Am I reading prophecies into undirected tea leaves,
stringing together mythical creatures from an unconstellated sky,
composing poetry of indiscriminate rhymes?
Then so be it.
What is a soul’s chief work in this life but to make meaning of its substrates,
no matter how haphazard their arrangement,
no matter how stray and unsystematic its loves?
Names and identifying details have been changed to protect patient privacy.
Why pediatrics? is a difficult question for me to answer. It is difficult not because my decision is cursory, my reasons underdeveloped, or my commitment incomplete. Rather, it is difficult because I never truly considered any other field of medicine. I can no more easily picture myself as a non-pediatric physician than I can as a politician or a Power Ranger. Entering medical school, I had no doubts about my specialty choice, but had I, they would have dissolved the day I met Ava.
It was the first week of my pediatrics clerkship. It was also the first week of the year, peak RSV season. By week’s end, the bronchiolitis workflow had become second nature: Get ED sign-out. Auscultate lungs. Titrate oxygen. Pend orders. Staff patient. Start hospital course. Write note.
When I followed the intern into room 324 to evaluate Ava, I expected to find “a previously healthy 9-month-old female presenting with URI and increased work of breathing.” What I found was a sickly infant, too feeble to sit up or cry louder than a whimper. Standard-issue hospital footie jammies, sized for a 6-month-old, swallowed her up. Her head was too large for her body, and her eyes too large for her head. They seized my affection and my attention; they told me, in the words of Madeline’s Miss Clavel, “Something is not right.”
They also brought to mind a second voice, that of a former mentor; this one said, “Once a year or so, you’ll admit yet another case of bronchiolitis. This baby will indeed have RSV. But she’ll also have a primary immunodeficiency, or an undiagnosed metabolic syndrome, or tell-tale signs of child abuse. Don’t miss this; don’t bury the lead under RSV. This will be your chance to intervene.”
In this case, intervention would not be easy. Ava’s family was devoutly religious. Favoring naturopathy and prayer over modern medicine, her parents had deferred regular check-ups and declined routine immunizations for their eight children. Now pained to watch Ava struggle for air, they reluctantly accepted hospital admission and supportive treatments for RSV.
Back in the workroom, I pulled up Ava’s growth chart. It was sparsely populated, last updated at two months of age. I plotted the day’s metrics. Her length teetered precariously on the second percentile, and her weight dangled far below, in desolate, uncharted terrain. I handed the growth chart to the intern. He walked up to the whiteboard, where we had listed: “Ava | Rm. 324 | RSV.” He added a comma, then “FTT.” In Ava’s case, RSV bronchiolitis was mere decoy; her failure to thrive was the true headline. An extensive workup revealed severe upper airway obstruction, which had been impeding respiration during feeding. Following surgery to open her airway, Ava’s growth took off; she began to thrive.
When I stopped by the room to say goodbye before her discharge, Ava was sitting independently for the first time. She was also smiling. Her cheeks were now plump; her eyes, still big, now bright. Her mother thanked the team profusely. With newfound trust in the medical system to care for her daughter, she had scheduled an appointment with a primary care pediatrician to follow Ava and catch her up on vaccines.
Of course, home runs like this are not commonplace in medicine. But when we are privileged to be players on the field when they occur, we must allow them to revitalize what has become routine and redouble efforts where they have fallen short.
The supreme joy of helping a sick child come to life: this is my why pediatrics. True, I have other reasons; I could go on about the fascinating developmental and disease processes, the research and fellowship and subspecialty opportunities, the high job satisfaction and low burnout rates, how I have found pediatricians to be “my people.” But these are subtitles, bylines. Kids are the headline. Let’s not bury the lead.
[When you’ve resolved to write and post something at least once a month but the last day of a short month sneaks up on you right when board studying has you feeling like your mind is going everywhere and getting nowhere, and then you come across a poem you wrote for an assignment in 8th grade and realize that maybe nowhere and everywhere is not all that bad of a place to be, but you also have way too many practice questions left to review so you decide to just recycle that old poem and let it count as your monthly writing and call it good.]
Nowhere and Everywhere
I pull myself up
and swing my leg
over her broad back
while she stands still and calm.
I run my fingers
through her pearly mane.
She lets out a deep sigh,
then returns to her hay.
I lay back and rest
my head on her rump.
I take in a deep breath
of sweet afternoon air.
Fluffy cotton ball clouds
in the vast blue sky.
I dream I can float on one.
I close my eyes;
every thought and worry
drains from my mind.
My head is light, my heart heavy.
A pony is no longer beneath me;
air is no longer above me.
I am nowhere and
And for those moments
— those few brief moments —
I am at peace,
and the world is perfect.
A former math colleague once told me of his divinity school experience: “It’s a strange thing, but sometimes graduate programs teach you just enough to make you dangerous. Know what I mean?”
“You do realize you’re talking to a half-M.D., right?”
My first day on hospital service, as I loitered in the hallway waiting for the medicine team to assemble for rounds, I watched a hospital aide wheel past a stretcher carrying a maroon body bag. He reached the service elevator at the end of the hallway, pressed the “Down” button, and whipped out his iPhone to pass the seconds-long wait. Was he checking his stocks? his Facebook feed? a text from his wife reminding him it was his day to pick up the kids from daycare? Apparently even the escort of a corpse can become so routine that contemplation of the present, solemn moment is no match against the dopamine hit of technological divergence.
Seconds later, my attending physician rounded the corner and assembled the team for our pre-round huddle. He reviewed the gameplan for the day, then issued his version of One, Two, Three, Break!: “Let’s keep everyone alive today. Go team!”
“Too late,” the intern replied. “We’re already starting in the red; that was Mrs. X they just wheeled past.”
The primary function of a third-year medical student on an inpatient medicine team:
Just substitute with the following: “Senior resident, the intern would like me to tell you that the social worker told him that the fellow was told by the charge nurse that the attending is looking for you.”
The needs of the patient come first.
This, the fundamental theorem of the Mayo Clinic, is to guide every decision we make and every action we take. Theoretically, everything we do should be done in service to the patient, in alignment with his or her best interest. However, it seems that the emphasis we place on upholding a façade of professionalism can interfere with true service to the patient. When I am alone in a room with just my patient, it should be as raw and real an encounter as one can achieve. This is the kind of human connection that drew most young physicians including myself into medicine. But instead, my experience is more often one of me, my patient, and Mother Mayo. The institution has such a presence that it seems to be an entity of its own standing between us. Don’t say the wrong thing. Don’t be unprofessional. Don’t let on that you have absolutely no clue what you are doing, it whispers in my ear.
One morning on my pediatric outpatient rotation, I saw a preschool-aged boy with an inflamed cheek and lip, plus some nausea for good measure. (Why do kids throw up no matter what kind of sick they are?) His mother had taken his temperature the day before but had not taken it that morning and wondered what it was. Apparently the nurse failed to take it along with the rest of his vitals. As they were wrapping up the encounter, the mother asked the doctor if she could quickly take his temperature. She responded, “Well, I can’t, but I can put in an order for the nurse and the nurse can take his temperature.” The mother looked perplexed but dismissive; not wanting to inconvenience the doctor, she said, “Oh, that’s okay.…”
I stood by, dumbfounded. It takes all of ten seconds to take a kid’s temperature with an automatic ear thermometer. Did the pediatrician feel this to be below her pay grade? Would insurance not have been properly billed for the temperature-taking if the nurse had not filled an official order and itemized the charge? Did it really matter? We had become so hung up on professionalism and institutional protocol that the needs of the patient had slipped to second place, and I was embarrassed to be part of this exchange.
Sometimes we have to choose between so-called professionalism and our patients. When this is the case, we should choose the patient. After all, it is the needs of the patient – not of the professional, not of the practice, not even of the profession, but those of the patient – that come first.
“Get ready,” they said, “Going to medical school is like trying to drink from a fire hydrant.”
I drank and I drank and I drank. If a fire hydrant it was, it achieved its aim: it extinguished any and every flame. But it doused so fast that it left me to question: was a passion ever ablaze?
Upon return to the firehouse, the Dalmatian received his reward, a bone for a job well done. He delighted in his prize for the full extent of its three-minute lifespan. Then, trophy-less, he was left to wonder: did he like his job — the fire runs themselves — or just the bones? Though he started down this path of introspection, he could not ponder for long. He was soon interrupted; the fire bell rang. It was off to the next house call, off to put out the next flame.
My dad was a PhD/MD. Bucking convention, he always listed the PhD first because 1) he earned it first chronologically and 2) more importantly, he considered it the more valuable and meaningful degree of the two. During college, I wavered with regard to the graduate track I should take. I considered pursuing a PhD in genetics but ultimately decided I needed the human component, and particularly the pediatric connection, that a career in medicine could offer. My dad advised that this decision would have ramifications on my college course selection. If I were to go the PhD route, I should choose the more challenging courses that fostered intellectual depth and rigor, including some graduate-level courses in biology and mathematics, even if that meant coming out with a few Bs. If, on the other hand, I wanted to apply to medical school, I should focus more on protecting my GPA than on the rigor of my course load. Medical schools, he said, were more concerned with a candidate’s stats than their pursuit of a rich academic life.
During the application process, I witnessed these assessments borne out. In one of my interviews at Mayo, I was asked why I got a letter of recommendation from a professor in whose class I had received a B. The question caught me off guard, as I had a wonderful relationship with the recommender, both academically and personally, and knew it would be a glowing review. It was also a hard class, and I worked hard for that B, and I wasn’t ashamed to say so. But I would later learn that nearly every pre-med advisor and website advises applicants to select their recommenders first on the basis of the grade awarded (i.e., only As), and second on the rapport with that professor. To many applicants and admissions faculty, the medical school admissions process is a game of strategy, and the way to optimize one’s chances of success is to forego challenge and nuance in favor of certainty and conformity.
Perhaps the greatest difficulty and, frankly, disappointment I have faced in medical school has been the enormous emphasis on memorization and the relative paucity of creativity and critical thinking. The culture of medical education breeds a strategic, surface-rational approach to learning. External motivators (namely performance on board exams) are king, and time pressures force us to deploy techniques to maximize scores at the expense of understanding broad principles and assimilating disparate ideas. This multiple-choice madness is deeply unsatisfying.
Coming from a math background, where memorization is not only unnecessary but actively disparaged as a poor proxy for true learning, this has been a more difficult adjustment than I expected. I struggle to convince myself that memorizing things like immunization schedules and cancer screening guidelines, which, thanks to the wonders of smart phones, are literally in my pocket at all times, is worthwhile, especially when there are more interesting puzzles to ponder and more pressing patient pains to attend to.
But I still have to pass board exams. And so to convince myself that it is worth hours, days, and months of my life to cram all these terms and facts in my brain, I think back to third grade, when we spent weeks memorizing multiplication tables. This rote memorization was painful, but without a basic level of familiarity with fundamental mathematical facts, higher-level problem solving would not be feasible.
I am in elementary school, I keep telling myself, memorizing my multiplication tables. Once I have this vocabulary down and these basic facts mastered, once they are as easily produced as 3×7, then I will be able to move on to the higher-order thinking I crave. I hope I am telling myself the truth.
Ergo: Something, at some point, has got to give.
Perhaps, despite centuries of attempts to distance itself from sorcery, to shore itself up as a hard, evidence-based science, the practice of medicine is not entirely unlike magic after all. Perhaps in this amphitheater, too, it is only the audience, ignorant of the painstaking hours of rehearsal, unlearned of the crude gadgetry, unaware of the incompleteness of the maestro’s expertise, undisturbed by that remote chance of showtime catastrophe, who yet has eyes for its mystery, who can witness healing and linger long enough in the afterglow of life salvaged and death revoked to catch the glimmer of enchantment and wonder. The magician is spoiled for the magic.
An adaptation of Rafael Cardinal Merry del Val’s “Litany of Humility,” to be repeated every day of third year, and twice on the days I work on my application for residency, and every day of my medical training and practice thereafter: