October 27, 2010

Trial by...?

This somewhat follows my previous entry, "Reincarnation."  Intrinsic to the idea of reincarnation is the concept of being born anew on a different plane of existence. It is not simply living another life, but ultimately the goal is to learn something from what had happened before and use this in the next life.

Part of medical school is remaking yourself on a different plane of existence, this time on a different social plane. As a doctor, you are expected to transcend social niceties because it suddenly is your job to worry about someone you've never met's sexual history and practice; suddenly you are remiss if you do not inquire into drug use or marital status or infections previously endured. In a way, this is why we need the socialization and the standards of professionalism written into our curricula: our teachers are there for us to model ourselves after, so that we can learn to properly guard this trust given us by virtue of our position, by virtue of our profession.

There are few other relationships held as sacrosanct as that between a physician and her patient; those that come to mind are lawyer-client and parishioner-priest. In the same way, the physician guards secrets and knowledge and intimacies that even couples do not share with one another.

This was particularly on my mind last week--the things that must remain unspoken after the visit is over, after the examination. In some ways, this is a paradox: the physician should keep careful notes of what she observed, what the patient said, how the patient felt, what findings can be cobbled together to support a diagnosis of the etiology of the complaint. At the same time, however, for the nascent physician--more specifically, the medical student--there are things which are not considered.

I was shadowing a geriatrician last week, and a patient came in complaining of persistent diarrhea. The doctor examined the patient in many typical ways, but he also decided to examine the woman's rectum. He put on a pair of gloves and used a little lubricant to test for the tone of the woman's sphincter, to make sure there was no damage there. He then told me to put on a glove so that I, too, could examine the woman.

I did as he asked.  He squirted a dab of lube on my finger, and I rubbed it around to spread it across my finger.  I gently probed the patient and felt her muscles tighten around my finger.  I quickly withdrew and stripped the glove away.  

Several thoughts went through my mind at once as I was doing this.  First, I was surprised by the willingness of the patient to let me do what the doctor was doing.  Second, I was surprised by the fact that I was able to do this without an outward reaction (with the possible exception of tearing off the cuff of my glove as I was putting it on).  Third, I felt guilty, as if I were violating this woman because I didn't actually know what "normal" would be--so my attempt at the exam was really just me prodding and poking at things I had no knowledge of.  Her trust in me, a medical student, told me more about the position I had come into than anything abstract ever could.

I have yet to tell any of my M1 friends at school about this; many of them have shadowed one or another physician here (lots of them our psychiatry professor who works with veterans).  But somehow, this seems too personal, as if I shouldn't talk about it.  I don't know if that says more about my relationship with my classmates or more about how I feel about the experience.

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