had achieved the maturity that experience confers. We gamely braced ourselves and headed towards the exam room for our first exam – the male exam.

I’m not sure how to say this, or what this says about me, but I was much more concerned about the female exam than the male exam, so I was happy to get “warmed up” with the delightful and elderly male GUTA whom we will call Mr. Brown. I think relative lack of apprehension had to do with a few things, namely, the relative simplicity (straightforwardness?) of male genital anatomy (dear readers -- uncomfortable yet?) and the fact that I wouldn’t be shoving implements into someone’s body as you do with the female exam. Just my fingers. Hooray?

It was impressively less awkward than it might sound, and I think that is a credit to the calm and reassuring nature of Mr. Brown. He was compassionate and understanding of our unease, while also being mostly matter-of-fact. I gamely volunteered to go first for the first few procedures, in an attempt to a) get it over with quickly, b) have the lower standard of being the first one out of the gate and c) try to pretend like it was no big deal to stroke this man’s testicles. Among other things. All in all, it was over before I knew it and I had successfully, if not mastered, at least performed, all the wonderful series of tests that take place, including everyone’s favorite, the prostate exam. Thanks, Mr. Brown, that wasn’t has bad as I might have imagined it would be.

Little did we know what awaited us in the next room.

Our next GUTA was the female GUTA, who we’ll call Ms. Devil, because I’m fairly confident that she is related to the little red man who carries a pitchfork and delights in uncomfortably high temperatures. To begin with, she was morbidly morbidly obese. And smelled bad. Really bad. Although I suppose those two things are good preparatory experiences for taking care of sick Americans for the rest of my life. I was willing to look past her enormous mass of body and unfortunate odor because, well, she's a person too. Until she started talking. And I began to question that single simple fact.

Basically she had none of the warm, comforting, reassuring charm that Mr. Brown possessed. Or even the small bit that even the most reticent of teachers possesses. So there was that. She began by berating us for not introducing ourselves as “Student Doctor [last name here].” One, that’s a dumb term and sounds as dumb as it is. Two, we’ve been told explicitly since coming to medical school to always introduce ourselves by full name and then state that we are first year medical students. But no matter. To hell with that. Student Doctors it is!

The first part of the female GUTA exam is the breast exam, which includes palpating the breast for masses, as well as palpating the lymph nodes in the axillary – basically beneath the arm pit. I went first (game face?) and essentially just got yelled at for 10 minutes. So that was fun. But not constructive yelling. Yelling more along the lines of – “why did you move your hand there?!?” Me: “uh….” Her: “put your hand back where it was! What ARE you doing? Why did you move your hand! PUT. IT. BACK.” It was awesome.

Palpating the lymph nodes was no better. She insisted we contort our arms in a completely comical way that involved sticking your fingers between the muscles below her armpit and was somehow was supposed to end with us putting our thumb on her scapula (that triangular flat bone on your back, right beneath your shoulder). But....upside-down. There were a couple of problems with this – she was so overweight that palpating her scapula, even with your entire hand, was somewhat of a challenge. Her excessive weight also meant that even if my hands were the size of Shaq’s, I’m not sure I could have reached her scapula with my thumb if my life depended on it. And finally, the absurd position she had us twist our arm into cannot possibly be the correct technique. There’s no way. Maybe she should try right side-up?

I somehow got out of that relatively unscathed, but one of my fellow “student doctors” simply could not satisfy her demands. She kept yelling “put your thumb on my scapula” and he tried the very best he could to no avail. It got so bad that we all seriously started to wonder if we were doomed to spend the rest of our days camped out in that exam room as she continued to berate him for the rest of eternity. It was almost comical. And then it was comical. The third of us started laughing. And couldn’t stop. And then the student with his poor fingers still in the GUTA’s axillary started laughing too. And I looked around for the candid camera crew to jump out.

They didn’t.

Somehow we moved on to the real substance of the female GUTA exam, examining the genital area, including palpating the ovaries, and visualizing the cervix. Shoving a large metal speculum into someone’s vagina is not exactly my favorite way to spend a Saturday morning. But at least now I’ve done it?

The remainder of the exam was just as bad as the beginning, especially in terms of the vague but demanding yelling and generally hostile learning environment. Thanks, Ms. Devil, you got the worst evaluation I've ever given in my entire life. In spite of all that, I could still see myself going into ob-gyn (whaaaaaat?). I’m certainly more interested in the obstetrics component of that specialty, but I realized that I, if not “get into” the rest of the residency, I could at least tolerate it, and probably even enjoy it. It’s a special kind of responsibility (and scary "power") for someone to place the health and protection of their genitals into your hands.

I also think this experience drove home the point that we’re very much in medical school. One fellow student commented that this experience is the start of differentiation between us and the graduate students. There are many biomedical engineering students, medical illustration students, or genetics graduate students, in most of our classes. But obviously, not this class. This is a doctoring class, in the most essential way. There’s something special about that. And I wouldn't trade where I am for anything in the world.

A Medical School First

"To be a doctor, then, means much more than to dispense pills or to patch up or repair torn flesh and shattered minds. To be a doctor is to be an intermediary between man and God."

-from "To Be a Doctor " by Felix Marti-Ibanez

It’s an arrogant quotation to be sure. I don’t fancy myself an intermediary between man and God and hope I never do. I know too little about the former and infinitely too little about the latter to presume to be much of a useful messenger (see C.S. Lewis on the word “infinite”). But, however I might feel about it, dealing in the business of health and wellness, of disease and death, necessarily places medical professionals in the uncomfortable position. I hope that by the time I am an actual professional, and not the fumbling, ignorant imposter running around in a short white coat with a few cranial nerves memorized, I’ll have a better time understanding how to deal with that position.

As it stands, I have no idea. I’ve been to my fair share of funerals…and frankly, sometimes think far too many. But while that sort of early desensitization to the aftermath of death allows you to appreciate wellness while you have it, sympathy for other mourners when they need it, and gallows humor when it seems appropriate, it certainly doesn’t prepare you for impending death. Which is, after all, what doctors deal with (although hopefully less often than not).

And impending death is the very card I got dealt in order to add another “first” to my medical school career – first time making a patient cry. I’m fairly certain this is a lifetime first – I don’t recall making any amputees cry in my Walter Reed days nor autistic children or breast cancer patients in my summers at UNC. Upon further reflection, two years at Walter Reed probably rendered me more woefully unprepared to deal with tears than any other singular experience. There’s no crying in baseball! Or the Army! So I wasn’t sure what awaited me when I walked into Mr. Hatch’s (name/life details/disease changed) room.

Mr. Hatch was an affable in-patient who had gamely volunteered to let my Clinical Foundations of Medicine class (five first year medical students led by a general internist) practice our medical history taking and abdominal exam techniques on him one Wednesday afternoon. As we walked through the hallways of the ward, we split up tasks – one of us would do history of present illness, another past medical history, another family history, another social history (me), and the final lucky contestant – the abdominal exam.

Everything was going swimmingly…until the student before me took all the social history questions. No matter, urged my preceptor, ask about how the man’s disease condition has affected his life. Medical ignoramus that I am, I had no idea that his specific diagnosis had a prognosis of one year. And that it had been 12 months since his diagnosis. As an aside, it can be strange asking people such personal questions, but medical school is pretty uncomfortable….you’re constantly doing things you don’t feel like you’ve completely mastered. Asking questions you haven’t quite learned how to phrase correctly. Or receiving answers you’re not prepared for. But the key, or at least what I’ve convinced myself is the key, is to gamely jump in there and do your best. Maybe you’ll do just fine and if not, the mistakes you make will certainly be instructive. So, take a deep breath and let the learning begin!

“Mr. Hatch,” I began, “can you tell us a little about how your diagnosis has affected you personally?” He gave me a troubled look and said he didn’t quite understand what I meant. “Well,” I ventured, “maybe we can start at the beginning – can you tell us how you felt when you first learned of your diagnosis? What kind of emotions?”

The response started out strong – the man’s lived with a terminal disease for some time, so he’s reached a certain level of peace. But that level of peace is never quite as peaceful or as level as any of us would like it to be. “Then I called my mom,” he continued. “She’s 80 years old…I’m 60. And I cried. I sobbed like a baby.” And then…he started to cry. Not the sobs of small children or melodramatic teenagers, but those powerful streaming tears that run down the lines of a weathered face, find creases to flow through, and collect in rivulets along the chin or neck. They accompany a voice that starts stoic and firm and manly and strong, and gradually then quickly wavers and breaks and cracks. And there I was sitting there – an impetuous student confidently caught up in my power to ask questions…and incredibly unprepared for the responses I might get. Tranquilized. Ashamed. And wanting quite a bit to cry myself.

I swallowed hard and tried to remember that those long uncomfortable silences aren’t nearly as long as you think they are and that possibly there was time to rescue this yet. Don’t smile too much, I cautioned myself, you’re too smiley sometimes. People who are crying don’t want to be smiled at. “I don’t think you ever get too old to call your mom and cry,” I ventured quietly. Stupid thing to say? Or understanding and sympathetic? Nooooooo telling. I could feel the other students’ eyes upon me – what.to.do.next. Touch him? A sympathetic pat on the hand? Too soon? Too close? Not close enough? His eyes locked in to mine…searching, questioning, pleading. What did I have to offer him?

The uncomfortable thing about medical treatment is there’s this immediate intimacy that everyone finds….close to normal. Or at least tacitly accepts. In normal human interaction, if you’re a genuinely good and fairly socially competent person, you can do just fine in interactions with other people. In patient interactions, however, everything you know is wrong. Your instincts have to be re-defined because, after initial pleasantries and introductions, you skip steps/dates #2-some high number and jump right into getting naked (for the patient at least…!) and talking about bowel movements. And death. And God. And hopes and dreams and aspirations. It’s disconcerting. And disorienting. And takes some getting used to.

And so…you just fake it till you make it. We talked some more. He cried some more. I felt tears welling up and weighing heavily on my eyelids. I fought it off. I said some things that I’m not sure whether or not they were comforting, but, judging from his reaction, weren’t horribly soul-crushing either. I’ll flippin’ take it. And then suddenly the next student moved on into the abdominal exam. I breathed a sigh of relief, shuffled over to sit on the window sill and tried to stave off the tears a little longer. Game over.

Except for this time around, it really wasn’t a game. Obviously I’m not involved in this man’s care in any way and nothing I did or said, right or wrong, was going to have any effect on his care. But even in this “meaningless” interaction, you can’t walk around thinking that nothing you do will have any effect. Because he’s a real person. With a real life. And with a real disease. And a real cross to bear.

I’m probably a meaningless person in Mr. Hutch’s life. Which is quite alright with me. Because I’m woefully inadequate at this point in my training to be a meaningful person. But he’s not meaningless in my life. Because he’s one of the first to help me realize that this uncomfortable intermediary position is one that will, with some level of certainty, be projected upon me many many times in the coming years. And it’s best to come to terms with that earlier rather than later. And be prepared, or at least better prepared, for the next time around. I don’t think I need to know the answers…because so few of us do. But I at least have to be comfortable with the question. And aware and humble in my ignorance of the answer.

Introduction

Greetings!

After my Africa travel blogging experience many people encouraged me to continue blogging during medical school. While I found the idea intriguing, I wasn't sure I would have time for it...and I was mostly correct. But now that Anatomy is over (okay, it's been over for a month...) and I do have at least a touch of free time, I'm willing to give it a try. In part because it was pretty cool to hear that people enjoyed reading the Africa blog, but, even more selfishly, because I find myself having conversations and discourses with myself on any of a number of the thousands of ethical, practical, and ridiculous questions and issues that arise during the study of medicine. And I need an outlet for them. Or at least, I think it might be a healthy and constructive escape from studying. And if my mom is the only one who reads it, that's fine too ;)

At the end of Anatomy, I wrote the following as a reflection and feel like it's as good a place as any to start this process.

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The strangest thing about Anatomy Lab was when it wasn’t strange. After some initial trepidation and nervous laughter, after the first cuts were demonstrated, after we were in awe that our lab instructor would casually set his clipboard on our cadaver’s face (that’s a man’s face! You can’t just put your papers there!), I quickly and maybe too easily engrossed myself in the experience. This experience, our first in medical school, has, after all, all the trappings of “doctor-dom” – scrubs, gloves, and masks; blood, guts, and gore; the power, ability, and opportunity to do things most normal people never think of; an intimate interaction with a person’s body, a naked body, a dead body. This is why I went to medical school – blood! And scalpels! And muscles! Oh my! All the fascinating, often magically elegant structures of the human machine were literally at my fingertips. It was the very intrigue of this complex machine that made me and makes me want to be a doctor. It was easy to get caught up in all of those trappings, not to mention the metric ton of minutiae that was required learning for exams, and to forget the horror. Too easy, maybe. So easy that within minutes, I was cutting, pulling off skin and fat, within days, I was sawing through bones and ripping out lungs, within a week or so, I was leaning on our cadaver’s naked chemically-preserved abdomen with my elbow, forgetting my initial shock and dismay at so much as a paper touching his covered head unnecessarily.

Which isn’t to say that was an equilibrium state of emotional affairs. We named our cadaver (whose earthly name was and is unknown to us) Pete, which was a stark and initially not-so-happy reminder of a good friend of mine by the same name who dropped dead last year at age 23 while running the Baltimore Marathan. A reminder that Petey was a man, a real man, who had a real name probably not unlike Pete and whose death probably caused himself and those around him anguish and pain. As we dived deeper into Petey, we learned of his heart surgery, his hernias, his pneumonia, his lung blackened by Baltimore pollution, and many other signs of how his body interacted with the world. It was an odd sensation to known a body this intimately and yet not know his soul. Or even so much as his favorite food. Or how deep his voice was. And yet, as the weeks went on, it seemed unimaginable to me that we could have gone through this experience without naming Pete and I surprised myself at being surprised when other lab groups said they hadn’t named their cadavers. Petey was an important member of our group; in many ways, both those incredibly obvious and some incredibly subtle, he was the most important member.

There were moments where the frenzy and fascination of the science weren’t enough to distract from the grotesque tasks at hand. Cutting through a man’s testes is not something I ever imagined myself doing and it felt like a violation of most things sacred. Skinning the face, popping out an eyeball , and disarticulating the skull invoked similar reactions for me. As someone with a profound and awesome respect for human life, as I imagine (or maybe just hope?) most medical professionals and students possess, sometimes looking at the shredded tissues of our cadaver was distressing and seemed…disrespectful and wrong in some ineffable way.

As consolation, we had the knowledge that Petey had willingly donated his body for this very purpose, and probably had specifically done so for Johns Hopkins. Before I knew I was going to medical school, before I imagined that I would get accepted to Johns Hopkins, before I even thought about the prospect of dissecting a cadaver, Petey thought about it. He probably imagined it too. Before I knew, Petey knew. And that was, and is, and will continue to be, an incredibly comforting and infinitely humbling piece of knowledge.

On the first day of lab, and on the last, one of my beautiful and talented lab partners recited a piece from Walt Whitman which seemed appropriate for the occasion. Walt Whitman wrote ‎"Re-examine all you have been told at school or church or in any book. Dismiss whatever insults your own soul, and your very flesh shall be a great poem and have the richest fluency not only in its words but in the silent lines of its lips and face and between the lashes of your eyes and in every motion and joint of your body." Petey’s very flesh WAS a great poem and I will be forever grateful for its richest of fluencies.