Those encounters that they can’t prepare you for in medical school…
by: Maureen N. Onuigbo
I was in the midst of my Obstetrics and Gynecology rotation, but by the looks of my patient, it could have been Pediatrics. She looked about twelve, and her companion, a male looked a year, maybe two, older. She stared at her fingers, twiddled them around each other in a delicate dance. I could not see her face. He looked everywhere about the room except at me, like he was searching for something. She responded to my questions with monologues, or just sheer silence. Thank God I had just completed my Pediatric rotation. Eight weeks of Pediatrics has made me an expert on teenage disposition. I refused to take their reactions personally. I understood it, even expected it. Clinical equanimity was my slant.
She was pregnant, and not a happy pregnancy. It was clear enough. No kind offerings of congratulations here. Long stretches of silence passed as I regarded them, weighing my approach. As a third year medical student, the “Doctor” in this encounter, I was supposed to lead. Go, doctor, go…
Her youth shocked me, a shock I dared not express. That would be unprofessional. How old was she exactly? I could look at her date of birth and do the calculation easy enough. Not here, not now. This was no time for such distraction. She would sense it. Patients demand their doctor’s undivided attention. The Clinic was so busy I had no time to review her chart before coming in. In a situation such as this, she may think I was passing judging if I asked her age directly. I had other ways of finding out.
“What grade are you in?” I asked. Grade level plus five equals age, approximately. She looked up, at the ceiling. Her head tilted, she pursed her lips. A film of tears drifted across her eyes as she rolled them, thinking of an answer. I tried not to look puzzled. It was a simple enough question. Her response shouldn’t taken this long.
“My mom says I am between fifth and sixth grade,” she said.
“Between fifth and sixth grade.” I said.
“We’re homeschooled,” the boy said.
Ah. He must be her brother. They were homeschooled by their mother, perhaps. At the back of my mind, the very back, which could belong to another person at times like this, I remembered the time during the Nigerian Civil war when my mom tried to homeschool us. There was no school on account of the air raids. It was a riot. We played and giggled and carried on. Mom looked so funny playing teacher. It was not long before she gave up and made other arrangements. There was the teacher and then there was your mother. When the two become the same person, a certain confusion set in. I wondered how it was for them, having their mother as their teacher. How would they complain to their mother about their teacher?
At that same back of my mind lived a nasty little voice, the one that pestered me. Sometimes, it insulted me outright, calling me names like “fraud.” I have successfully ignored it for years. That little voice and I understood the three “C’s” of third year medical school. Confidence. Compassion. Competence. The three “C’s” that make a good doctor. But they never tell you where to find them and this little voice knew that.
Here in this room, I was the doctor, three “C’s” or not. I put on my best clinical smile and set out to inspire some confidence in my patient, if not in myself.
“How far along are you?” I asked her.
She twiddled her fingers. He looked at me and then looked away. I repeated the question.
“I don’t know,” she hummed without opening her mouth, shrugging her shoulders.
“What I want to know is how she got pregnant,” he said. I stared at him.
“How she got pregnant,” I said. This was no time for a “birds and bees” lecture. Ours was a busy Medicaid clinic run by the medical residents and students. Only a handful of attending Physicians were there to supervise and teach.
The clinic was located in the heart of Hartford, Connecticut. Our clientele were the poor and forgotten that called the city home. In droves they came. Here I saw a different side of America, its underbelly. I could live in the United States for years without knowing about this aspect of the golden US of A. Once an obese patient sat in front of me, leaned forward and whispered, “Doctor, what is this metazolizim?” They always called you “doctor” as long as you had a white coat on. I had my student ID on the coats lapel. It did not matter. To her I was the “doctor” and that was it.
“I was always careful,” he said, “I used a condom every single time.”
He was not her brother. They were a couple. I was proud of him for showing up with her. Most of our patients showed up by themselves or with female members of their family. Sometimes, a group of women, several generations of them, strolled in with a patient. The only males in the clinic were infants and toddlers, like baby-making was an all-female activity. For most of our patients, the other parent was a nameless, faceless alley cat generically dubbed “Baby Daddy” or “Father of Baby.” “FOB” was a clinical term we used in our notes. “FOB is not in the picture” or “FOB is involved and supportive.” The latter was rare. The societal trend prescribed more unsupportive FOBs. This was none of our business, of course. We remained clinical and matter-of-fact. “Thou shall not judge the patient” was our mantra and we lived by it. I would define “judge” loosely. Very loosely.
During one rotation, a third year medical student was expected to talk to a patient and obtain a history, a list of the patient’s symptoms and concerns: When did the symptom start? What made it better? What made it worse? What is your past medical history? Past surgeries? Any current medications? Do you suffer from any allergies? Do you smoke, drink or do drugs? How much a day? After the history, a physical exam was conducted starting from the head down to the feet. This was called the H and P, History and Physical. The H & P was presented to the resident or attending physician. It was during this presentation that the teaching and learning occurred in a teaching hospital like ours. The product was a firm diagnosis and a list of alternate diagnosis and a treatment plan. In spite of all this instruction, time was of the essence in a busy Medicaid clinic like ours. There was no time to waste on any one patient. The third year students were expected to go into a patient’s room, get a H&P and come out to present the case. No more. “Get them in and get them out!” the resident physicians yelled at us. They called it teaching.
My encounter was taking entirely too long and getting nowhere. I thumbed through the chart again. I did not want to say the wrong thing. Nor did I want to rush them. But I knew I was up for evaluation at the end of the month. The pace had to pick up. I was yet to conduct an exam.
“But are you sure you are pregnant?” I inquired.
“Oh yes!” They both said.
“All the tests are positive, the blood tests too. That’s why we are here. She’s pregnant,” he said.
“Yes, I am pregnant, I am sure,” she said. She looked up at him.
“But there was nobody else. It was only you.” The innocence on her face made me sad. She was merely a child. I was touched, briefly. I had to get them out of the room, but my responsibility was to the pregnancy so I moved on. I needed to get to that.
“Condoms sometimes break. They are not a hundred percent safe,” I said.
“I would know if the condom broke, right?” he said.
“Right,” I said. “Did you check to see?”
“Yes, I did and it never broke,” he said, cocking his head at me.
“But you used to cut it,” she said.
“What?” I asked, dropping my pen on the table with a little more force than a real doctor would have.
“Yes, but that don’t mean that it broke,” he said.
“What did you cut off?” I asked him.
“The tip. I used to cut off the tip. There was always this little flicker at the tip of my….you know….” He waved his hand in front of his pelvis. “It irritated me. So, after I put the condom on, I cut it off.”
“No!” I tried not to shout. A real doctor would never shout. “You are supposed to leave that on.”
He shrugged his shoulders, showed his open hands, as if to ask “what on earth for?”
“The little space at the tip of the condom, the part you cut off, is there to catch the semen,” I said.
“Semen!” They said in unison. They looked at each other then at me.