Scrape.

My fingers remember surgery.

I was standing in the operating room. It was the first time I had actually scrubbed into a surgery. I stepped to the table on the patient’s left side, his face hidden behind blue drapes. His abdomen was open and exposed, orange with iodine, with a careful blue incision site tracing down his midline. I placed my gloves carefully on the blue sterile field. My warm breath filled my mask.

The surgeon swept into the room, hands and arms still dripping. His work is world-famous, specializing in melanoma, the most aggressive of skin cancers. His research focused on developing a ground-breaking virus to inject into patients that would kill the melanoma cells. So far, the trials showed it works.

He stepped to the table. They raised the table to his towering height, and I climbed onto a step beside him. Nurses in blue gowns and masks whirred in preparation around us, bustling with sterile instruments hot from the oven, and I could hear the anesthesiologist adjusting the tubing flowing from the patient’s mouth.

“Are you ready?”, the surgeon asked, glancing at me from behind his lenses. He knew it was my first time being scrubbed in to assist in surgery.

“Absolutely,” I replied.

Until that moment, medicine had always pulled me. I figured it was my father having life stripped away from him as his brain cells shriveled with ischemia. Or possibly it was my mother’s bruises, constantly coating her body like an ever-changing mood ring. Maybe it was the lack of stable family structure I had at home, a love and caring that I found in the patients needing me at the hospital.

But as I stood above the table, watching fingers twisting silk sutures and the way fascial layers peeled away from the pressure of blunt scissors, I remembered. Rather, my body remembered. I had a visceral reaction to it, with tears and a twisting in my stomach, remembering something I have never known.

 

Internal Medicine.

Internal Medicine.

  • How did I feel when I got home?

 Happy. Most of the time, I felt validated and confident about the work I had done that day, and I had enough time and energy after work to get things done or to do the things I enjoy. I had a sense of purpose and meaning. I also found my mindset shifting – my thoughts more frequently trailing into questions about the meaning of life, why we do what we do, and how we can better ourselves.

  • Did I feel excited to look up the illnesses and diseases in the patients I was caring for, or to study for the shelf exam? Was there diversity in the conditions being treated?

Yes and yes. I loved learning about the intricacies of the signaling pathway from the brain to the gland atop the kidneys to determine if my patient was in septic shock or adrenal crisis – or both. I loved reading New England Journal articles about empyemas and when to refer to my patient for surgery, or scouring the literature to understand why it might be better to re-start the blood thinner in my patient with a bleeding stomach vessel sooner than later. Weaving symptoms together and teasing out the abnormalities in the blood work in order to arrive at the right diagnosis felt like solving a mystery, and I think I was good at it. The diversity of the conditions that hospitalists are expected to know is enormous – often I would think to myself, “but they can’t know everything” – but they did.

  • What were the main feelings I encountered while working with the patients? The medical team?

The patients made me feel connected. I often cared for them from the day they arrived at the hospital until the day they left, and I loved that sense of short-term continuity in the acute inpatient setting. The outpatient care setting was (if I’m being entirely honest) – repulsive in many ways. But I loved the continuity aspect. The medical team made me feel respected, encouraged, and supported. They listened to my reasoning through various diseases I was considering could be affecting my patient, and why I wanted to pursue one treatment over another. They often complimented me on my knowledge about my patients and my ability to maneuver in the hospital setting, and I felt like my hard work was appreciated.

  • How much direct patient contact was there? 

As much as I wanted. There were times while I was in the physician’s workroom, typing up progress notes or printing research articles, and I realized that was not what I should be doing. Great doctors aren’t molded over a keyboard. So I would spend a fair amount of time sitting in patient’s rooms and hearing about their experiences in Afghanistan, or in the darkness of the radiology reading room pointing at the bright structures on my patient’s scans. I realized that work is a sliding scale,  a balancing act. If I wanted to spend more time in clinical experiences and at the bedside, then my documentation time and the quality of my notes would be sacrificed. I was okay with that, it made me happy.

  • What were the humdrum aspects in the patient population or workflow that would have to be tolerated for the rest of your life?

Pages of tedious paperwork. There has to be a more efficient system for documenting treatments administered and medical decision making. Long rounds didn’t bother me as much as I thought they would. I felt like the patients who greeted us in the room deserved that time. They were likely having one of the worst experiences of their life, and they were the reason I endured years of grueling coursework. The least I could do was spend more than 5 minutes in a sterile hallway outside their door discussing their illness and how we were going to help them. Too often, we brush past the surface and never step deep enough to see the exposures and co-morbidities  fueling the disease we see lying in the hospital bed, or to appreciate their values that should guide how aggressive we are or aren’t with their treatment. I can see myself feeling like the time-consuming aspects of internal medicine are “chores” – until I pause to remind myself of the deeper meaning of medicine. It’s not always fixing people.

  • Does this specialty address one of the leading causes of death in the world?

Yes. That is the essence of internal medicine, really. Heart disease, hypertension, diabetes, and a little splash of renal failure.

  • How easily can motivational impact be integrated into a career in this specialty?

I would argue that there is no better specialty for the role of motivation in having the largest impact on patient health.  I think there is beauty in the short-term encounter of the inpatient setting. You, as a physician, haven’t struggled with this patient before. They are new to you. You are new to them. You are a fresh page, and this is the chance for a new beginning. The perfect opportunity for an intervention. They are out of their normal routine, a stranger in their environment, isolated and stripped down to their rawest self in a hospital gown – without labels or reputation or distractions. They have the chance to peel away their layers and stare their humanness in the mirror, to ask themselves for forgiveness for damaging their body, and to see the need for a change.

  • Does this specialty focus on preventing problems or fixing problems?

Both. For the patients caught early, there is the opportunity to alter their disease course and to avoid yearly hospitalizations. For the patients reeled in later with a roaring storm of imbalanced drugs in their bloodstream, or soggy lungs filled with bacteria, or intractable headaches due to an un-solved mystery, there are always new problems to fix.

I see the beauty of life –  in all of it’s distressing disguises.                                                     I see the unfolding of human spirits.                                                                                        I see the core of what lies within us.