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Issue Date: August 2009


White Coats

Into a medical system on the brink of change, Case Western Reserve University School of Medicine graduates an Army man with a family, an activist for equal health care and a rebel in green sneakers.
Jacqueline Marino
marino@clevelandmagazine.com
White coats  White coats, part iv White coats, part iv White coats, part iii White coats, part ii White coats, part i
On a pretty spring Sunday, a bright blue procession stretches from Veale Center to Severance Hall. Bagpipes play. Children wave. Toward the back of this quickly moving line, Millie Gentry files past the hospitals and full parking garages of Adelbert Road. She is wearing battered, kelly-green Chuck Taylors with a gown she put on for the first time today and a cap that won’t stay on her head.

She is talking about doing something mildly inappropriate in the $186 rental regalia, something worth the money. Bowling, perhaps. Or grocery shopping. It’s too late for anything more involved. “Shenanigans is now professional misconduct,” she quips.

In many ways, she is the same young woman who arrived late to the White Coat Ceremony, the symbolic start to medical school, four years ago. The middle daughter of grocery store owners from Florence, Ariz., Gentry still would rather have two kids and a minivan than a Nobel Prize.

But today, at least from the ankles up, she looks like all the other graduates wearing blue gowns with velvet bands on their sleeves, fussing with their caps. They carry green hoods that, aside from matching Gentry’s sneakers, identify them as new doctors of medicine.

“Holy mom,” she says, not for the last time today. “They made us doctors.”
 
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Four years.

That’s what it took to graduate from the Case Western Reserve University School of Medicine. That and lots of classes in windowless lecture halls and labs, learning your way around labyrinthine hospitals, taking apart dead bodies, letting your friends practice sticking needles in you, getting complete sexual histories from strangers, removing foreign objects from children’s noses, disimpacting bowels, memorizing drugs, spelunking orifices and, of course, trying not to embarrass yourself in front of actual physicians.

For Gentry, medical school also involved a great deal of rebellion. She worked hard to resist the culture, one she sees as steeped in tradition and conformity. Then she’s had trouble sleeping, wondering if she would blow medical school just by being herself.

Other students have heard the voice of self-doubt, too. It reminded Marleny Franco, the daughter of a nurse in the Dominican Republic who had to take blue-collar work in the United States, she isn’t like the rest of the student doctors, the ones who are American-born. Upper-class. White.

For Mike Norton, a Mormon who left a good research job in Provo, Utah, for Case Med four years ago, accompanied by his pregnant wife, the voice fed his incessant worry, his fixation on perfection. Doctors seem God-like, all-knowing. How could he join their ranks?

The people in the long white coats must live up to the most elevated of expectations: They must save lives, or at least improve them. This perception exists despite the grim reality of American health care today. As the Commonwealth Fund has pointed out, the United States ranks 19th among industrialized nations for preventing deaths with timely and effective care. Access to health care here has actually declined since 2006.

This isn’t all doctors’ fault, though medical educators tell students that they must change things. The CWRU class of 2009 pioneered a new curriculum, one that integrated the studies of medicine and public health. They are supposed to be the new community-minded doctors the 21st century needs.

Four years ago, Gentry envisioned a tight, student-centered community with engaging physician-teachers and life-altering experiences awaiting her in hospital corridors.

The reality of medical school nearly crushed her. Dragging lectures. Accumulating debt ($232,000 by the end of her fourth year). Some clinical experiences so boring that she slept through them.

Not turning papers in on time got her in trouble during her second year. She modeled at Fashion Week Cleveland and tended bar on weekends at the downtown bar Anatomy. She developed a reputation as a party girl, a slacker.

But her quest to learn medicine never faltered. The steady hand she cultivated working the meat counter at her parents’ grocery store performed well on the cadavers in gross anatomy. She volunteered at the Free Clinic and led the CWRU chapter of Medical Students for Choice.

And she kept looking for that life-altering experience.

Her worst day in medical school was the day she found out her cat died and then had to report to her surgery rotation, where one surgeon grilled her so hard she started crying in front of him.

The next day, she was supposed to follow a different surgeon. This one made it clear he was too busy for her. No problem, she told him, secretly relieved to get out of surgery clinic. She’d just get some studying done instead.

While sitting at a computer in the Cleveland Clinic Breast Center, she saw a woman in heels and a flowing, rose-print red dress. They started talking.

The woman was a medical breast specialist who had just gotten back into medicine after taking time off to raise her children. She was the first physician Gentry had met who freely told her this. It impressed her.

So when the doctor offered to let her sit in on a consult, she took it immediately.

The patient was a middle-aged woman with a dime-sized lump in her breast. Even after a thorough interview and exam, the specialist couldn’t tell if it was cancer, not without an ultrasound.

So Gentry followed the patient to the imaging room. There Dr. Christine Quinn, a radiologist, ran the ultrasound probe over the patient’s breast. Amorphous black and white blobs appeared on the screen as Gentry watched.

“I know what this is,” Quinn told the patient. A benign mass, possibly something left from the patient’s former breast implants. Definitely not cancer.

The patient’s expression of concern morphed into relief.

And Gentry had found her specialty. The radiologist was the problem-solver, a compassionate doctor and really nice person. She was who Gentry wanted to be one day.

She just didn’t know if the competitive radiology specialty would want her.

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Thinking about a radiology residency kept Gentry up at night. When she did sleep, nightmares woke her, and worries knocked around in her brain.

Her scores for Step 1 of the United States Medical Licensing Examination, otherwise known as the boards, were relatively low for that specialty. She would be competing with students who studied more, dressed snappier and got distracted by fewer cookbooks. (By the end of her fourth year, she had amassed about 70.)
Many radiologists enjoy regular business hours and a high salary, even by physician standards. (This year, newly hired radiologists brought in an average salary of $391,000, according to health care search firm Merritt Hawkins & Associates, which compiles such information from annual searches.) Compare that to the average pediatrician’s income, which also comes with middle-of-the-night calls, at $171,000.

Medical students, especially those trying to get competitive residencies like Gentry, spend their fourth year on the road, interviewing with as many residency programs as possible.

Then they compile a list of the programs they like, ranking them in order of preference. The residency programs make their own lists. Applicants and programs are not allowed to request one another’s lists or to bargain — there is no “If you rank me No. 1, I’ll rank you No. 1” allowed. An impartial nonprofit corporation, the National Resident Matching Program, processes the lists and spits out the matches.

Its placements are binding.

The process is supposed to protect both parties from making decisions before all their options are known, but it’s sheer torture for medical students.

After submitting their lists, students must wait three weeks for “Black Monday,” the day they find out if they matched to any program. “People become doctors because they want to have a sense of security,” Gentry says. “You lose all of that with the residency match.”

Every year, there are medical students who don’t match. Often, it’s not because they did anything wrong. It’s because an algorithm determined they weren’t as good a fit as someone else.

But sometimes a medical student sets herself up for failure by not ranking enough programs. Between 10 and 20 is the norm, more for competitive specialties, says C. Kent Smith, Case Med Society dean and senior associate dean for students.

Gentry ranked five.

To her, even five is too many. She only wants Maricopa Medical Center, a county hospital in Phoenix about an hour away from her parents. She has been away nearly 10 years — first at Smith College in Massachusetts, then teaching English in her mother’s native Taiwan, then medical school in Cleveland. She wants to come back home. She wants to shop at Scottsdale Fashion Square and eat the best refried beans on the planet.

She also wants to see more of her mother, who underwent surgery for a brain tumor in September. The surgery itself was successful; the tumor was removed. But the recovery was slow.

Gentry flew home to help. She fumed when she took her mother to a follow-up appointment with a neurosurgeon. “He was so rude,” Gentry recalls. “He didn’t answer [my mother’s] questions. Mom was dizzy, falling down, and he said it’s not his issue.” The same went for the problems she had with her medication. Not his problem. Talk to the neurologist.

As a doctor, she wants to treat her patients better. Her mother’s illness taught her that much. But it also made her feel the physical distance between herself and her family.

She is going to do everything she can to get to Phoenix.

Gentry visits Maricopa in the fall. Afterward, she keeps replaying the message the residency coordinator left on her voice mail: “You were very well-liked,” the coordinator says. “We scored you very high.”

She even tries to schedule another visit, known as a “second look.” But it is the winter holidays, and no one calls her back until January. Over the phone, the residency director asks, Why this county hospital in Central Phoenix? She tells him the truth: The program impressed her, the people were nice, and it’s home.

In January, she uses frequent flyer miles to get back to Maricopa. Afterward, the other residents e-mail her, telling her how much everyone liked her.

Gentry has a good feeling she will be Maricopa’s top-ranked candidate. But any medical student knows feelings shouldn’t be trusted.

If she doesn’t match, Gentry is definitely not going to Match Day, the day fourth-year medical students throughout the country find out where they’ll spend the next three to seven years of their lives. At CWRU, Match Day is a big celebration, the kind of traditional, self-congratulatory shindig Gentry hates. She might not go even if she does match.

“It’s so competitive, and these programs are so small,” she worries aloud over coffee one morning, the tears pooling in her eyes. “I don’t know if I’ll have a job.”
 
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Around noon on Black Monday, Gentry’s Blackberry dings.

She shouldn’t be in bed at this hour, but insomnia kept her up much of the night. She rolls over, picks up her phone and clicks open the new e-mail.

“Congratulations, you have matched!”

She doesn’t call anyone or even jump out of bed. She just rolls back over.

She’s headed to Maricopa. She’s so sure of it, in fact, she can finally sleep.

Around noon, Marleny Franco takes a lunch break during her geriatrics rotation at the Cleveland Clinic and checks her e-mail in the library. She, too, has matched. But she has no idea where.

Franco interviewed for pediatrics residencies at 13 hospitals, including Johns Hopkins, Stanford and Brown, her alma mater. She liked several programs, including Rainbow Babies and Children’s Hospital. But one truly impressed her: Children’s Hospital of Philadelphia, ranked the best children’s hospital in the nation byU.S. News and World Report for the past six years.

Franco considered CHOP a reach.

Her fascination with medicine dates back to when, as a child, she used to wander the emergency department where her mother worked, intrigued by the gore and fascinated by the action. She cut open her dead goldfish with a butter knife just to see what was inside.

But parts of medical school have been difficult. In her first year, she failed biochemistry and pulmonology. In her third, she fought depression. But after how far she’d come — all the way from the Dominican projects where she grew up in Boston — she wasn’t going to fail. She was the recipient of the coveted Jack Kent Cooke scholarship, an honor accompanied by $50,000 a year for medical school. She was her mother’s “beautiful genius.”

And then, of course, there were the children. At the Thomas F. McCafferty Health Center on Lorain Avenue on Cleveland’s West Side, she checked reflexes and tonsils, counseling children on exercise and eating vegetables. The experience reaffirmed her desire to work with low-income kids someday, to help them receive quality care, regardless of the color of their skin or the language they speak.

Going to CHOP would give her a great start. For weeks, she obsessed over her Match Day results. She counted down the days on her Facebook page. The night before Match Day, she mumbled the word “Philly” in her sleep.

She gets up early, along with her mother and her sister, Jade, who came to Cleveland for this occasion. They arrive at the Iris S. & Bert L. Wolstein Research Building around 11 a.m. The envelopes wait on tables in an area sectioned off by a ribbon. Franco walks over to hers and takes its picture.

She can’t decide how to open the letter: Alone in a corner where no one can see her reaction? Surrounded by her family and friends? Maybe she should have Jade open it?

She pulls out her cell phone and checks the time. The closer it gets to noon, the tighter the students and their families squeeze into the light-drenched area where the envelopes beckon.

Around 11:45 a.m., the first of many speakers takes the microphone, trying to fill the last few minutes of an agonizing three-week wait.

Dean Pamela B. Davis congratulates them on “an extraordinary match.” She warns that trampling her during the rush for the envelopes will put them at risk for graduation.

As another dean assures the students they will remember this day for the rest of their lives, Franco is no longer paying attention.

She and a friend are strategizing the envelope-opening. “We’re going to get the envelope, and I think we’re going to convince one another that it’s OK,” Franco explains.

Finally, it’s noon. The ribbon is cut. The crowd surges forward. Franco elbows her way to the envelope that has her name on the outside and her future on the inside.

Someone yells, “Yes!” Someone else squeals. People cry and cheer. Jade urges her to just open it.

“God!”

“CHOP?”

“Yes!”

“I told you! ... I told you. ... I told you.”

“Oh my God,” Franco says, her voice breaking. “Congratulations. You’ve been matched with Children’s Hospital of Philadelphia.”

Then the tears are hers. So are the shouts of joy and the hugs that go on and on. One of those hugs is from assistant registrar Theresa Hancock.

“No one’s matched at Philadelphia in 10 years,” she says. “Not since I’ve been here. She’s the first one, and that’s why I’m so proud of her. She drove me crazy. Oh my God, I’m so proud of her.”

At 12:20 p.m., a tall woman in tuxedo pants, a tuxedo T-shirt and black Chuck Taylors walks into the building alone. It’s Gentry. She has decided she wants concrete evidence of what she feels she already knows.

She finds her envelope quickly — there aren’t many left on the table, all neatly spaced and pristine. She opens it as if she were opening the telephone bill.

It says what she expects: Maricopa. She will start next year. This year, she will complete the first year of her residency, called a preliminary medicine internship, at St. Joseph’s Hospital, also in Phoenix.

Although plenty of people remain in the building, still congratulating one another and ogling the match lists that have been taped up for public view, no one pays attention to Gentry’s moment, which happens just as she planned it.

There are no hugs, no cake. Just sweet relief.

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Two months later, the procession of graduates meets an exuberant crowd inside Severance Hall. Photographers lean over the second-floor balcony taking shots. Thumbs are raised high in the air. An “I did it!” wafts through the crowd.

Mike Norton walks toward the front of the line, eyes fixed toward the stage, looking incredibly relaxed. Today he has become the object of his own adoration, a physician. His father once said Norton never went through the fireman phase or the astronaut phase; he only wanted to be a doctor.

“Medical school has both demystified and elevated doctors in my view,” Norton says. “A doctor was always the guy you could go to who had all the answers crammed into his brain.”

He doesn’t feel that way anymore. In medical school, he’s seen attending physicians swivel in their chairs and rub their heads in frustration. He’s heard them say, “Crap, I don’t know what to do. What do you think?”

To Norton, what doctors have lost in deification they’ve gained in humanity. A doctor knows death will win sometimes, but he does everything he can to help his patient, even if it means staying later, working harder and sacrificing more.

When Norton is called to receive his diploma on the stage, his picture flashes across the screen. It includes his wife, Kate; 3-year-old daughter, Megan; and 18-month-old son, Robert Bryan II. It was taken on the porch of the Cleveland duplex they will soon leave for El Paso, Texas.

Besides the two kids, something else stands out about Norton’s photo: the word “Army” in the caption. He’s going to William Beaumont Army Medical Center first for one year, then to Brooke Army Medical Center in San Antonio, where he will complete his anaesthesiology residency.

Norton is now an Army captain, though he does not yet have the haircut. He joined the Army after his second year, driven by the money and a desire to follow his grandfathers in service. Medical school is expensive for anyone, especially families. As the years wore on, things became more difficult for the Nortons financially. Megan was born during his first year; Robby came during his third.
An Army stipend has helped. In addition to paying for his third and fourth years of medical school, the Army will compensate him $60,000 for his residency this year. In a civilian hospital, he’d earn about $10,000 to $20,000 less. If Norton chooses to stay in the service longer than the three years he owes following residency, the government will begin to take over the loans he incurred during his first two years.

Since doing rotations at two Army hospitals, Norton says one of his biggest concerns before he joined — the war in Iraq — has lessened, even as he’s become more certain he will be deployed.

“In anaesthesia, if there’s a conflict anywhere in the world, I’m getting deployed,” he says. “They need battlefield care.”

He’d rather stay home, of course. But so would everyone. “At the military hospitals, I saw lots of doctors who were deployed,” he says. “All of them said they were glad they could serve the soldiers.”

Though nothing like he’d encounter in battle, Norton has already experienced his share of trauma during his time at MetroHealth Medical Center.

On his last day in the emergency department during his last year in medical school, he had already seen a 10-month-old whose brother sprayed Shout in her eyes and an overweight man in his 20s with chronic headaches and chest pain. He had stapled shut a head wound and completed an arterial blood draw in one poke.

Around 7:40 p.m., an ambulance brought in a 48-year-old woman who had stopped breathing, her eyes glassy, her blood pressure 40 over 30. A paramedic squeezed a bag connected to the tube down her throat, getting the air into her lungs. Another walked alongside the stretcher, doing chest compressions.

The emergency team gave her epinephrine to stimulate her heart. Someone placed sticky pads on her chest.

“Clear!”

The patient’s body jumped just a little, not like it does in the movies. Her heart started beating, weakly, then stopped. They did CPR. They tried more drugs. They did CPR again. Norton helped find her pulse so they could get an arterial line in. Like the children’s game of Pin the Tail on the Donkey, it took several tries before they finally got a line in her femoral artery.

When the patient’s heart stopped for the last time, they pulled the sheet up to her neck. They closed her eyes and cleaned the vomit off her face. In the trauma bay window’s reflection, Norton could see the patient’s son, a man about his age, sobbing with his father.

Death is an ugly thing to behold. In his doctor fantasies, he is always beating it back.

He won’t always win. But he also won’t lose hope.

This is what he’s learned from watching his father fight amyotrophic lateral sclerosis, Lou Gehrig’s disease. ALS attacks the nerve cells that send messages from the brain and spinal cord to the rest of the body. The cause is not understood, and there is no cure or treatment to significantly slow the disease. In its advanced stages, the patients’ brains can no longer control their muscles. Fifty percent live from three to five years following diagnosis. Norton’s father, his son’s namesake, was diagnosed two and a half years ago.

Before they were even married, Norton told his wife that if they had a son, he would name the boy after his father. “I want Robby to go through life with that name and have that to live up to,” he says.

“That” is the example his father set when Norton, his brother and two sisters were growing up. Although his dad had a demanding job in marketing at IBM, he always made time for the family. They often went out on their boat to fish and water ski. Each Sunday night, they gathered for scripture readings.

Norton’s parents live in Oregon. Every time he sees his father, there’s a decline in function. He now uses a wheelchair. Sometimes his wife needs to translate for him. But mentally, he’s sharp. He doesn’t want anyone to fuss over him. Norton says his father is an optimist.

Norton, on the other hand, has never been a hope-for-the-best kind of guy. He needs to know what’s going to happen and work as hard as possible to secure a good outcome. That’s why he obsessed over studying for the boards, even though he did well in all the subjects they covered. That’s why he can’t read a book without skipping to the end. He needs to make sure the hero lives.

At the diploma ceremony in Severance Hall, Dean Davis asks the graduates to turn around and salute their families. Norton doesn’t expect to see his father, who should be sitting in back of the balcony where there’s wheelchair access. But his father has managed, somehow, to get to the front.

Norton immediately finds his father’s eyes and, for a moment, they lift him up.
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Millie Gentry is planning to enter her tequila-crusted jalapeno-apple pie in the county fair. When it comes to pie, she is a gunner. Medicine is work. Baking is living.

“I’d rather be successful at life and experience life than be the world’s most decorated physician,” she says.

In a profession that values typification, she stands out in green sneakers at her graduation.

They are proof that you can get a medical degree and have a life. They symbolize victory over the conformists, including the doctor who said wearing Chuck Taylors, even brand new ones, to clinic is inappropriate. They are a victory over the students who excel at medicine at the expense of their social lives and overall humanity. The sneakers are even a victory over the voice she couldn’t quiet at night, the one saying, What if I fail?

At medical school’s end, Gentry has finally figured out her problem: She wasted a lot of time being miserable. Like most diagnoses, if she had realized her problem earlier, she would have had a better time of it. Attitude affects experience. She’s seen that in patients. Why didn’t she see it earlier in herself? Instead of fighting the medical school culture, she could have peacefully coexisted with it, as she’s doing now.

Before she makes her final medical school journey, the trip to the stage to get her diploma, Gentry takes off her sneakers. She pulls a bag from under her gown and slips on a pair of 4-inch heels.

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