Jun

14

 My home office adjoins my daughter's room. Her last day of high school (and therefore public school) was today, and now that she's finished it, she's home finally clearing out her room of the school year's detritus. It's amazing how much "stuff" she managed to keep in her bedroom. Walking by that room's door brings to mind the scene in A Night at the Opera of the ship's storage locker holding something like 10-15 people. Tomorrow, she will join her class at graduation; at some time, she and some of her peers will be saluted for academic achievement. I'm told that that's the top 5% of the class. Given the nature of the high school, that's a better result than my wife and I had expected. Her high school is rigorous–almost to a fault. During spring break, some of her friends now freshmen at MIT and Cal Tech came by for some pizza. The frosh from both schools kept commenting on how much they were enjoying college. It was easier, for some courses much easier, than high school. Both my wife and I were shocked, but perhaps these kids aren't aberrant in their assessments.

That my daughter, our youngest child, will be graduating within 24 hours brought to mind my graduation. For my daughter, the biggest graduation in her life thus far will be the one tomorrow; for me, it was 29 years ago when I graduated from medical school. It's not that it was the last graduation I would share with my father, though it was–or even the last time I would see him, though it was that as well. It's not that I thrived in medical school. Hardly, having bombed in biochemistry (I think it's psychological moreso than the material, but that's for another thread) and having a simply awful experience with one medical resident (I nearly dropped out of school in my third year–almost unheard of; on hearing of my interest, the Dean inquired as to what was my reason, and when I explained, she promptly called in that year's class of 2nd year residents in medicine and read them the riot act about abusing the 3rd year medical students. My classmates were aware of the situation, and when the abuses stopped-at least for my rotation–many thanked me, though I told them it wasn't altruistic on my part, it was survival), I saw my graduation from medical school as a triumph. It's not the degree of which I am most proud–that would be my MSEngineering, and it's not the one I worked hardest for–that would be my MBA in marketing, nor even the degree which most of my peers associate me with–that would my MPH in epidemiology. It is, however, the degree with which I most identify, the one most enmeshed in my identity.

There are parts of medical school I would dearly love to forget–but I can't, though I have no doubt that I am a better physician for having lived through them. Telling the mother of a 3 month old kicking and screaming with a 103 degree fever a few hours later that her son had died, being told of the attempted suicide of a pregnant 15 year old girl I had attended to at clinic three days before and diagnosed her pregnancy (she wanted an abortion and was terrified of what her parents–both alcoholic drug users (they were also "practicing" Catholics–at least that's what they said–who later informed me they wouldn't have consented to an abortion for their "slutty daughter"–might do to her if she asked for their permission), digging elbows deep into someone perforated bowels at 3 AM and dealing with seeming endless human waste–yes it's life saving, but that doesn't mitigate the stench and it doesn't stop the waves of nausea or the multiple re-gownings and re-glovings, the 17 year old who decided to take on a tree while riding his snowmobile during a blizzard–the tree won and he sustained multiple organ failure, including a closed head wound that left him in a vegetative state even as he recovered from a severed liver that a decade earlier would have rendered the head injury meaningless as he would have died of the hepatic damage, my first patient during my medical rotation–Mr. B–who had classic hypothyroidism–the confirmatory lab test had to be sent to the VA central lab in Ohio instead of the local lab and the results weren't due back until Monday; unfortunately, Mr. B developed a pneumonia, becoming septic, and dying on the Sunday before, and the too many meetings of the Baltimore Knife and Gun Club on Friday and, especially, Saturday nights. As bad as telling the mom about her dead baby (threw up afterwards, and my attending, cued in by my resident, had the good grace to sit down and talk with me about it; I asked her how she managed to deal with such things, and she responded that you don't, and that if you did, it was time to leave medicine. That may seem a bit harsh, I realize, but I've come to understand what she meant.

 In medical school, during the first year intro to clinical diagnosis, there's much effort expended on trying to get med students to empathize with patients, though not sympathizing with them. I began to understand the idea much better after talking with my attending what was meant by the empathic physician that we strive to be, that our patients need if we are to be effective in helping them maintain or improve their health.

Among the "ghosts" in my memory is the 20 year old man who presented at surgery clinic with his partner. He came from a religious family out west and had come to Baltimore when he was 16 to get as far away from his family as after he came out to his parents, they told him he would burn in hell, that he should forget that he was a member of their family, that his brother and sister were to be told he had died and that they should forget him, and requested that, as they kicked him out of the house without so much as a change of clothing, he change his name so no one would associate him with their family. He had met his partner while homeless on the street, and the two bonded. He managed to put his life together enough to gain admission one of the local colleges on full scholarship as his partner became got a job on a construction crew digging ditches (also a story for a different thread). He presented to surgery clinic with groin swellings. It was the fall of 1983, the AIDS epidemic was in full swing with every sign indicating that it was a infectious disease. (At that time, I doubt that the 2/3s of gay men resident in San Francisco in 1981 realized that they would die from HIV infection.) Understandably, he and his partner were terrified about these swellings. We biopsied them–it's the only time I've quadruple-gloved. He had a lymphoma, and in short order, developed pneumocystis carinii. Long story short, he had AIDS. I wasn't on the medical team treating him but I kept up with what was happening to him in hospital and I managed to stop in and talk with him a few times. He was a bright guy, witty too. He was thinking of becoming an engineer–he enjoyed math and dreamt of using that knowledge to change the world. He was dead within 6 months. I don't know what happened to his partner.

Those experiences contrast with some of the other ones, perhaps less emotionally challenging, perhaps not, such as my first appendectomy (not holding the retractors but doing the surgery; what should have been 30 minutes under anesthesia for the patient became 60 minutes for me–not unusual, I'm told), trying not to cut too deeply, hoping to pick up the peritoneum, all of 4 cells in thickness, sweat pouring out of my brow (and being attended to by a fortunately doting circulating nurse) even as the temperature in the OR stayed a steady 63 degrees. The patient came through the procedure OK. For many medical students, their surgery rotation, while grueling, is also the most fun one. One gets to see the pathology present, instead of surmising it the way an internist would. At the same time, one comes to appreciate that being a surgeon takes a certain personality–not just bravado or ego but also perspective on the role of a physician in the treatment of a patient. A surgeon is cutting on a patient to help the patient therapeutically. She cuts on living flesh seemingly on a daily basis. Granted, it's with anesthesia, but even so, it is a concept which in the abstract may not seem challenging, or even when one's encounters with the surgeon are infrequent. Seeing surgery daily, though, is different, whether it's the surgeon, the surgical nurses, or the anesthesiologist. I think the former two have the most challenge. It's one thing to nick someone's skin for a biopsy, it's another to open a chest to transplant a lung. There's the old joke about the surgical resident at the poker game tossing $20 into the pot with an ace-high hand, while the medical resident hems and haws about whether to raise a nickel with a full house. It fits better than most might appreciate.

Graduating from medical school meant a change not merely in life but in me as a person, in my identity. I don't know that that was true for all of my classmates, at least not that they were willing to say come reunion time. It was for me.

As my daughter graduates, so will my wife and I. Empty-nester syndrome may hit, hopefully not. My daughter will move on to the next phase of her life, to begin adulthood. Both my wife and I wish that she comes through her college experience as enriched as she has her high school one.

In 24 hours, her world will change in ways she won't appreciate for years to come. Perhaps her mother's and father's will do so too?


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