I fill the hours leading up to a novel experience by creating ridiculous stories about the person or place I’m about to see for the first time. After the occasion passes, I then take a few minutes to reflect on how my expectations lived up to reality. I’m sure it’s some sort of psychological defense mechanism evolutionarily adapted because it allays the most disconcerting of all human emotions, fear of the unknown.
If I imagine myself spewing wine all over my friend’s family’s Thanksgiving turkey after starting to laugh while taking a sip of chardonnay, the reality always seems much calmer and the experience a little, well, duller…unless, of course, my wildest imagination turns out to match the reality. This became the case for my first clinical instructor.
The pediatric hematology unit
Day One with Dr. R in a pediatric hematology unit. I had plenty of preconceived, wild notions in my head about this mysterious doctor. He was my ambulatory care preceptor, the only clinician with whom I would directly interact in a hospital setting during my first year in medical school.
The “clinical skills” part of my mind was essentially a blank slate for Dr. R to fill. After learning of my assignment, I needed to contact Dr. R to arrange my ambulatory care schedule with him. Simple? Not so.
After a few enthusiastic emails, calls to a phone number that wasn’t connected to a voicemail system, calls to his receptionist, and desperate last-ditch strategies discussed with the other student assigned to the same rotation, I finally received a two-word email from Dr. R in response to my elaborate plans for getting the most out of my shadowing experience.
My imagination went wild
Visions began to dance in my head of this new character about to walk into my life, this “Dr. R”. A Google search yielded few clues—a photograph of a bald, smiling, middle-aged Indian man and a few PubMed articles.
My findings left plenty of room for imagination. Dr. R was a high-profile pediatrician and extremely hard to contact. He was in the process of making great strides in research involving debilitating diseases.
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I envisioned myself regressing to “little girl” status with Dr. R as my disgruntled parent, dragging me along by the hand as he treated his patients. In my worst-case scenario, I accidentally broke a small child’s leg with a reflex hammer. Dr. R reported me to the appropriate authorities and I was sentenced to life imprisonment during which Dr. R visited weekly to laugh at me in jail.
When the first afternoon of my ambulatory care rotation finally arrived, I was confident I would exceed the low bar of my expectations. It was, after all, set at “not breaking a small child’s leg with a reflex hammer and dying in jail.”
How would my imaginary Dr. R compare to the living, breathing Dr. R? In his small office, I waited with a third-year medical student, twiddling my thumbs as we waited for him to return from lunch.
The other student spent the first ten minutes of the wait sharing tales of the third year’s horrors. I forgot her name so I mentally labeled her “Buzz Kill.” I zoned out as she droned on, letting my eyes wander around the cluttered desk and shelves. There were files holding pediatric patient information, a stack of papers for “stigma study” and a cabinet full of children’s books.
“Hello everybody!,” Dr. R said as he burst into the room like a ray of sunshine. He radiated a level of warmth disproportionate to his diminutive size. He shook our hands and pushed through to his desk, shouldering two large bags. He emptied one of the bags on his desk and Asian pears tumbled out.
“Can I pear pressure you to take a piece? They are very good, and fresh from the market!” Dr. R pulled out a pocketknife and began carving the large fruit in graceful strokes.
I was pear pressured for the first time
I was pear pressured for the first time that day. I held out my hand and caught the slice of Asian pear as it fell from the knife. I had never eaten an Asian pear and savored the crisp sweetness.
“OK, I will be right back.”
Dr. R walked down the small hallway, poking his head into each patient’s room. He asked the children to hold out their hands to catch the succulent Asian pear pieces. I heard their mothers laughing as they, too, experienced pear pressure. I looked at Buzz Kill. She seemed happier.
Dr. R returned with one pear sliver, which he popped into his mouth. He had an unbelievable amount of food left on his desk that I now realized was not for him.
After we exchanged a sticky handshake, Dr. R launched into a long-winded and heartfelt explanation of his practice. Dr. R’s patients hailed from an underserved African-American community. Most were on Medicaid or had no medical insurance. He worked mainly with patients with sickle cell disease and those who were HIV positive.
Dr. R’s practice: An introduction to Empathy
Dr. R was leading a study about the stigma many communities attach to HIV patients. His relationships with these patients were longstanding. This was because these chronic conditions required multiple visits for blood work and check-ups.
He had been practicing and teaching at the hospital for a few decades. Some of his “pediatric” patients were currently in their late twenties and now brought their own babies to see him. None of them wanted to change doctors and he wouldn’t turn them away. I learned why.
After our brief orientation, his work began. “Doctor’s work” doesn’t fully describe what I saw that afternoon. I saw “healing”.
Dr. R left each of his patients and their parents with smiles on their faces. Their stories were often moving, troubling, even frustrating. In addition to the obvious effects on children’s health, chronic diseases create great financial burdens for caregivers. Many of his patients’ parents lacked basic knowledge about good health practices.
Dr. R gave his patients all the time they needed, asking just the right questions to foster his relationship with them and steer them down the road to better health.
I saw a teen mom who had been kicked out of her parents’ home due to their strong religious beliefs against premarital sex. She was now living with an uncle, her baby’s father having long since vanished. I saw teens who were trying to get pregnant, which I questioned in my mind.
Dr. R’s good advice
Dr. R was a great listener. He was never judgmental. While we were waiting for more patients, he would give me what can only be described as “life tips”. Among them was the advice to never assume my own beliefs were shared by all people.
“It’s not ideal for a baby to be born to a young mother before she is married and has solidly established herself in the workforce. But some girls find their fulfillment in motherhood. Who am I to stop them from fulfilling the role they believe they were born to play? The baby will be loved. Our job is not to pass judgment, but to promote health and happiness.”
Dr. R explained with exquisite clarity the ramifications of sickle cell disease to a new mother whose baby was born with the condition. In the next room, he performed a well-child checkup on an albino girl with nystagmus, an eye disorder. Next door was a little boy with a rare fungal infection on his scalp.
Across the hall was a 4-year-old girl with sickle cell disease who knew she was there to have her blood drawn. Her mother told me her daughter wouldn’t cry. She never said a word when she came into the doctor’s office and saw white coats.
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As she was explaining this silent treatment to me, Dr. R rushed by in the hallway. The four-year-old saw him through the open door and said softly and adoringly, “Dr. R!” She leapt off the examination table and ran into the hallway with open arms to hug him. The mother smiled and said Dr. R was her daughter’s exception.
I chatted with these patients as I took their medical histories, listened to their hearts, and palpated their spleens. I became more aware than ever of my ignorance. This was all the more ironic after the months I had spent in a library trying to make sense of the human body.
There was so, so much I needed to learn, which simultaneously frightened and excited me. Whenever I had a question, Dr. R was there to patiently answer it.
Real patient engagement
The day ended with a visit from a 4’10” 20-year-old woman recovering from HIV encephalopathy, a problem with her brain. Dr. R sent me down the hall to meet her while she was being triaged by the nurses, describing her as a “stand-up comedian”.
He was right. She had me laughing immediately as I watched her beg the nurse to add a few inches to her height measurement so she could hit the five-foot mark. We walked back to her room together.
We could have been in Dr. R’s living room. He asked her about the iPod he had given her for Christmas. He also asked if she needed money. When she nodded, he pulled out his wallet and gave her a twenty-dollar bill and a Metro ticket.
He knew from her blood test results she wasn’t regularly taking the antiviral drug cocktail she needed for her HIV. He gently probed to learn how often she was taking it.
“So, how often do you take your medication? Once a month? Once a week?”
“I am taking my medicine.”
Dr. R did not reprimand her, but softly continued the conversation about the importance of the medicine.
Hugs, kisses, and a slice of Asian pear
Dr. R loved to hug his patients and kiss babies and build the confidence of teenagers in the throes of their “awkward stage”. His distinctive and contagious laugh resonated down the hallway the entire afternoon.
Every single patient that day received a hefty slice of Asian pear. All of the toddlers walked away with colorful children’s books from the stockpile he kept in his office. He had me personally autograph each book as if I were the author. I wrote little notes to the children above pictures of flowers and puppies.
When every patient had been healed, Dr. R and I walked through the hospital together on our way to the subway. Before we parted, he asked me to take some time that night to think about the people I had met that day.
“The best and most crucial part of being a physician is learning from the patients’ stories. I can give medicines, but I think listening to the stories is much, much more important.“
I never would have thought I could learn so much in a single afternoon. My hypothetical case could not compare to a pear-filled reality starring a doctor who placed all his patients on the pedestals the rest of society denied them. No wonder Dr. R had been difficult to contact.
He’s kinda busy.
More medical student essays: My First Patient, My First Death
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TDWI author, Margaret Cary, developed and taught the Narrative Medicine/Personal Essay course at Georgetown University School of Medicine. Her students’ essays, such as this one reflect their thoughts on being in medical school and becoming physicians.
This essay was first published on August 24, 2010 with the title, Pear Pressure. It was republished on December 5, 2019.
Caroline Green was a medical student at Georgetown University School of Medicine at the time she wrote this essay. She trained in Internal Medicine. She is now a full-time MBA student at the University of Texas at Austin McCombs School of Business in order to further enhance her understanding of business principles and policies driving healthcare delivery systems.
Caroline completed six years of Active Duty military service with previous stations in San Antonio, Texas, and England. She plans to assume a role that allows her to improve the safety and quality of care in the United States at a "macro" level, motivated by the experiences she has had delivering care in a classic physician-patient relationship. Her previous leadership experience and exposure to international healthcare delivery systems have primed her for new, exciting challenges in the complicated, ever-evolving U.S. healthcare environment. She has gained invaluable insight into the problems and frustrations physicians encounter and looks forward to addressing these challenges in settings where she can effectively promote therapeutic change.