MB Civic

Harvard Medical students share stories that brought them joy and pain on their way to becoming doctors.

Jerome Groopman  |  June 18, 2006  |  The Boston Globe Sunday Magazine

Physicians occupy a unique perch. They witness life’s great mysteries: the miraculous moment of birth; the perplexing exit of death; and the struggle to find meaning in suffering. An immediate intimacy occurs between doctor and patient. There is no corner of the human character that cannot be entered and explored. A physician’s experience goes far beyond the clinical, because a person is never merely a disease, a disorder of biology. Rather, each interaction between a doctor and a patient is a story. –

The 12-Hour Child

She was lying on the hospital bed in a small, curtained room in the preop area of the OR; she looked tired and wan. It was 7 o’clock at night, and she had been at the hospital all day. Her eyes were wet; she was quiet. Her two hands rested on the curve of her lower abdomen. Karen had arrived at the hospital that morning. She had tried for many years to get pregnant, and now, at the age of 38, after one miscarriage and three cycles of hormone therapy and intrauterine insemination, she was 15 weeks pregnant with her first child. So when she noticed some bleeding, she took it upon herself to go to the hospital, to make sure everything was still OK.

Her physical exam was, for the most part, normal. Perhaps her abdomen was slightly larger than would be expected in a 15-week pregnancy, but not alarmingly so. She had no pain, the bleeding had stopped, and she felt fine, if a bit nervous. The ultrasound revealed a healthy fetus in her uterus – the right size, the right shape, the right position.

However, there was something else. On the left side of her abdomen, somewhere outside the uterus but very close to it, the imaging revealed a round shape with a different echoic pattern than the surrounding area. It was fixed and painless. We ordered an MRI. There was the pregnant uterus, with the fetal soft-tissue structures inside, curled up in a tight little ball. There was also a large mass in the patient’s left lower quadrant, definitely outside the uterus but not really part of the bowels, either. Funny, it looked just like the mass inside the uterus.

Then it dawned on me: I wasn’t looking at a peritoneal or adnexal tumor, but at another fetus that was growing in the woman’s abdomen. A follow-up ultrasound confirmed it: Karen had a viable heterotopic pregnancy. She had twins, one growing in her uterus, the other in her abdomen, both alive and well at 15 weeks’ gestation.

Heterotopic pregnancies are rare, but intra-abdominal ones are one of the rarer subtypes. And with the pregnancy at 15 weeks, and viable, there wasn’t much literature that could help us decide what to do next. I found isolated case reports from Africa and Asia, featuring termination before week 11 and healthy delivery after week 34, but there was nothing comparable to our situation.

I wasn’t there when the senior resident told Karen the news. But I imagine it must have been difficult for her, finding out that she had not one but two babies and then realizing that she had little choice but to terminate one of them. How does a mother come to terms with that? I could only hope that she took some solace in knowing that the intra-abdominal fetus was a real threat to her health and that if she were to continue to carry it, she risked losing not only both babies but her own life. Thankfully, she chose surgery.

The intra-abdominal fetus, so fragile in its little sac at 15 weeks’ gestation, was removed along with the attached placenta, with moderate but controlled blood loss. You could see all the little features – the hands and fingers, the arms and legs, the big head.

After the procedure, I went to see Karen in the recovery unit. I wanted to ask her how she felt, what she was thinking, whether she desired some company. In the end, I didn’t have to say anything. “It’s just a miscarriage,” she said. “I’ll be fine.” As she smiled, her hands drifted to her abdomen, right hand cradling the healthy child still growing in her uterus, left hand resting on the spot where a child had been, a child that for her had existed for only 12 hours. – Dr. Wai-Kit Lo

An Emotional War on the Wards

Although medical school can be hard work at times, the most memorable learning experience of my first year occurred when I was a completely passive observer. I had approached a medical school professor about the possibility of my shadowing doctors specializing in palliative care. At the time, I did not know much about end-of-life care, but I had an innate conviction that it was important. As a first-year student, I was both grateful and surprised that the specialist and her fellow actually indulged my request. A few weeks later, I was on rounds with the fellow and an oncologist in one of the local teaching hospitals.

I followed them, both young doctors just shy of 40, into a hospital room. We greeted the female patient and her husband from the foot of her bed, and the doctors sat down next to the patient. I assumed an inconspicuous position in the corner of the room. Sitting up in her bed, the patient was engrossed in a coloring book, using a large set of crayons. None of this behavior would I have found peculiar, if it were not for the fact that she was between 30 and 40 years old.

I knew that her husband was an officer with the US Marine Corps. I knew that the couple had two children. I knew she was suffering from cervical cancer, which had already spread to other parts of her body. And I knew that this Marine and his wife were possibly about to hear the worst news of their lives – that her kidneys were only 25 percent functional and that chemotherapy was no longer a viable option.

What I did not know was how the young oncologist would break the news to the couple with clarity and compassion. As I watched her gather her thoughts, it occurred to me that she, too, was probably at a loss for the proper words. I could sense her uncertainty as she took a deep breath. The husband focused his laser-beam stare at the two doctors as the oncologist carefully began describing the extent of his wife’s renal failure. Despite the literally life-and-death importance of the news, the patient herself looked neither at her angst-ridden husband nor at the uncomfortable doctors; instead, she continued to focus on her coloring book.

The lack of eye contact in the room abruptly ended, however, as the husband’s previously silent anxiety materialized into vocal anger. Both doctors turned their heads and met the Marine’s intense gaze as he began to yell out a series of questions. Why had no one in the hospital noted his wife’s kidney status before it became too late? Wasn’t this hospital supposedly one of the best in the nation? Had there not been a team of doctors responsible for monitoring his wife’s care around the clock? Why could they not cure her?

The palliative-care fellow gave the questions her best shot. Looking directly at the Marine, she began to explain how doctors had tried their best to monitor his wife’s kidneys but that unexpected events sometimes occur in the course of cancers. The best that the doctors could offer at this point, she continued, was to lay out all the available options so that they could make the best-informed and most appropriate decision about how to spend the time the wife had left. Before I could see the Marine’s response, the patient herself interrupted and spoke for the first time since we had greeted her. Without looking up from her coloring book, she calmly explained that her situation was a complete misunderstanding. She was not terminally ill. She could not be terminally ill, she reasoned, because her husband was scheduled to go to Afghanistan in a few weeks to fight the Taliban. Someone would need to take care of their two children at home while he was away indefinitely. Being terminally ill was, therefore, not an option. The only option was to get better, and as far as she was concerned, the discussion of end-of-life care plans was a waste of time.

The Marine began to weep uncontrollably. Unable to contain his shock, aware of his wife’s complete denial, agonizing over the care of his kids, he cried like a child. A crying Marine is much scarier than a screaming one. The palliative-care doctor scrambled to find him tissues. As the Marine began to gather himself together once again, he fought back his tears and politely told the doctors that he needed some time to speak to his wife alone.

As strange as this whole experience had been, the strangest moment of all came next. This same husband, who minutes earlier had been consumed with rage and distraught with grief, thanked the doctors for doing their job well and for giving his wife’s prognosis in a humane and honest way. He said that he was very sad about his wife’s situation but that he appreciated the doctors’ clarity and empathy. Giving bad news about patients was one of the most difficult tasks he could imagine, he said, and the doctors had done well. As I watched the doctors thank him, I thought about how profound that comment was, especially from a man assigned to fight in Afghanistan in the coming weeks. – Dr. David Y. Hwang

Taking My Place in Medicine

Five weeks in the operating room and not a black surgeon in sight. I knew other black surgical hopefuls had gone before me with success, but that reality took on a more nebulous character each day. For five weeks, the only black faces I saw were pushing brooms, stretchers, and cleaning carts. The job segregation was as obvious as the day was long. Above me on the totem pole, the OR techs and nurses, most of whom were white females, exercised their seniority by putting me in my place with indirect and direct insults. The situation was only amusing when I remembered that this was a temporary relationship. In a few short years, I might be the surgeon taking delight in reminding them of their places. I could only imagine that they saw the future and were threatened by the possibility of a black female surgeon berating them for handing her the wrong size clamp.

Last week was especially trying. My week in anesthesia left me drained of reserve and full of self-doubt. I couldn’t intubate or place an IV in the hand to save my life or anyone else’s. Two months after taking Step 1 of my licensing exams, I was still waiting for my scores for a test I was sure I had failed. Questioning identity, purpose, and ability, I felt a sinking sensation deep in my gut.

And then I was saved. Friday morning, a black female orthopedic trauma fellow presided over my first case. She even invited me to spend some time with her in the OR after she found out I’d already rotated through the orthopedic surgery service before her fellowship began. In the afternoon, my second case belonged to a black male vascular surgeon. Although he did not ask me my name (medical students in the OR do not speak unless they are spoken to), he sent me a message later in the case. While the attending anesthetist was mercilessly questioning me about replacing blood products during an operation, the baritone voice of the vascular surgeon rose over the din of beeping monitors. He said, “What did Charles Drew do?” referring to the black physician who pioneered blood transfusion. Although he did not acknowledge me in any other way, it was clear that he was listening and looking out for me.

When I got home, I found out that I’d passed my boards.

God works in mysterious ways. I needed that day as much as I need oxygen to breathe. That day was the clarity I needed to remain on the journey toward taking my place in medicine. – Dr. Antonia Jocelyn Henry

Excerpted from The Soul of a Doctor: Harvard Medical Students Face Life and Death, published this month by Algonquin Books of Chapel Hill. Edited and copyright © 2006 by Dr. Susan Pories, Sachin H. Jain, and Dr. Gordon Harper. Foreward copyright © 2006 by Dr. Jerome E. Groopman. Reprinted with permission of Algonquin Books of Chapel Hill.