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Issue Date: August 2008


White Coats


Jacqueline Marino
White coats
 
Year 3
In the hospital, separated from your classmates, you wonder if you can do it. The academic rigors of the first two years were supposed to prepare you for this, but nothing can prepare you for this. The patients aren’t questions on exams anymore. Their suffering follows you on the wards, where you trek from service to service every few weeks, reporting to physicians who grill you and grade you.
This is your rite of passage. This is third year.

Jacqueline Marino

Mike norton - tim harrisonMike Norton, unshaven and looking as eager as he can on three hours’ sleep, paces a long, narrow hallway of the Cleveland Clinic where patients await surgical consultations. A surgeon he’s not, not yet — maybe not ever if his wife gets her way. But five weeks into his surgical rotation, Norton wonders if he can be happy doing anything else.

Yesterday he helped suction blood out of a woman whose aorta — a vessel that carries blood from the heart —was bleeding into her abdomen. The aortic walls were fragile, and the surgeon had to cut them to sew them up right. Blood pooled in her abdomen as fast as Norton could suction it. The sutures threatened to tear through the walls. But the surgeon kept working, snipping, slicing and sewing, fixing her.

During this rotation, another surgeon will tell Norton, “We’re the same as other doctors, except two days a week, we get to go to the playground.” Yesterday was one of those days, where life and death teetered like a seesaw.

A third-year medical student, Norton knows how to tie knots like the Eagle Scout he once was, place nasal gastric tubes and Foley catheters, even drive the little camera in laparoscopic surgery. But he still hasn’t managed to impress Dr. R. Matthew Walsh, a general surgeon who specializes in pancreatic surgery and the one in charge of him today.

During back-to-back gallbladder surgeries, Walsh pummeled Norton with questions about cholangitis, an inflammation of the bile ducts from which both patients suffered. He followed up Norton’s answers with, “Are you sure?” Again and again. “Are you sure?”

When Norton was wrong, a new line of questions followed. When he was right, a new line of questions followed.

Norton is among those medical students who ace most of their exams and pick up the physical part of being a physician easily. They’re used to smiles of appreciation from their instructors, who record their performance as “thorough” and them as “motivated” on evaluations. They thrive under the kinder, gentler instruction of the modern medical school.

But Walsh is not an instructor for the self-esteem junkies of Norton’s generation. If surgery is the playground, some see him as the bully. But is it bullying or conditioning? That depends on whether you can take it. 

When Walsh, a tall, elegant figure with a surgeon’s slight stoop, emerges from a patient room, Norton snaps his head. Walsh is indifferent to him, writing something.

“Mike, do you have something to do?” Walsh asks without looking up.

“I’m preparing to see Mrs. ----?”

Mrs. ----’s online chart says her condition is “not disclosed via Dr. [Toby] Cosgrove.”

“I should see her,” Walsh says at first. Cosgrove is president and CEO of the Cleveland Clinic. In Norton’s mind, the patient has VIP status, and he’s not surprised that Walsh doesn’t want to bother her with a med student.

Then Walsh changes his mind and tells Norton to see her first.

“I saw Dr. Cosgrove’s name and thought you might want to see her yourself ...”

Walsh waves him off as he walks down the hall.

Unlike the first two years of medical school, the third requires some weight-pulling in real clinical settings. Even though the students’ work is double-checked by doctors, they still have a place on the team. Expectations must be met beyond learning. Histories must be taken, physical exams given and presentations and assessments made. Above all else, medical students don’t want to look like idiots. Next they want to be useful.

The students
 
 Mike Norton

Hometown:
Beaverton, Ore.    Mike norton
Age: 28
Considering: Anesthesiology
If i wasn’t going to be a doctor, I’d be a microbiology or genetics researcher. Or an astronaut.
The worst thing I ever had to do to a patient was help disimpact a very full, very distended bowel.
I knew i was supposed to be a doctor when I got done with one of my first days of third year and realized I loved the work I was doing.


This would be easier if the students spent more time in each service, getting familiar with the culture and the personalities. But at Case Western Reserve University, the third year is characterized by short stints in the major services: internal medicine, surgery, family medicine, pediatrics, obstetrics and gynecology, neurology and psychiatry. The students complete two 16-week blocks during which they do clinical work and one 16-week block during which they do research, which is a feature of the school’s new curriculum.

At CWRU, administrators have married the study of medicine with that of public health, hoping to graduate better doctors who are more community-minded. Norton’s class of 2009 has had the most clinical experience of any third-year class to date. But it doesn’t seem to make things easier for him.

He enters the room of the VIP patient. About a half hour later he comes out and starts pacing again, studying a notecard he has pulled from the bulging pockets of his white coat. He spots Walsh.

“I’m ready whenever you are,” Norton calls.

“You’re totally ready.”

Walsh’s answer is neither question nor statement. He disappears into another patient room, leaving Norton to obsess over his presentation for a few more minutes.

“It doesn’t matter how thorough I am,” he says quietly. “Walsh will be more so.”

The surgeon flips through a chart as Norton begins: “She plans her life around eating and going to the bathroom.” Walsh asks about her allergies, her meds, her history of gallbladder disease, whether her colon’s enlarged. He asks Norton to tell him everything causing her pain, if she has cirrhosis.

“If I take her gallbladder and she has cirrhosis, what’s the chance she could die?” Walsh asks.

“I don’t know.”

“Eighty percent.”

After more questions, Norton follows Walsh into the patient’s room, his forehead shiny with sweat. When he comes back out again 20 minutes later, Norton looks shaken.

Walsh leaves him standing there thinking about why he didn’t tell him about the C-section scar or the severe and persistent pain in the right upper quadrant of the patient’s abdomen.

Disappointment spreads across Norton’s face like a rash.



Family Medicine
+

It’s June, four months into Marleny Franco’s third year of medical school, and her first patient of the day is Delia, a smiley 10-year-old with hair down to her waist. Franco asks her questions in a mix of Spanish and English: What kind of things do you like to eat? What’s your favorite subject in school? Who’s your best friend? Why won’t you wear your glasses?

The students
 
Marleny Franco

Hometown: Boston, Mass.  Marleny franco
Age: 27
Considering: Some pediatric specialty
If i wasn’t going to be a doctor, I’d be an event planner.
I knew I was supposed to be a doctor when, at age 10, after my fish died of natural causes, I tried to cut him open with a butter knife.
After third year, I feel more confident, but I act more confident than I feel.



For almost 20 minutes, Franco conducts a completely average checkup. Ears are clear. Throat looks good. Reflexes perfect. She learns that Delia still likes dolls, hasn’t started her period yet and won’t wear her glasses because her friend told her they look ugly. Then Delia’s mother tells Franco that one of the girl’s prepubescent breasts hurts.

“How often does that happen?” she asks, suddenly concerned. “It may be a normal part of breast development. I’ll check.”

When she examines the girl’s chest, she notices the left nipple has what looks like a vein running through it. The nipple hurts when she touches it.

Franco excuses herself from the room and sits down at a computer in the hallway. She takes a sip of her soy coffee drink and looks up the Tanner Stages of Sexual Development. She’s comfortable at the Thomas F. McCafferty Health Center on Lorain Avenue in Cleveland, but there’s still so much she doesn’t know. Dr. Wendy Cicek greets her from the phone across the hall. She’s on hold with an insurance company trying to get a preauthorization. This is good use of physician time, she says sarcastically.

Some patients at McCafferty, a center affiliated with MetroHealth Medical Center, speak only Spanish and have trouble navigating the health care system. According to the Centers for Disease Control, Hispanics are more than 14 percent less likely than whites to seek and receive health care coverage, which may be why they have poorer health and higher rates of serious disability and death. Cultural barriers often get in the way, as do language problems.

That’s one reason Franco loves it here. Of all the clinical experiences she’s attended, this is the one that most fits her ideal: It serves a poor population — her population — or the population she was part of while growing up in Jamaica Plain, a Latino neighborhood near Boston. The doctors were good there, but they didn’t speak Spanish well, and, as a child, she became the spokesperson for her family’s health. At McCafferty, most doctors do speak Spanish, and the cultural disconnects seem to be fewer than at the Boston clinic. Once patients realize Franco is Dominican, they open up about all the home remedies. When one patient told her he uses Vicks VapoRub for everything, it didn’t surprise her. A member of her family did the same thing.

Franco writes notes from her visit and her research on a notecard, which she holds like a security blanket in front of Dr. Douglas Van Auken, the always-busy medical director. Presenting a case is still tough, though she’s gotten better at it since her surgery rotation, when there were times she couldn’t muster the courage to speak. She goes over her speech in her head and swallows hard. Once she begins, she tries not to stutter. Van Auken listens, most of the time without making eye contact.

“She has no issues whatsoever,” Franco says in closing. “Just breast tenderness.”

One Night in Labor and Delivery

Mike norton - tim harrisonIt's 7 p.m. when third-year medical student Mike Norton throws his coat into a heap behind the nurses’ station. He wears clean scrubs, but his cheap shoes still have umbilical cord blood on them.

An amplified fetal heartbeat pounds out of a nearby room. He knows the heartbeat can speed up — knockknockknock — or slow down — knock, knock, knock — causing flutters of activity and flurries of emotion. Sometimes it just pads along like a ticking clock he forgets is there.

They lost a baby on the floor the week before Norton arrived. With a walkway to Rainbow Babies and Children’s Hospital — ranked among the best children’s hospitals in the nation — most babies at MacDonald Women’s Hospital do fine. Still, this is a city hospital. In one room, a teenager in her second trimester is having labor pains, and she’s had no prenatal care. In another, a 15-year-old labors actively, her pregnant 18-year-old sister and her 30-something mother waiting nearby.

At 7:15, Norton visits Ramiasha Muhammad. She’s contracting every two to five minutes. He asks if she’d be comfortable with his doing a cervical exam. She says yes. After 12 hours of labor, she’s six centimeters dilated. Four more to go before she can start pushing. After that, he sits in a room no one is using, waiting for something to do.

Norton sees younger versions of himself waiting all over this floor: In the hallway, the first-year medical student waits for a doctor who never shows. In Room 6, the nervous first-time expectant father waits for a whole day to meet his daughter, Megan. In Room 8, the nervous second-time expectant father waits for his son, Robby, to be born.

Across the hall, someone pushes a swollen and crying postpartum woman in a wheelchair.

Labor and Delivery is a place of miracles and nightmares. So far, Norton has been lucky. He’s seen only miracles.

At 1:17 a.m., Ramaisha’s room fills with doctors and nurses. The baby’s heart rate is dropping. Gloves are pulled on, masks placed, scrubs draped.

“You’re having a contraction,” a doctor tells Ramaisha. “Take a deep breath and push.”

“Push, push, push,” a nurse says.

The baby’s heartbeat thumps out of the monitor, knock, knock, knock.

“Push, push, push. One ... two ... three ... four ... five ... six ... seven ... eight ... nine ... 10.”

Knock, knock, knock, knockknockknockknock.

“Push!”

At 1:31 a.m., the baby cries. “She’s got lungs,” the doctor says. Loud, beautiful lungs. Norton delivers the placenta and sidesteps the huge bag of blood under the delivery table. “That’s why these are my hospital shoes,” he says.

He doesn’t care if he gets more blood on them. It’s another miracle.


No medical issues, maybe, but Van Auken continues to bring up new subjects that could affect her well-being. What activities is she in? Is she reading much?

“It’s important to talk to her about strangers,” he adds. “Two girls about her age disappeared around here.”

He’s referring to Amanda Berry and Gina DeJesus, West Side girls who disappeared in 2003 and 2004, respectively. Neither have been found.

Franco didn’t know that. She adds “abduction” to the long list of things to bring up with this patient population, these younger versions of herself.

Later, in the patient room, Van Auken retraces all of Franco’s steps. He tells Delia’s mother not to worry about the breast soreness.

He tells Delia to be aware of her surroundings when she’s outside.

“If someone talks to you on a busy street, what do you do?” he asks.

“Run!” Delia answers.

“Good. What else?”

“Scream!”

“That’s exactly right.”



Cardiology
+

On an elevator at the Cleveland Clinic Heart & Vascular Institute, Millie Gentry practices her presentation. She has written an intern’s pager number on her arm, in case she has questions, and stuck the book Pocket Brain: EKG and Heart Murmurs in her white coat pocket, in case she needs a quick reference.

This is Gentry’s second day with Dr. Richard Krasuski, an attending physician at “the nation’s No. 1 heart program,” and she needs to not blow it.

She found out recently that a doctor-instructor from second year gave her a negative evaluation. And she’s had other bad clinical experiences, one so uneventful she passed the time snoozing at the nurses’ station.

She knows she needs to work on her motivation, but she keeps dreaming of becoming a housewife.

Gentry does not want to be a “gunner,” a med-school star who tries to excel at everything. She wants to be good at what she will do one day, in her chosen medical field. She also wants a husband and kids, and she’s not been afraid to say so.

Still, she could have been more of a self-starter; she could have been more thoughtful with her words. She could have asked for more feedback earlier. In year three, Gentry is determined to turn things around and hopefully find her place in medicine in the process.

Today, she couldn’t have a better patient, a smart, talkative 31-year-old single woman who runs a few miles three days a week. She went to her local hospital after having chest pain that lasted all day, got better, then seemed to turn into bad upper gastrointestinal pain. Routine tests yielded nothing helpful. When they wanted to do a heart catheterization, an invasive procedure, she came here.

Yesterday, Gentry spent a long time with the patient and her parents. Today, the patient complained about being awakened six times during the night and giving the nurses what seemed like gallons of her blood. Gentry smiled sympathetically and listened to her heart. Sounded good to her, but she’s still learning to listen to heart sounds. One cardiologist told her you have to hear something hundreds of times to be sure what it is.

On the eleventh floor, Krasuski’s team gathers around a too-small table. Like Gentry, some have been there all night, handling patients who range from Gentry’s seemingly healthy young woman to a lifelong smoker. In their heads are stats and studies, social and physical histories and questions for Krasuski, a Harvard Medical School graduate with a gentle, mannerly way that belies a fierce intellect.

Members of the team take turns presenting. Krasuski, an expert in adult congenital heart disease, listens, questions and offers insight, usually in that order. He asks the most questions of Gentry, who maintains her calm demeanor that some have mistaken for aloofness, even when she admits she has no idea what answer he’s looking for.

“Oh, man,” she says in response to a drug-related question. “I’m blanking because I’m under stress.”

“You can ask for a consult from a pharmacist,” Krasuski offers.

And so it goes on like this, for more than two hours.

The willful infliction of humiliation on a medical student is called “pimping,” but Dr. Dan Wolpaw, a CWRU professor of medicine in charge of the clinical curriculum, explains that questioning is necessary to “diagnose the learner” — find out what a student knows and how to help her learn what she doesn’t. True pimping still happens, but not nearly as much as it used to, Wolpaw suspects.

At the end of the meeting, they still don’t have a diagnosis for Gentry’s patient. Every test she took was fine except one. It may be a false positive. But Krasuski says there’s a slim chance she could have acute coronary syndrome. He decides she needs one more test to rule it out.

For the rest of rounds, Gentry follows Krasuski in and out of patient rooms, observing his bedside manner, which is both pleasant and intense. “Can I have a quick listen?” is how he asks patients to let him listen to their chests. “I know you’ve already gone through a lot” is how he asks them for just one more test. Even though his phone rings every few minutes — he’s in charge of approving transfers to the hospital today — causing him to duck out of the room, he doesn’t forget Gentry. When he has a quick listen, he makes sure she does, too.

“Lead the way,” he tells her at one point. “You’re the doctor.”



Psychiatry
+

In November, Franco finds herself standing before the attending physician in psychiatry at University Hospitals Case Medical Center, wanting to disagree with him. She hardly resembles the nervous third-year student she was, the one afraid to open her mouth in front of attendings. It helps that psychiatry has been one of her favorite rotations. Although it resembles the McCafferty Clinic very little — there are no cute kids getting checkups, no easy rapport with other native Spanish speakers — the inpatient psych ward is interesting and unpredictable. One minute she’s talking with a patient eating orange slices. The next she’s brushing them off her shoes.

The students
 
Millie Gentry

Hometown: Florence, Ariz.   Millie gentry
Age: 27 
Considering: Radiology
If I wasn’t going to be a doctor, I’d be a nutritionist with an empire, like Dr. Andrew Weil or Ellie Krieger.
This year I’ve learned I don’t want to live in the hospital.
The worst thing I ever said to a patient was, “You’re pregnant.”


The psych team asks her opinion on every patient. Most of the time she agrees with the attending physician, but not in the case of her most recent patient, a normally high-functioning bipolar woman. He wants her released. Is he sure, Franco asks, given the woman’s obviously speeded-up speech pattern?

Regardless of whether he ends up agreeing with her, Franco is glad she has enough confidence to challenge him. In June, she couldn’t get off her couch. She thought she was just exhausted from an incredibly tough first clinical block. It started with surgery, while she was still recovering from a strange illness that caused debilitating vertigo. Then, a surgeon pricked her hand with a scalpel in the operating room, necessitating AIDS and hepatitis tests. (Both were negative.) Throughout the rest of the 16-week clinical block, she rushed from service to service, never getting fully acclimated to any of them. When the block finally ground to a halt, so did she.

Days on the couch turned into weeks on the couch. She cried at every little thing. Her mother visited in August, and that cheered her up. But when she left, Franco cried more. She left her apartment only to get groceries. Once in a while, her boyfriend, a salsa instructor, got her to salsa night at downtown nightclub The View. She never stayed long.

Franco knew depression is common among medical students. According to a 2005New England Journal of Medicine report, “White Coat, Mood Indigo — Depression in Medical School,” medical students are more prone to depression than others their age because of the emotional and academic strain involved in becoming a doctor. They seem most at risk during the third and fourth years, when they are separated from their peers and frequently moved into new situations with unfamiliar physicians. Often these experiences include the students’ first encounters with illness and death and “may unmask psychological vulnerabilities.”

Even though student doctors can often diagnose depression in others, many don’t seek treatment themselves. Like Franco, who even hid her symptoms from her friends and family, they fear a depression diagnosis could limit career opportunities. One study showed residency directors were less likely to ask a candidate to interview if he or she had a history of counseling, theJournal pointed out.

Franco was supposed to spend the summer interviewing low-income women about the human papillomavirus vaccine. Instead, she spent it watching daytime television. In September, people at the school contacted her friends, who contacted her family.
Marleny franco
The phone tree of concern helped her snap out of her funk, as did the realization that she was risking her future. She had pursued her dream of becoming a doctor all the way from the hospital where her mother worked as a nurse in the Dominican Republic to Jamaica Plain to Brown University to medical school, and she wasn’t going to stop pursuing it in her third year. She suspects the idleness of the research block contributed to her problem, and she decided against taking time off from school. She changed the order of her coursework, first doing her electives and delaying the research block. She started seeing a counselor.

One doctor who became depressed in med school warned Franco about the psych rotation, but it’s only made her more empathetic. She’s seen so many professionals, so many “normal” people with “normal” lives. Psychiatric diseases don’t discriminate.

As if on cue, the patient Franco wants to keep in the hospital starts talking really fast, as if someone pressed the fast-forward button on a tape recorder.

Witnessing this, the attending decides Franco was right about the patient acting too manic to be released.

At the end of the rotation, he asks Franco if she’d consider becoming a psychiatrist.



Prognosis
+

When the fourth year of medical school begins in the spring, Marleny Franco still wants to be a pediatrician, though she’s not sure about the specialty. She regrets not completing her research on time, but it did give her one advantage: She took her electives, which are part of the fourth-year curriculum, early. After one in pediatric gastrointestinal medicine and one in adolescent medicine, she’s sure she wants to work with sick kids — a diverse population of sick kids.

“I want to work in the inner city,” she says. “I feel it’s my duty. If I’m not going to do it and I come from there, then who’s going to do it? And I want to do it.”

Norton and Gentry have changed their minds about the sort of doctors they’ll become.

Dr. Walsh was the toughest instructor Norton ever had. He taught Norton a lot about surgery and identified what may be Norton’s biggest problem: his compulsiveness, which Norton thinks may be a side effect of his attention deficit hyperactivity disorder.

The surgeon advised him to stop looking for a clean clinical picture, the kind Norton can always figure out on exams. Real people are more complex; they have a variety of ailments. Sometimes they don’t tell you what you need to know; sometimes they lie.

“He is bright and has a very good fund of knowledge,” Walsh wrote in his evaluation of Norton. “Overall, his performance has been quite good and he may consider a career in surgery.”

For most of his third year, Norton planned to become a surgeon. But then he took an anesthesiology elective in April. He watched an anesthesia team quickly and safely sedate a man with a life-threatening postoperative hemorrhage, so the surgeons could cut him open again. Even though the specialty isn’t as sexy as surgery — the man’s family is more likely to remember the surgeons who saved his life than the anesthesiologists who made him comfortable — Norton thinks he’ll like it.

Anesthesiology offers plenty of intellectual stimulation, and the lifestyle will afford him more time with wife, Kate; daughter, Megan, 2; and 9-month-old Robert Bryan, born during his family medicine rotation in October. Because Norton is in the Army (he joined last year), it’ll also mean less time on active duty — only three years after his residency — to pay the government back for taking on his med-school tab.

“A surgeon told me, ‘If you could be happy doing something other than surgery then surgery isn’t for you,’ ” he says. “I could be happy doing something other than surgery.”

While Gentry’s cardiology rotation at the Cleveland Clinic went well, surgery nearly broke her. During one line of questioning, she almost started crying in front of a patient. “If you told me I had to be a surgeon, I’d be a waitress,” she said afterward.

But during the surgery rotation Gentry followed a breast specialist through a women’s imaging clinic. There, she met a female radiologist who turned her on to the field. The radiologist, who studies images of the body, is a “doctor’s doctor.” She does biopsies and other procedures trying to make diagnoses, but her patient interaction isn’t draining. She works manageable hours. It’s a good profession for someone who wants to have a family.

It’s also highly competitive. Gentry will have to take the boards early to bolster her application to residency programs. Luckily, she’s already received good feedback during a radiology elective.

Gentry has enjoyed watching some of her peers change their future plans. Even if they once wanted to pursue illustrious careers in surgery or look for the cure for cancer or spend their days treating sick children in the Third World, some are choosing less personally demanding specialties, such as radiology and anesthesiology. They want to wear the long white coat, but they want to wear some other garments too: an apron, perhaps, or a jogging suit or an evening gown. They want fulfilling jobs, along with families and travel and pagers they can turn off sometimes.

After the third year, some have told Gentry they now want the same thing she has wanted since the first: a life.

“In first and second year, people would say, ‘How can you say medicine isn’t the most important thing?’ ” she says. “Now in the third year people are saying ‘You were right.’ ”


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