Dear Second Years,
Welcome to clerkship, a year that taught me countless lessons, and certainly more than I am able to fit on one page. But of the many tips I have for you with my infinite MS3 wisdom (kidding!), here are my top three.
I was fortunate enough to work through the vast majority of clerkship year emotionally unscathed. For the MS3s reading this, do not recoil—I was as stretched thin and stressed as the next guy—but my cases had happy endings. The codes I witnessed in the ED were sent up to the ICU before anything devastating was observed; my patient crashing post-op survived a second, and third, return to the operating room. The year seemed to fortuitously mirror my personal life, in that all of my elder family members remain alive and well. Death had always been a foreign concept, a taboo in my superstitious household. To even discuss the theoretical (though mind you, inevitable) death of a family member is a frank insult. So my first tip is to ruin your holiday break! Think about mortality, death and dying in a real way. And hopefully you will be even marginally more prepared for what may come.
Fast forward to the end of my tenth month on the wards: inpatient oncology. My patient, let’s call him George, had stage four metastatic cholangiocarcinoma. This may be a poor reflection on my own knowledge, and for that I apologize to the PennMed administration, but I had never heard of bile duct cancer.
George was a pretty stoic gentleman, admitted for evaluation of a hepatic abscess. His care was rather straightforward for a medical student, since I met him post-drainage: touch base with ID, touch base with ID, and touch base with ID. George was also on contact precautions for C. diff, which I somehow overlooked, and subsequently hung around his room sans gown, gloves, and goggles. But that is a story for a different time.
I was pre-rounding on George on either my first or second day on the service. I asked him the usual slew of questions for review of symptoms, felt his belly, and made my way towards the door. He then, out of nowhere, blindsided me with the question every student fears: “Will I survive this?” All of the comically dramatic standardized patients in the world cannot prepare you for the whiplash of that moment. I forgot all of the words of the polished, rehearsed, perfected script that we all have performed so many times. Each OSCE, each SP session of first year, they all vanished. My apologies for the lack of a more intellectual comparison, but think of the episode in which Spongebob burns all of his memories that do not relate to being the perfect waiter, and in the process, forgets his own name. And then I committed the cardinal medical student sin. I looked him in the eyes, my own full of sheer panic, and responded, “I think so,” when I had absolutely no idea.
Later that morning, after furiously searching UpToDate about cholangiocarcinoma in advance of rounds, the gravity of my mistake hit. The 5-year survival rate is about 2%. Compounded by the fact that this was one of many bouts of infection complicating his treatment course, his prognosis appeared dismal. My team and I discussed our surprise that this far into his diagnosis and care, nobody had yet told George the reality of his fate. Or, if they had, not in a way that he understood. That afternoon, I had a discussion with George and his wife for almost an hour about the acute concern—the infection—and the bigger picture of the cancer. His wife sobbed. He quietly nodded. It took a random check-in from the medical student for them to fully grasp the nature of their situation. I would not dare to assume what that conversation meant to them, but it was easily the hardest moment of my year. I would trade fainting during a C-section (yep, it happens), time and time again, over that encounter. I left his room and cried in a restroom stall.
My time on the oncology service did not get simpler. More than a few patients passed. I dreaded checking Epic in the morning to see how the patients on our service fared overnight. I thought about death more than ever before—certainly too much. It was all-consuming. I would feel fine and distracted one moment, and cry the next. I, someone who loves sleep more than anyone I know, began to toss and turn all night. I had dreams about my grandparents dying one night, then my stepfather the next. I had to fight the urge to burden friends and family, both in medicine and not, as these weeks weighed more heavily on me than I was able to coherently verbalize. I would jump from artificial cheer, the classic “well we only live once so let’s do something special today!” to inexplicable sadness, in a matter of minutes. And that brings me to tip number two: lean on virtually anyone willing to prop you upright this year, no matter how annoying you (mistakenly) feel—your partners, your families, your friends, your co-med students, or a professional counselor. It is exponentially harder to push through on your own.
That being said, what happened near the end of the solid oncology rotation disturbed me even more. I called my parents on a particularly difficult afternoon. “It will get easier each time,” my mother advised. I scoffed and told myself she did not understand how difficult the rotation was on me. But as short as the rotation seemed, in an alarmingly quick turn of events, I stopped crying for my patients. My friends reading this reflection probably smirked at the mention of me crying earlier. I cry at the drop of a hat. I cry at television, at books, at a mildly disapproving statement from a loved one. Death became expected, routine.
I often think about one morning in particular, with substantial guilt. I woke up at 5:45, rolled over to check my phone and groaned. A patient of mine had passed overnight. And rather than weep for him, my grief for him was managed with one exasperated sigh. His entire existence was processed in seconds. Then I got up to brush my teeth.
I wish I had a wise conclusion for you, MS1s and MS2s. Even so early in my career, I feel I have lost a small piece of myself, and I have no idea of the solution. We cannot mourn each life lost with the time and respect each one deserves without losing the majority of the work day and in turn jeopardizing the care of our new patients. But I cannot continue to coast on emotional repression without feeling as though I lost a bit of my humanity. I am still looking for that balance as I move on to electives, sub-Is, and frighteningly soon, my career as an actual physician.
With my story, I hope to normalize this particularly difficult aspect of the clerkship experience for some of you. We don’t talk about it. We don’t know how to talk about it! I will close with tip number three, a cliché for a reason: it is our true privilege to be a part of, and learn to reflect on, the lives of others. I look forward to continuing to learn to navigate and communicate this balance between remembrance and resilience. Best of luck this year!
Danielle Zamalin is an MS3 at the Perelman School of Medicine.
