Beginner’s Mind

I paced in the hallway outside of the patient’s room, going over my mental checklist of items to do during the history and physical examination. Bringing in a paper list was discouraged; we were meant to “flow” through the exam “naturally.”

I stuffed my hands into the pockets of the white coat I’d received three weeks earlier, during the White Coat Ceremony for first-year medical students. Feeling around the deep pockets to make sure that I had everything I needed, I felt my left hand graze a cold metal reflex hammer with a sharp tip, used to test for nerve damage in the feet of diabetic patients. (Alternatively, it could be used as “a medieval torture device,” my mother had said the previous weekend, as I’d practiced my exam on her.) In my right pocket, I felt my tuning fork, blood-pressure cuff and ophthalmoscope.

Around my neck hung my bright red stethoscope. When I was ordering it, its color had felt “fun”; now it seemed only to highlight the discrepancy between the medical status that it conferred and my utter lack of medical knowledge. The day before, an old friend had texted to ask about a weird leg pain she was having, and had we learned about that yet? “I don’t know about the leg pain,” I’d replied, “but do you want to hear about how mitochondria are the powerhouse of the cell?”

Unable to think of another way to delay the exam, I lurched into the patient’s room.

“Ms. Stanton?” I asked.

“Yes?” said a tiny voice. Before me was a diminutive woman about seventy years old, sitting in a chair next to the hospital bed, wrapped in blankets up to her neck. Her head protruded from the top like a bird’s from a nest. Just one look told me that she was ill. Her cheeks sunk in deeply under her cheekbones, and her arteries bulged beneath the paper-thin flesh across her temples.

“Hi, I’m Jessie Stuart!” I stammered. “I’m a first-year medical student, and I’ll be interviewing and examining you today.” Sticking out my hand, I realized that I’d forgotten item number one on my checklist: “Wash your hands with the hand sanitizer dispenser outside the room.”

“Sorry, one moment,” I sputtered, snatching back my hand. I scanned the room and located another dispenser by the sink behind me. Turning around, I pumped a few dollops into my hand, then turned back to the woman for a second attempt at item number two: “Introduce yourself and shake the patient’s hand.”

Suddenly I realized that my hand was full of sweet-smelling pink soap rather than clear sanitizer. I spun around to the sink again, rinsed my hands, grabbed some paper towels, and surely the whole thing must have taken about thirty minutes, the patient undoubtedly staring at my bright red stethoscope all the while.

Finally, I reached out my hand, now pale and slightly damp, and she slowly pulled hers from the mess of blankets. Her hand was thin and very cold.

“Tell me about what brought you to the hospital,” I said. We’re taught that open-ended questions like these allow patients to tell their story, rather than reciting a limited store of facts. Shockingly, it worked: This woman whom I’d just met began to share her story.

“Well, I came in for surgery to have a fistula placed,” she said, her voice soft and smooth. “There was some sort of complication, I’m not sure exactly what. Anyway, I’ve been here for two weeks now, while they give me antibiotics and keep an eye on me.”

The term “fistula” sounded familiar, and I realized that I’d read about it in Abraham Verghese’s book Cutting for Stone. I knew what she was talking about!

Excitement was replaced by terror as I remembered that a fistula was some sort of wound in the vagina, and–oh dear–would this mean that I would have to examine her down there? I’d already been dreading listening to her heart sounds, what with those breasts in the way, but now the thought of doing a vaginal exam made me want to retract my head into my white coat, like a medical-student turtle.

Looking down at Ms. Stanton, I couldn’t think of anything to say except “I’m so sorry.”

We’re taught not to say that, because it imposes our own interpretation of events on the patient, who might be feeling gratitude or relief over the hospitalization. Ms. Stanton’s eyes welled with tears.

“Thank you,” she said. “You’re the first person to say that. You might not know it from looking at me, but I was very healthy a month ago.”

She went on to describe how she’d spend her days when caring for her young grandson, Joe: “Every morning I go over to my son’s place and wake up Joe. I make him his favorite breakfast, waffles, then I bring him to day care. Day care ends at two, so I drive him to my house to play until his dad gets home from work. But some nights Joe falls asleep before his dad gets there, so he’ll just sleep in my bed. I don’t mind: I keep extra clothes and toys and waffles at my house.”

She paused, her eyes brimming with tears. “They tell me I have to go to dialysis three times a week, and that it takes up half the day. My son says he can take Joe to day care on those days, but I don’t believe him–I know his boss is strict. Since I’ve been in the hospital, he’s been using sick days to visit me and care for Joe, but….” She looked down. “I’m so scared he’s going to lose his job again, because of me.”

I tried to think of responses, of empathic statements, but everything sounded hopelessly trite. Out of bewilderment and sadness, I just listened.

After a while, one of the course coordinators came by. “Time’s up,” she said.

I had not done a single component of the physical exam. I thought about all those unchecked boxes on the list, which included tasks like, “Place the vibrating tuning fork in the center of the patient’s forehead and elicit where the patient hears it the loudest.”

“Thank you for coming by,” Ms. Stanton said simply.

I felt drained and overwhelmed–by everything I hadn’t done and didn’t know, by the injustice of her illness, and most of all by the experience of being thrust so suddenly into the intimacy of this stranger’s life.

With my classmates, I went to the debriefing session.

“Any questions?” the instructor asked.

I raised my hand. “I learned about how horrible fistulas are in Cutting for Stone, so why would someone wantto undergo surgery to create one?”

The instructor gave me a patient smile. “A fistula is a general medical term for any abnormal connection. In the book, it’s between the vagina and rectum. But it sounds like your patient was having an arteriovenous fistula placed, so that she can undergo dialysis.”

I began to realize that the first year of medical school means not knowing more than knowing.

It means having one foot in the nonmedical world and the other in the privileged sphere of white coats and stethoscopes.

And it means saying “I’m sorry,” even though you’re not supposed to–because you really mean it.
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