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T1 – 001: Reflections on One Week of Medical School

Et in Arcadia Ego by NIcolas Poussin

Et in Arcadia Ego by NIcolas Poussin

First, on Wednesday, our first meal after leaving Boston was Subway off the New Jersey turnpike: buffalo chicken; bacon, egg, and cheese; and chicken salad – all footlongs.

Then, a potluck dinner with my sister’s boyfriend’s family in Philadelphia – grilled, marinated chicken and salmon, salad with romaine lettuce, diced carrots, red onion, walnuts, and cranberries, toasted Italian bread, pasta salad, and cheesy potatoes.

Thursday morning was leftovers – both Subway and potluck. Baja Fresh in Delaware was for lunch, Then it was Cracker Barrel in Fredericksburg, Virginia for dinner. I had the deep fried catfish, my wife ordered grilled rainbow trout. The kids split a burger, and we all shared everything.

Friday morning was our first continental breakfast, then Cracker Barrel for dinner again, this time in Gaffney, South Carolina, home of the peachoid.

Another continental breakfast followed on Saturday, this one identical to the one the day before, down to the very last detail of the hotel architecture. We grabbed lunch at the Texas-themed steak house next door: big, fatty steaks with many deep-fried things dripping in melted butter. There was a beer tasting in Greenville with long-lost friends and to-go burgers for the road to follow.

Another continental breakfast on Sunday, this time at an Auburn, Alabama Quality Inn. Like the continental breakfasts before it and the continental breakfasts to follow, this continental breakfast consisted mostly of hard-boiled eggs and Raisin Bran, with a waffle-maker waffle or two with some high fructose corn syrup syrup thrown in depending on how we were doing on time. After some Googling and asking around, we found a Starbucks at which to safely obtain caffeine, and we loaded up for the road. We were at Pensacola, Florida by early afternoon.

After some time at the beach, for dinner we hit up Pegleg Pete’s, where we gorged ourselves on some three-dozen oysters of various preparation, a pound of shrimp cocktail, and massive portions of grouper and mahi mahi for a small fraction of what these items cost back home. That night I indulged at our hotel in two-for-one bushwackers – a potent Pensacolan concoction of rum, ice cream, rum, coconut, chocolate, rum, coffee, and rum, with a float of Bacardi 151. The next day, we enjoyed one last continental breakfast, some final down time at the beach, and then our last lunch at the crab shack across the street: red snapper, gulf shrimp, mahi mahi – variously deep-fried, soaked in butter, and/or with strong tartar sauce for dipping.

On Monday evening, after driving through the Deep South, where in-car temperatures reached 108 degrees, we got to New Orleans – our destination and the place we would be living for the next four years. It was late by the time we brought all our stuff up to the seventh floor, so we ordered a pizza from Domino’s.

The next day, I physically craved a return to the vinegar-based accoutrements, vegetable umami, and bitter flavors that have formed the basis of my diet for the last several years – as these are noticeably absent from the US interstate highway system culinary watershed region. Our first real meal down here, after buying enough kitchen supplies to make it, was whole mangrove snapper, braised in soffritto, served with chianti and a salad of bibb lettuce, dried cranberries, shaved roasted almonds, grape tomatoes, crumbled goat cheese, cucumber, red onion, kalamata olives, and French dressing, finished with a small cup of Bialetti Moka Express brewed Italian roast.

After a week of road food, finally, the bacterial overlords who live in my gut have stopped warring with each other, and a postprandial peace has come to the land.

***

I am now a T1 – read first-year – student at Tulane University School of Medicine in New Orleans, Louisiana. I will be writing about the process of becoming a doctor here at the Ordinary Times in the weeks, months, and years ahead. I am hoping that this series can be informative for prospective medical students, an insight into a different world for the lay reader, a place for me to reflect on the transformation I am undergoing, and an avenue for us all to stretch and strengthen our shared notion of humanity. A special thank you to Dr. Russell Saunders, who has graciously allowed me to write under his well-established Blinded Trials banner.

I went through my medical school orientation this past weekend. It consisted mostly of speeches, team-building exercises, paperwork, and parables:

The other day, while in line at PJ’s – PJ’s, by the way, is the best coffee house in New Orleans – some people like Spitfire, some people like Cafe du Monde, I like PJ’s. Starbucks is last. Anyways, in front of me in line was this high-maintenance coffee order – the pink one instead of the yellow one, extra foam – and this was aggravating me, since service in New Orleans is mind-numbingly slow to begin with and here we have this pain-in-the-neck coffee order. And all I wanted was a large regular black coffee – just some plain coffee poured in a cup! (laughter)

Anyways, I realized that the gentleman in front of me, the one with the high-maintenance order, was trying to stall for as long as he possibly could, because he was talking to this girl, and he was trying to work up the nerve to ask for her number. I sort of got into it vicariously. You see, I’m married now, and I have been for a while, and this is as close as I can really get to that time in my life when I was going through that. I mean, I felt for this guy, and I actually started to forget about my own coffee order taking so long and I started to root for him! (laughter)

C’mon dude. Do it. Get her number. And then, just as his coffee was coming out, he did it – he asked her for her number: ‘so, uhh, can I, can I have your number?’ And she was really into him too, so she said “oh, yes!” and gave it up right away. (laughter)

Now, after this I just couldn’t stop thinking about those two, and I kind of, as I drove back from PJ’s, I imagined how everything would play out in my head. I don’t know what actually happened, but this is what I think probably might have happened. And this is just my imagining of the situation, because I don’t actually know what happened. If I did it would make me a stalker. (laughter)

If it were me, and I remember back in the day, when I was going through this stuff, I wouldn’t have called her right away, because I wouldn’t want to seem too desperate. So maybe I wait a few days. Like, I might call her on Tuesday or Wednesday. You know what – roll the dice – let’s call her Tuesday! (laughter)

So, he calls her up – “Hey,” he kinda says awkwardly. “How are you? Do you remember me? So, uhh, so, what are you doing this Saturday?” But she’s busy on Saturday, and she’s busy the next Saturday too, and it looks like the first date is maybe going to be three weeks from now if at all, but then, “what are you doing on Friday?” she says – “nothing!” (laughter)

And look – now it’s Friday, the night of the first date, and I’m imagining that later tonight, they’re going to go out to a nice restaurant. It won’t be like the third or fourth date where it’s – where’d’you’wanna’go? dunno – where’d’you’wanna’go? dunno, you decide” “No, you decide” “Well, I don’t care.” “Well, I don’t care either.”  – there will be a plan.

And now they’re at the restaurant, taking forever to order their first course. They have a couple of cocktails, maybe, one or two each or something, finally they order. The waiter is like, I need this two-top. (laughter). They have dinner, dessert, whatever.

And now it’s the end of the night, and he takes her back to her apartment. Now, this is a G-rated story (laughter), so I’m going to stop right here for a moment and keep it G-rated. (laughter) Now, he thinks about it for a second and leans in to give her that first kiss – that first special kiss – he says to himself, man just go for it. And they kiss for the first time…

…Now he says goodnight to her, and she goes inside the apartment and closes the door and just stares up at the ceiling for a few minutes, and he slowly comes back to earth, starts up his car after who knows how long, and he waits until he is at least two blocks away before doing a big congratulatory fistpump. (laughter).

Now, also at this very moment of this very night, one nucleotide of one cell in his body copies itself incorrectly, randomly, and this cell becomes immortal. This cell goes on down the line to copy itself and to copy itself again and to copy itself again, and five years from now the first symptoms will appear, and he will be diagnosed with lymphoma.

And it will be you waiting for him in the hospital, armed with all of your knowledge, prepared to recognize his symptoms and get him to the right specialist in time for treatment. And she’ll be there too, holding his hand at the bedside. And ten years from now, it might be you announcing to him that it’s been five years since his cancer has been in remission.

Your race against that one nucleotide of that one cell starts tonight.

There was, notably, a “white coat ceremony”, an indoctrination to the profession, since almost no one fails out of medical school. The white coat ceremony is a neo-tradition for medical students. I was skeptical at first of the practice, because I assumed the white coat ceremony was a self-congratulatory pat on the back for the profession, but it turned out to be an opportunity to reinforce the seriousness of the social role being assumed by the medical student and the cautiousness with which we must go forward.

A young medical student had a girlfriend who was going away on vacation for the weekend. The last time she went away her cat had developed extreme anxiety and had completely destroyed her apartment. This time she asked her medical student boyfriend for some help controlling her cat.

Her boyfriend diligently consulted the most accurate and up-to-date medical journals, determined that a single dose of morphine would sedate the cat sufficiently and safely until the girlfriend returned, procured morphine from the medical supplies of his university (this was apparently in the days when morphine was readily available), weighed the cat and calculated the correct dosage, and wrote out clear and explicit instructions for administration. His girlfriend administered the morphine exactly as instructed by her medical student boyfriend and went on vacation with her family for the weekend.

Later that weekend, the medical student was bragging to some vet student friends about how he had solved his girlfriend’s cat problem. About halfway through his story he noticed his vet student friends giggling to each other and stopped. “What is it?” he asked.

Apparently, cats have a paradoxical reaction to morphine, and it actually causes extreme anxiety and hyperactivity.

When the medical student’s girlfriend returned from vacation, he nervously asked her how everything had gone with the cat. “Oh, it was terrible,” she said. “He was even worse than the time before! He tore all the furniture apart, tore the curtains to shreds, broke the TV, and clawed completely through the carpet! But thank you so much for prescribing the morphine. Who knows just how terrible things would have been if it weren’t for you.”

At the end of the white coat ceremony, we were asked to go up to the stage one-by-one to get our picture taken with the deans in our new white coats and to be welcomed to the profession.

We were also asked to speak into a microphone and say the one word that we felt best expressed what had brought us all to this point…

***

I had only four days of actual school this past week (Monday was all administrative), but in those four days I had seventeen lectures – covering: development through gametogenesis; the anatomy of the back, spine, circulatory, lymphatic, and nervous systems; pathologies of the spine; TeamSTEPPS, patient interviewing, and medical ethics, among other topics. I also had two anatomy labs – on the muscles of the back and on the spinal cord respectively.

My first cadaver did not appear as I had expected it to. The last deceased human body I had really experienced was my cousin, who died in his twenties when I was about twelve years old. I remember him lying there, a beautiful young man, pink and painted and dressed by the funeral home staff to look nice in an open casket, looking like he could open his eyes at any moment and come with the rest of us to the carnival just down the street.

A cadaver does not look like a recently deceased human being, nor does it look like anything Googlable, presumably out of respect for the deceased. The skin is leathery and thick, and it appears the same shade of gray no matter the racial background of the deceased. The face may be unrecognizable. The body is preserved with formaldehyde, which emits a unique and easily-recognizable smell. Some can tolerate it or even adopt a neutral stance towards it. I cannot do either of these things.

Our first cadaver lab was on the muscles of the back, which look remarkably like pulled pork. Despite following the advice of more-senior students and double-gloving, and despite being somewhat reluctant to get involved at first, my hands still smelled like formaldehyde hours after lab. I had carefully removed and double-bagged my anatomy scrubs; washed my hands and arms four or five times; went to the gym – something I’ve been doing nearly everyday – to try and sweat out whatever formaldehyde smell remained; went in the sauna in my apartment building; took a ridiculously hot bubble bath for forty minutes while listening to a lecture at 1.4 times speed. About half a bottle of mango shea butter body wash in the tub finally removed the formaldehyde smell sufficiently that I felt comfortable biting my nails and hugging my children.

The shock for me did not come from cutting into a human being. It came later that night, as I held my youngest in my arms, while she fell asleep. I noticed especially the trapezius and latissimus dorsi, innervated as they are by the accessory nerve (CN XI – for motor only) and the thoracodorsal nerve respectively. As I stroked the back of my youngest daughter’s head, I recalled the occipital protuberance of my cadaver, like deja vu.

I could consciously perceive the paradoxical and potentially dehumanizing nature of gaining extensive knowledge of the human body via the complete dissection of a human body. This loss of innocence so to speak – this tectonic shift in understanding of what makes a person a person – is something I, and students of medicine across the world, must continue to wrestle with.

I was more enthusiastic for our second lab, on the spinal cord, welcoming the new scent of sawed bone as a pyrrhic reprieve from formaldehyde, which I will never get used to. At the end of this lab, after removing the spinous processes from T1 to S2, we were able to identify the dura mater and the arachnoid layer, the pia and the cauda equina, the conus medullaris and dorsal root ganglia…

The cadaver, of course, was once a living person, probably someone who had a great deal of interaction with doctors before he died, someone who knew just what kind of contribution he could make by donating his body to science. At the end of the semester, we will meet his family, learn his name, occupation, and cause of death. And we will appreciate even more the knowledge we were able to discover through his very last act.

***

…When it was my turn to go up to the microphone, to speak the one word that I felt best expressed what brought me here, from Japan and the earthquake, back home to Boston and through extended unemployment, through night classes I initially could not afford and the year and a half long application process; here, finally, having taken three years to complete the prerequisites and me being several years older and at a very different stage of life than my peers, with wife and kids in tow, thousands of hours, and thousands of dollars later, to the white coat ceremony, to medical school at Tulane, to the struggling, great city of New Orleans, to the profession of medicine, the answer came to me rather quickly:

“Life,” I said.

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13 thoughts on “T1 – 001: Reflections on One Week of Medical School

  1. This was wonderful. As a (fairly) recently graduated veterinarian (3 years ago last month), I’m looking forward to seeing how medical school is similar and how it’s different. Best of luck.

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  2. I hope you keep this series up, Chris. I rather enjoyed the description of the white-coat ceremony.

    As for the legend about the doped-up kitty and his separation anxiety, similar stories are told by and about lawyers; save, no matter what the lawyer does, the bad result is always perceived to by the lawyer’s his fault (as opposed to the proverbial doctor, who is never perceived as being at fault even when he is).

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    • Interesting, Burt. During our first ethics lecture we learned about the traditional three professions being law, medicine, and theology. We were told that the lawyer’s duties, the physician’s duties, and the priest’s duties do not end at the end of the workday. The lecturer also asserted that traditionally all three professions were afforded strict and unyielding rights of confidentiality, but that that right only remains inalienable for the priest. I wasn’t really sure about this…do you have any idea?

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      • The right is not sacrosanct for any of these three traditional professions. California, as always, led the way, with a case presenting truly awful circumstances called Tarasoff v. UC Regents. I’ll leave exploration of the facts and ideas in that case for your medical ethics class, but the law pretty much throughout the USA after that case is such that if there’s a credible threat to life disclosed within a communication normally cloaked by privilege, you’ve got to do something about it. It goes on from there: most states require doctors seeing harm done to children (and possibly other protected classes, varies state by state) to become “mandatory reporters,” so there’s communications that otherwise would be confidential that you need to pass along to law enforcement, and I bet it’ll be a matter of some dread should that happen to you.

        Lawyers have similar piercings to their privilege, and in fact so do clerics in most states. I’ll bet the attorney client privilege is the easiest to waive of these three, but that may be because it’s what I’m most familiar with.

        There’s another privilege you may be interested in exploring: peer review panels. Let’s say Something Bad Happens with a patient and it might be partially your fault. Peer review committees may evaluate your work, and perhaps make a finding that you delivered substandard medical care. Is that evaluation usable in the event of a malpractice suit? Does making it available discourage constructive criticism aimed at making a doctor better at her craft? Again, the wrinkles vary from state to state legally. More universal, but less well-defined, are the ethical principles that run parallel to the applicable laws.

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      • There’s also one other thing that you need to bear in mind when considering confidential communications. Who holds the privilege? It is not the attorney; rather, it is her client. It is not the cleric; rather, it is the penitent seeking absolution. It is not the doctor; rather, it is his patient. The holder of the privilege has the choice of waving it. The professional who is bound by the privilege has a duty to safeguard that privilege until and unless it is waived.

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  3. Great post! It’s the first week of orientation for our MS-1s at our medical school here.

    Your noticing “the paradoxical and potentially dehumanizing nature of gaining extensive knowledge of the human body” reminds me of a line from a Social Science and Medicine article I read recently that catalogued various “functional and non-functional forms of dehumanization in medicine” — enough distance to maintain sharp cognitive and diagnostic capabilities, yet not so much distance to lose the compassion and care connection you referenced in your one-word summation. Quite a razors edge really….

    So appreciating your reflections here and looking forward to your next installment!

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    • Hi Niki. Welcome! I’m glad you enjoyed my first post in this series.

      “…enough distance to maintain sharp cognitive and diagnostic capabilities, yet not so much distance to lose the compassion and care connection you referenced in your one-word summation. Quite a razors edge really….”

      This is a good point. It seems like learning that the body is a machine helps insulate doctors against the psychological horror of, say, cutting open another human being or exposing themselves to disease or parasites or any of the other things that people are normally afraid of.

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  4. Apologies for being so late to this. I am too distracted these days.

    First of all, I’m delighted to have you contributing under the Blinded Trials banner. It’s not like I’ve been doing all that much with it lately. Alas.

    And this was great. I look forward to following along with you in the coming years. My medical school instituted the “white coat” ceremony several years after I matriculated, so it was something I never experienced myself.

    Good luck and all best wishes, as always.

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