A crisp, fall Sunday in Philadelphia could only mean one thing: game day. I sat perched on the air mattress that occupied my living room (in lieu of a couch, obviously, because I was a medical student living like a frat brother), can of watery beer in hand, eye on the game. My high school buddies sat scattered on various surfaces throughout my unfurnished apartment—in my beanbags, on my chairs that lacked a table, and on the floor—drinking and chatting and switching between channels. Most of us had gravitated out of state for college, but by some force or another we found ourselves back in Philly after graduation, an unexpected blessing as I navigated the discomfort and unfamiliarity of starting school during the pandemic. No need to introduce myself with my name and my fun fact with this crowd. The only thing on my mind right then was the fate of my fantasy football team. (I won my league last year. The question was, could I do it again?)
As I checked the updated status of my in-play roster, my buddy Sam posed a question to the group. “Anyone know what side your liver’s on?”
Well, that caught my attention. There were certain topics of conversation I had come to expect when hanging out with my high school friends—discussions of new music, sharing dumb stuff we saw on Twitter, bemoaning the Eagles’ terrible season, and of course talking trash about people we knew from high school. But a question about the sidedness of the liver was a little out of the ordinary. Conveniently, we had just covered the para-alimentary tract in Anatomy the week before, so in theory I knew a thing or two about the liver. Okay, well, innervation was a little fuzzy, and blood supply was a lost cause (was it celiac trunk to common hepatic to proper hepatic?). But forget the details. During radiology small groups, as we scrolled endlessly through scans that looked like Rorschach tests of grey blobs and loops and sadness, the liver was my trusty landmark. That broad, familiar, right-sided expanse presided over the abdomen and anchored me within the anatomical clutter. You could tell me a kidney was the bladder on CT and I’d probably agree with you. But the liver? The liver I knew.
I added “medical student” back to my list of currently occupied identities, alongside “bandwagon Eagles fan,” “beer-drinker,” and “air mattress inhabitant.” The liver is mostly on the right, I told Sam. “Why?”
“Well, my right side kinda hurts. I’m thinking maybe it’s my liver.”
I sat up taller, perceptibly, the air mattress shifting lazily to accommodate the change. Memories of OLDCARTS and our last standardized patient session rattled around in my brain. Was this… a chief complaint? I took a millisecond to gather myself, giddy at the prospect of practicing my budding clinical skills in a setting that wasn’t virtual, that didn’t involve me sweating over Bluejeans, that didn’t require my enthusiastic yet clearly forced Hi, my name is Julia, I’m a medical student here to ask you a few questions. But first, how would you like to be addressed? This was Sam. What’s up, homie, you’ve known me since we were eleven. I bummed rides off you in high school. We went on senior week together, to Spain, to China. You are currently sitting on my floor because I have no furniture.
“Okay, got it. And how would you describe the pain?” Onscreen, one of the teams was running a two-point conversion but I couldn’t care less. My beer sat forgotten on the floor. My only focus was passing off my shiny new clinical skills in casual conversation without getting caught. Here was an opportunity to test my potential as a clinician in real-life and real-time, beyond the preclinical bubble of esoteric structures on endless flashcards. Here was a patient, and here was someone—me!—who could maybe help. After a month and a half of med school, this was my first real test. I was determined not to let the moment pass me by.
Sam tells me that the pain is dull, non-specific. He’s had it for a few hours. He took a few Advil and it went away, but he hasn’t noticed anything that made it worse. I ran through my mental list. Ugh, what’s “T” in OLDCARTS? I couldn’t remember, so I hopped to a different line of questioning. Had he ever gotten his appendix taken out? No. Okay, there’s an idea. Had he ever felt a pain like this before? Yeah, he said. This morning, when the pain started. Okay, unhelpful, but thanks. I did a review of systems, from head to toe like they taught us, but there was nothing else of note in the interview. No headaches, no fever, no chills. No respiratory symptoms. No other pain. I racked my brain for anything else that could cause right-upper quadrant pain. Uh… gallbladder? Jaundice? Sam’s eyes didn’t look particularly yellow on my glance across the room so I crossed it off the list. The gears in my head were practically audible as they turned, cranking through anything useful I’d picked up in my first six weeks of medical school that could help me crack the case. Unfortunately, it seemed I’d exhausted my diagnostic acumen.
Disappointed, I decided to stop the interview after the history of present illness. My roommate had made nachos and I was losing Sam’s attention anyway.
I sank back into the air mattress, deflated and embarrassed, waiting for someone to call out my failure to construct any sort of a diagnosis for Sam’s pain. But, of course, that didn’t happen. Life in my living room went on as normal. Someone ran something somewhere on the screen and my friends cheered; it was as if my failed fact-finding mission had never happened. And, to them, it hadn’t. Realizing that, perhaps this moment wasn’t as significant as I imagined, I tuned back into the room. Moments later, I was no longer the baby doctor-in-training with no real clinical skills, desperate to prove myself but lacking the tools and knowledge to do so. Instead, I was the bandwagon Eagles fan surrounded by friends who had known me long before I could put “M.D. Candidate” in my email signature, before I knew the connection between jaundice and the gallbladder, and before I saw interpersonal communication as a skill to be mastered rather than a foundational feature of my closest friendships.
So, yeah, I couldn’t make a differential. There would be other vague aches and pains, discussed casually over football, for me to ponder as I progressed through the many stages of my medical training. For now, I was content to watch the Eagles lose and to remind myself that I have been someone for far longer than I have been a medical student. Sam’s right-upper quadrant pain, as mysterious as it may have been, was not yet mine to solve.
Julia Gasior is an MS1 at the Perelman School of Medicine.
