Its summer, and in hospitals throughout America were celebrating Medical New Year. Med students are graduating. Residents are finishing their training. In July, newly minted interns will sign MD after their names as they pick up their hospital beepers.
Another transition is taking place during Medical New Year. With less fanfare, second-year students are morphing into third-year clinical clerks. Theyve spent two years plowing through classes in anatomy, physiology, genetics and pathology. Now, at last, theyre making the leap to the wards.
Theyve been preparing themselves for months. Theyve practiced examining one another. Theyve worked with simulated patients from whom they extract simulated histories. Still, theyre nervous, wondering whether theyll know what to do when the patients are real. Will they actually hear the heart murmurs? Will they be able to draw blood? And will they actually be able to talk to people about sex and exercise, bowel movements and death?
Twenty-eight years ago I was a new third-year student, and I reported as instructed to a Boston hospital ward where I picked up my first patient. He was a 30-ish-year-old man, DU.
DU was short of breath and his chest X-ray showed pneumonia. When I admitted him, DU told me that he was a gay IV drug user. His private doctor, he said gamely, was worried that he might have AIDS.
It took a couple days to diagnose him, but his private doctor was right. He had pneumocystis pneumonia, which meant he had AIDS. When my resident and I told him his diagnosis, DU looked scared.
After diagnosis, DU got sicker fast. He asked me to call his family, from whom he was estranged. His parents and a brother came. They sat quietly at his bedside, struggling to assimilate his life and his illness.
Predictably for that time, we failed to fix DU. He died after a week in the intensive care unit. Afterward, his family thanked everyone for taking care of him. Then they took his bag of clothes and went home.
My resident sent me home too.
Get out of here, she said kindly after wed filled out the death paperwork.
I hesitated to leave. It felt wimpy. Surely, I thought, people die here every day. We cant all leave work every time someone dies.
Im OK, I told her. I can stay.
No, youre not, she answered. Go home. Youll get more used to this eventually.
So I went home. What did I do there? I cant remember now. Probably, I wandered around my apartment wondering what Id gotten myself into. The next day, I came back to work, and picked up a new patient.
Not every student remembers every detail of his or her first patient. And not everybody remembers his or her first death either. I suspect that the combination first patient, first death burned DU into my mind. I think of him now each Medical New Year as the new students show up. Are we preparing them for what will come, I wonder? Can we even begin to prepare them?
This year, as I wrote about him, I was struck by the words I used in telling DUs story. I picked him up. That was what we said then about the patients under our care. We picked up individual patients as we met them in the emergency room
Then we carried them until discharge. As junior students we carried four or five patients. The interns were more efficient and carried 10 or 15.
At the time that I picked up DU, I didnt notice these word choices. Picking patients up and carrying them were just the background vocabulary of my new job. I learned this language unconsciously. The words I studied were the medical words, like jejunostomy or cholelithiasis. Those were the kinds of words that seemed important and new. Those were the words that wed practiced in preparation for the wards. In retrospect, though, it was the simple words that were the keys to the inner world of doctoring. Words like pick up and carry spoke simply and eloquently of the weight of being responsible for other peoples lives.
In reflecting on DU, I realized that what our doctor language didnt include were words for leaving patients. We did it, of course, as we rotated from specialty to specialty, but we didnt have language for it.
For the students, I think, this absence should be another clue to the world that they are entering. What I know now, but didnt know then is this: we dont need a word for leaving patients. Once we pick them up, we carry our patients forever.