"Into the water--the clinical clerkships"

Another NEJM essay that puts words to the surreal experience of the third year of medical school:

"There's nothing particularly natural about the hospital — ever-lit hallways, the cacophony of overhead pages, near-constant beeps and buzzes, the stale smell of hospital linens. This unnaturalness was strikingly apparent to me when I arrived as a third-year medical student — freshly shaven, nervous, absorbent — for the first day of my surgical clerkship.

As I joined my team, my resident was describing a recent patient: “He arrived with a little twinge of abdominal pain . . . and he left with a CABG, cecectomy, and two chest tubes!” This remark was apparently funny, as I surmised from the ensuing laughter. And the resident sharing the anecdote — slouched in his chair, legs crossed and coffee in hand — seemed oddly . . . comfortable.

As the year — known at Harvard Medical School as the Principal Clinical Experience — proceeded, the blare of announcements dulled to a low roar, the beeps and buzzes seemed increasingly distant, and the stale smell of hospital linens became all too familiar. Occasionally, however, there were moments that evoked a twinge of my old discomfort, some inchoate sense that what had just transpired mattered more deeply than I recognized at the time. These moments were often lost amidst morning vital signs, our next admission, or the differential diagnosis for chest pain.

At the end of the year, we were asked to reflect, in writing, on our first year in the hospital. What eventually filled my computer screen had nothing to do with vital signs or chest pain.
I began to write, “I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently' because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips. I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.' I have said nothing about that incident. I have delivered a baby. Alone. I have sawed off a man's leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night. I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

In a 2005 commencement address, the writer David Foster Wallace told the story of two young fish swimming along.1 An older fish swimming by greets them, “Morning, boys. How's the water?” As the young fish swim on, one looks at the other and says, “What the hell is water?”

The third year of medical school is like being thrown head first into water. Although the impact is jarring, eventually the experience becomes natural. We become comfortable — legs-crossed, slouched-in-a-chair, coffee-in-hand kind of comfortable. Occasional moments, however, remind us that we are immersed in water. If we focus on them closely, we see that our lives are filled with these moments. The challenge is to collect them in a meaningful way — to spend time with them, wrestle with them, allow the discomfort they generate to sit inside us.