Clinical, Featured, Housestaff Wellness, Intern Year, Internal Medicine
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The following manuscript was submitted to the May 2018 Mental Health theme issue.

He pulled his chair up to the desk and flipped open his laptop. The young doctor, with thirteen years of pre-collegiate preparatory schooling, four years of college work, and a final four additional years of relevant medical education underneath his belt, attempted to yawn away exhaustion and scrolled through the patient list for the day. Tuesday morning was dedicated to the hospital follow-ups in the resident clinic, which he knew could bring its share of either ‘no-shows’ or ‘train-wrecks’. The first one appeared to belong to the latter.

Ms. Kernig was an older woman who appeared to have let life get the best of her.  Her most recent hospitalization was last week: an admission primarily for COPD exacerbation, although it was complicated by several expressions of threatening self-harm. She was a psychiatric patient for several years, and the history of multiple trials of various anti-depressants and augmenting anti-psychotics revealed a difficult case of depression and anxiety. The resident doctor cursed the schedulers for this ‘present’ as the first fifteen-minute appointment of the day. He tried to muster the empathy but lamented that awful sense of ‘jaded-ness.’ He couldn’t quite shake the feeling anymore that he swore would never befall him when he first donned the short white coat. It was now time to begin the fake smile, the friendly touch, the understanding nod, the clear and concise explanation of the daily plan, and the quick exit without an additional thought of Ms. Kernig once the clinic room door shut. This was the method he was taught and on which he was tested, a standardized false empathy that is repeated in every resident clinic across the country.

The resident opened the door and saw the image of a woman worn down by years of a self-defeating attitude. Every strand of her thin and untamed hair was gray, her shoulders were slumped, and her eyes appeared as a lifeless black similar to window curtains to the soul. He began the routine of the courtesy introduction, the short steps into the room, and the turn back to produce a glob of soap from the dispenser adjacent to the doorway. The process had become second-nature at this point and subconsciously derived from the way he would obtain maximum points during his clinical skills examinations in medical school. Occasionally, he would look into the full-length mirror attached to the door’s backside. He always presumed its purpose was to produce the façade of a larger room. Today, the doctor used it to make sure everything was in order, particularly after his terrible haircut at the chain hair salon yesterday which was made worse from the morning’s rush. Turning back toward Ms. Kernig, he began his scripted interview.

“Looks like you were in the hospital recently, Ms. Kernig. How have you been since then?”

In a blank stare, she gave her monotone response, “Well, I’m still here.”

“I heard about your thoughts of hurting yourself, and you not taking any of your medications, including your inhalers. That’s why you had to go the hospital. Have you been taking them? I also read your psychiatrist has been changing around your medications. Have you had more thoughts like the ones in the hospital?” At this point, the young doctor’s eyes peered past that sad, sunken shape of a woman to the analog clock over the patient’s chair. He had been taught in his first year of medical school to pose one question at a time or else the patient is guaranteed to solely respond to the last of the sequence of inquisitions. However, for some reason along the path of his training, this was a standardized rule that was thrown away by the resident. Maybe, it was in the interest of time, or perhaps he didn’t bother to care about the potential answers to the rolled-over questions. There was always another hurried encounter he had to begin in a timely manner.

“No, I’m good,” Ms. Kernig answered unconvincingly.

“So, how can we make sure you will take your inhalers so you don’t get sick or have to go to the hospital again?” The resident was now clearing the way for the imagined home stretch. In a couple minutes, he would place his stethoscope half-heartedly on her chest and back. If he felt the need for some showmanship, he could shine a quick light in her mouth for added effect before spitting out a generic plan and leaving through the door with the purposeless mirror.

“I’ll take them.”

“Okay, I will make sure you have enough refills at your pharmacy,” he stated, acknowledging the reality of this ineffective encounter.  But now, in an act of self-preservation, he can record, ‘patient denies suicidal/homicidal ideation’ in his note.

The resident stuck out his hand as a gesture signifying the end of the visit. Ms. Kernig responded in kind, however, instead of the typical graciousness bestowed upon a doctor for his or her time, she calmly shook the routine.

“You look tired. How are you doing, doctor?”

“I am doing well. Thanks for asking. Bye now.” For a brief moment, he pondered this question and the fact that, in the timespan of three seconds, the roles of the inquisitor and the examined were reversed. This was the perception of the resident, though. There was very much the possibility that he was the object of observation during the entire visit, while he operated under the pretense it was he who would question, instruct, and possibly heal the one who sat in front of him.

She knew him like she knew herself. Even though only ten minutes passed since the initial greeting, she recognized him when he first opened the clinic room door with the mirror. He appeared hurried since the very first moment, and his anxious idiosyncrasies were pervasive until the gesture for a handshake. His hands could not remain still, and they would appear to produce a slight tremor during his breaks from typing the patient’s short responses into his laptop. His eyes would have periods of rushed blinking as if uneasy nerves produced direct stimulation of the contractile muscles of his eyelids. The leg of the young doctor was like a jackhammer, tapping the ground at a rate that required full concentration if one were to quantify it. While his sympathetic system seemed to be set in overdrive, a sadness exuded from those eyes that stared past her, and the skin underneath them was sunken. Physical manifestations of the inner restlessness were as apparent as night and day to Ms. Kernig.

She wondered if anyone else could recognize these signs of anxiety as easily as she could. As the one who never completed a degree but had years of training, she was the diagnostician at this point. It was the most effective kind of training: lived experience. She could accurately predict the etiology of his condition from simply seeing and hearing him. This was her sixth sense. A thorough history did not need to be obtained.

Her patient was a twenty-seven-year-old man without any other significant medical history who has faced years of constantly striving for perfection. This has resulted in a crippling fear of failure, although he could never express this openly. The young man has avoided many risks in his life and has sought after a sense of satisfaction from the act of producing. Once a goal had been achieved, he experienced a glimpse of that inner sense of calmness, only to be shaken by the realization there was always a next step. After summitting a mountain, he would trek down to the valley, only to stand at the base of another mountain and plan his next expedition. He produced in middle school, high school, college, and medical school, always near the top, yet always consumed by the storm within him. Ms. Kernig knew he could relax but sensed these moments were fewer and further between, exacerbated by his current state of sleep deprivation, the constant humiliation the medical field presses upon its newest inductees, and the open disrespect he had experienced from several older colleagues and patients. Yet, there was no time for him to sit with deep introspection. There were notes that needed to be written, exams that needed preparation, and patient calls to be made. She diagnosed him and knew lack of insight on his part was going to be the barrier to treatment. Ms. Kernig was not going to tell her patient since she realized the fruitlessness of that endeavor. A simple question would suffice so he could reach the same conclusion himself, although it would be a time-consuming process.

The two shook hands and he turned to make his exit, catching a glimpse of himself in the mirror on the door. The young physician paused for a brief second, realizing the oddity of her question.  However, this was a fleeting thought. He continued into the clinic hallway with two additional patients already waiting for him on this busy morning of hospital follow-ups.

Image sourceRoom 3 by Jay Gorman licensed under CC BY 2.0.

Ryan Yarnall, MD Ryan Yarnall, MD (2 Posts)

Resident Physician Contributing Writer

OU School of Community Medicine

Ryan is a second-year internal medicine resident at OU School of Community Medicine in Tulsa, Oklahoma. He had published a few articles for in-Training as a medical student and wishes to continue writing during the busy times of residency and beyond.