The Naked Truth
Joseph Corkery
THE COMMON MIND-SET among most college-aged men was that pretty much every scenario involving a naked woman was exciting. I remember wondering, somewhat anxiously, before the first few days of medical school, how this experience would necessarily change in the clinical setting. I frequently found myself contemplating how I (not to mention my then girlfriend) would react to the frequently intimate examinations of members of the opposite sex.
Our class’s first encounter with clinical nudity was in the anatomy lab. In general, the formaldehyde stench of death and the dangerously clumsy manipulation of our scalpels greatly overwhelmed any of our concerns about modesty. I remember a significant classwide loss of modesty as people began to casually change into and out of their scrubs in the hallways. In many ways, the anatomy course served as a dual rite of passage, accustoming us not only to death but to the unemotional clinical view of the human body. Within a few short weeks, we grew accustomed to viewing the naked body in a completely detached way.
It was not long after this that we learned to cast aside (without being intoxicated) our fears of and judgments about discussing sex with relative strangers. Within months, a medical history that included sexual questions such as “Do you prefer men, women, or both?” ceased to be taboo. By the end of first year, I felt reasonably confident that while wrapped in the protective garb of my white coat, I was ready to comfortably, appropriately, and with a straight face discuss sexual practices with any of the Victoria’s Secret models.
In our first year, we had mastered seeing and talking, but something even more personal remained: touching. Most of our second year was dedicated to learning how to touch a patient and how to accomplish this in the most comfortable manner for both parties. With extensive practice and the amazing generosity of my patients, I learned how to touch patients in a way that allowed me to acquire clinical information without creating an uncomfortable or inappropriate situation.
With all this experience under my belt, I felt ready to begin the “undressed” rehearsal that is the third year of medical school. I was surprised at how easy it was to interact with patients clothed only in hospital gowns. There was something strangely unique about the entire situation that made sexy lingerie strewn over a chair surprisingly normal and not out of the ordinary. Perhaps my experience was tempered by the fact that I am married and could more easily distance myself from these otherwise bizarre situations. And I noticed patients eyeing the gold ring circling my fourth finger and wondered if that might ease the situation for them. Of course, I didn’t like what that interpretation implied about possible patient perceptions of unmarried physicians, but as a result, I did find myself making sure my left hand was easily visible.
As my surgery rotation progressed, I was pleased at how it was becoming easy to view all patients in a completely asexual manner. Sadly I was not prepared for the coming experience that would shatter my “clinical goggles.”
It was another ordinary day on my plastics elective during my surgical clerkship. I reported bright and early to the operating room for a breast-augmentation case. I was definitely somewhat uncomfortable helping out with cosmetic surgery but felt some comfort in that this was a redo of a postcancer reconstruction. As I entered the OR, I found the patient lying naked and prepped on the operating table. Her breasts were exposed and soon the focus of the group’s attention. One of her implants had leaked, and now there was a mass of crumpled plastic where a smooth surface was supposed to be. The surgeons took turns examining this breast to learn the results of a failed augmentation.
The procedure went smoothly from first incision to insertion of the new implants. However, before closing the incision, the surgeons had to adjust the size of the new implants. Implants are adjusted by increasing or decreasing the amount of saline in them. To get the adjustments correct, the operating table was raised into a reclining position so that the patient (still under anesthesia) would be sitting upright. At this point, the attending, the resident, the scrub nurse, the circulator, and I found ourselves all eyeing the patient from the foot of the table, trying to decide which side was bigger. There seemed to be no good consensus, particularly because nobody could agree upon whose left we were talking about. The dispute was resolved by the resident, who cupped both breasts simultaneously and assessed their symmetry. Multiple iterations of this process occurred before the decision to close was made. I found myself surrounded by, and being drawn into, discussions of which sizings looked best and were the most visually appealing. Then someone jokingly suggested inviting the husband into the room to find out what appealed to him the most. I remember the resident expressing confusion that the patient requested not to have them significantly enlarged, only to be rebuffed by the scrub nurse with the comment, “She doesn’t want to have to buy a whole new wardrobe after this.”
It was at this point that I realized that somehow we had all lost our clinical mind-set in the examination of this woman. This was a discomforting realization, but at the same time, it seemed almost a necessity if the surgeon was to accomplish his task with the perfection to which most surgeons aspire. I see now that the ongoing challenge will be to accomplish the surgical objectives without losing respect for the patients’ bodies.
Losing Your Mind
Esther Huang
The brain is the only organ that is aware of its own dysfunction.
—My attending
“I’M SUCH A DUMB-DUMB.” The words seemed strange coming from the lips of an attractive elderly woman poised in bed with an aristocratic air and Pilates-perfect posture. Strange, but perhaps not unexpected, given that she had just been unable to spell world backward, subtract three from ninety-six, or recall the current month of the year. It was sadly striking to see her mind come so close (“Who was the president before Bush?” “Mr…. Cool …”), to hear her frustration (“Oh, I used to know!”).
“We understand this isn’t you,” the intern told her, “that this is something put upon you—we all know. You shouldn’t blame yourself.”
With an imploring smile, she asked, “Would you please tell everyone else that too?”
This woman had no warning of the fungus that spread to her brain, and could have done little to prevent it. The condition was so rare that none of her previous physicians had seen it before.
She would look over at her husband and ask, “Am I doing OK?” during the history taking. “You’re doing fine, sweetheart,” he’d say every time in his low and resonant tones. When she grew forgetful or weary, he’d fill in the rest. When he recounted poignant events, his voice would break down. He refused to let her go to the bathroom by herself, to the point of inconvenience; he didn’t want her to see how she looked in the mirror after her craniotomy—half her hair shaved, bruising around her eyes from the surgery—not when she’d always been sensitive about her appearance. Perhaps some things in which we stake our identities last longer than others. Or perhaps the loss of one makes another stand out in bolder, more beautiful relief. Perhaps in the end, the identities that last aren’t found in anything we possess at all—skills, objects, appearances, even our minds—but in the relationships we cultivate, with our loved ones and perhaps with our God. It’s good to be reminded of these things: because cultivation takes intentionality, investment, sacrifice, and some deal of courage. Courage to love and receive love. Courage to be entrusted with vulnerabilities and to reveal our own. Courage to value the journeys we make together. It’s good to be reminded, because the voice telling me to heed these things more is not the blaring one signaling an upcoming exam or a call night, nor the sirenlike lure of prestige; it is that quiet, still voice inside, ready to speak if I’m willing to listen. When I decide what to invest my identity in, what to value most in life, what to have faith in, here’s hoping I tune in to that one. Here’s hoping I remember the woman who lost her mind, only to find herself more loved by the one beside her.
Breathing, the Movie
; Joe Wright
LONG BEFORE I decided to go to medical school, I wanted to become a film director. In college, I took classes in film and video production and analysis and history. Friends often asked me whether those classes ruined movies for me; they thought that knowing the mechanisms of moviemaking would spoil the experience of escaping into the world of the film.
I knew what they meant. But I never found that I enjoyed movies less. In fact, during that time in my life I usually saw at least two movies in the theater each week. Often I would walk to a nearby movie theater and just see whatever was playing next, whether it was a B-grade Hollywood cop movie or a slow ponderous European film. A nice shot of a city, a clever twist in a genre formula, or an adventurous use of sound—all might excite me even in the midst of a totally insufferable film.
Probably any rigorous training changes the way you see the world. In the Vipassana Buddhist meditation tradition, as in many other meditative practices, one tries to simply focus on the physical fact of breathing fully in and out, as a way of living in the present. Before medical school, I took a class that taught this kind of meditation. As we sat and our minds inevitably wandered, our teacher would softly say, “Return to your breathing,” meaning to return to simply feeling your breathing moving your body as a constant, gentle physical fact. After that class, I thought about breathing in a new way: as a kind of center of daily experience, a source of calm.
Now, becoming a doctor, I also think about breathing as pushes and pulls of tissues and muscles and fluids, full of nuance. Not just air moving in and out, but the complex mechanics that move it, and the structure of the hemoglobin in a red blood cell picking up oxygen, and more than that too. And this is a new kind of awareness. It is like what I once knew about films, thinking, How’d they do that dolly shot? or Nice L-cut. I am aware not only of the breath but also of how it is made.
Just as in my film-student days, it’s not that I always understand it. In fact, at least as often, I eventually realize that I’ve got another part of it wrong again, and I have to go back and relearn it. Medical school makes me see breathing differently not only because of my new understanding, but even more, because I know there are huge worlds of things to be understood, ever-finer levels of detail to struggle with and then, finally, to know.
And so my friend’s little boy is sitting on my lap, listening to a story I’m reading him, and I feel his body moving with his breathing. Giving my friend a hug good-bye, I feel the movement of air moving in and her chest and belly pushing out, then falling back as air moves out. Ribs expanding and pulling the lungs out with them, and then the lung tissue pulling back. And in moments like this, I feel it or see it in someone else, and think about it for a second, and breathing becomes one of those sudden short moments where the filmmakers have done something beautiful and clever and I think, That’s genius, and I think, I love this movie.
Donor
Kimberly Layne Collins
You stared through the white cloth into
the other side, while your body lay
exposed on the table before us.
You, our teacher, our first patient,
would not complain through our probing
or criticize when we cut too deep
or in the wrong direction.
As we opened your chest and looked
into ourselves, what we saw mirrored
what we all feel inside but could not know
until you showed us: how fragile is our flesh,
which gives so easily beneath the scalpel:
how thin the boundary between self and world.
I knew you’d been under the knife before—
the gray scar marking where your right breast hung.
I wonder how that must have felt. I know how
your lungs sit in the recesses of your thoracic cavity
and how your bowels twist through your abdomen
because I have pulled and cut and lifted them out.
I have sliced through the muscle of your heart.
What kept it beating so many years?
Who did you love? Who loved you?
How strange it was to be able to reach inside you
when you could not reach back,
your nimble fingers stiffened into place by rigor mortis;
to pull at your limbs, without asking permission,
in order to crack your ribs;
to saw through your skull and lift out
the center of your thoughts, without knowing
what last ones still lingered.
Living With Ms. Longwood
Rajesh G. Shah
EVEN BEFORE YOU START medical school, there’s this feeling—this unwritten rule passed down from practitioner to student—that your first patient will always be a part of you, that he or she will touch your soul in a way you didn’t know possible. No matter the condition or problem the patient has—even an ingrown toenail would count—that patient will always be a part of your birth as a healer.
I knew this; I even expected it, with a certain logical fallacy that this patient was merely the first of a long line I would treat in my lifelong education as a conjurer of the medical arts. I knew this with all certainty, and therefore a part of me even wanted to challenge such a stereotypical notion of attachment and prove the entire medical establishment wrong. But I’ll be damned if the medical Gods didn’t conspire to teach me otherwise and to show me the exact reason why all doctors remember their first patient so well, and why they always cherish that memory with a certain familiar fondness.
Let me tell you about my first patient, Mrs. Longwood.
The first mention of her name came to me with the sort of wry medical wit that invariably becomes necessary to pass days filled with unending hours and ever-demanding illnesses. No disrespect is meant to the patient, and certainly you’d be hard pressed to prove otherwise, but still there is an unsaid bit of communication that becomes obvious when your resident says to you with a huge grin on her face, “Why don’t you go take care of the patient in room eleven of the ER? This will be a nice and easy one for you.”
So I did. I was expecting a hard case, but I certainly didn’t expect a simple, blank stare and nonsensical guttural sounds when I asked her name and why she was here. I paused for a minute and was dreaming up new and interesting ways of primal communication when her son entered with a fresh cup of coffee. I felt relieved to see him, knowing that my job would be easier, but this feeling was soon washed away by the obvious realization that someone who could not even communicate with me was very, very sick.
They transferred Mrs. Longwood up to an inpatient floor fairly quickly, and I pulled her son into an empty conference room to get a history as best I could. It turned out that Mrs. Longwood had a bulging right knee filled with a corrosive osteosarcoma that was slowly progressing. The pain from this was unimaginable, and as the pain became worse, the long-term facility in which she resided had increased her transdermal fentanyl patch. But they had done so too quickly in the past couple of days, and she had become delirious and began to speak in nonsensical words and point toward visual hallucinations of her adolescent children, who had long since become middle-aged. It seemed simple enough: reduce the pain medication back to her previous baseline, and wait until she regained her cognitive abilities. And for the most part, it was just that simple—at least until we began to address her other major problems, like the cancerous mass growing in her knee.
The first three days were unremarkable, as she slowly but steadily flushed the fentanyl from her system and regained her mental faculties. As this happened, though, little personality quirks came to the surface. For one, she had a severe anxiety problem. She had taken Valium several times daily for at least the past twenty years and requested what she liked to call her “happy pills” whenever I asked about her pain. This was not a problem, mind you, as we could not safely withdraw them anyway, with the danger of a withdrawal-induced seizure. Besides, since she’d taken them every day f
or twenty years, to withdraw them now would have been downright cruel.
I must admit that I felt a certain resentment toward her. In my mind, all anxiety problems were nothing more than a discreet way to obtain recreational drugs—a socially acceptable way to get “mother’s little helper” for those times when one needed to relax. It had never occurred to me that some people live with an anxiety so severe that they cannot contain it.
The irony is overwhelming—that I, someone who takes pain medication daily to deal with chronic pain from meningitis, and who constantly chastises the medical system for its fearful inhibition about prescribing pain medication to those who complain of pain, would categorize all anxiety patients as liars and socially acceptable drug abusers. But thus is the nature of prejudice: we take only those examples that validate our preconceived notions and discard any examples to the contrary. And in doing so, we prove to ourselves time and time again that our beliefs must be correct.
But in treating Mrs. Longwood on the third day, a miraculous event occurred. She asked for her “happy pills” as usual, and I ordered 0.5 mg of Ativan. Almost instantaneously, as the nurse pushed the intravenous drug into her veins, she was transformed from a blathering fool filled with nonsensical half sentences into a lucid, well-mannered, kind old lady who told enchanting tales of days gone by and carried on normal conversations just as the rest of us did.
The Soul of a Doctor Page 6
