Narrative Medicine
2022; Lippincott Williams & Wilkins; Volume: 44; Issue: 11A Linguagem: Inglês
10.1097/01.eem.0000898288.48263.06
ISSN1552-3624
Autores Tópico(s)Empathy and Medical Education
ResumoFigureFigure‘Welcome to the profession!” Big smile, clean shaven, diamond-bright eyes. I stood beside my colleagues excited but nervous to pursue my lifelong dream. My white coat was crisp and embellished with the logo of the David Geffen School of Medicine at UCLA. I am no longer Rigoberto Perez Hernandez, pre-med; my new white coat reads Rigoberto Perez Hernandez, Medical Student. Now, as a fourth-year medical student about to begin more specific training into my specialty of interest, that memory seems so distant, but it is still so close to my heart. First year. Community health fairs, interest group meetings, my first OSCE, and a pandemic to top it all off. First year. I barely scraped by on my first medical school midterm—I was not proud of that 76. Imposter syndrome? Nah. Second year. Social isolation and record-high cases of COVID-19, the era of Zoom University. I remembered our well-being lecturer saying approximately 50 percent of medical students develop burnout. Was I feeling burned out? Maybe a little more tired, anxious, and sad than usual. Nah. Third year. Pushing near the 80 duty hours every week, multiple shelf exams, and dealing with life-and-death situations. Am I good enough to be here? Statistically, I was not supposed to be wearing the white coat; I was supposed to be wearing chains. The odds were against me. Luckily, an education allowed me to break free from these shackles. I had worked hard to push through the first two years, but nothing had prepared me more for the wards than the resilience I developed from growing up as a first-generation Latino. Soon enough, I was about to be responsible for the lives of others. Reality quickly set in as I was about to see my first patient on my internal medicine rotation. My team was called to the ED to see an older man with failure to thrive and a mass encasing his kidney and large vessels. He had a history of non-Hodgkin's lymphoma and had been in remission for some time. The concern was that it had returned. His name suggested a Mexican origin, so I was the first to see him, past the buzzing monitor noises, painful cries, and teams running codes in the nearby trauma bay. He was not a standardized patient from the OSCEs. He was laying on a gurney with his spouse by his side, dressed in a hospital gown with lines and wires as convoluted as the confusing nerve plexuses I had learned in anatomy class. They were desperate to hear what was going on. I introduced myself in English as a medical student, and began to take a history as we were taught. They both looked at me with looks of confusion and anxiety. “ ¿Hablas Español?” they asked. “Of course. Please let me start over,” I responded in Spanish. A look of relief flooded their faces. I was just as nervous as they were, but speaking in our native tongue put us at ease. “ ¿Tiene dolor?”—Do you have pain?—I asked as I pressed on his belly. He said no. His face was as stoic as a statue. I explained the next steps and told him that he would be admitted for further workup. “¡Gracias, doctor!” they said to me. I was no superhero or doctor. I was just another medical student rotating through, but to them I had become their doctor. I saw my patient early the next morning. “¿Tiene dolor?” I asked again as I examined him. He seemed uncomfortable as I palpated his abdomen but still said he had no pain. I explained what we knew so far, that we suspected a recurrence of his malignancy, so we needed to proceed with a few biopsies for confirmation. I had made extra time that morning to get to know him. He was originally from a small town in Mexico and had just returned from Las Posadas, a religious festival. It seemed as if he had forgotten everything I had explained to him because he began to smile at memories from back home. He described the celebrations, dances, singing, and scenery as if they were straight out of a Disney movie. He was the first from his family to immigrate to the United States and was proud to have created a life for his extended family here. He had been a cook for several years and was the primary breadwinner for the household. He was a true macho man. Taking days off were not an option for him, at least not until lymphoma put on the brakes. He had begun therapy and ultimately underwent stem cell transplant. He later went into remission and was lost to follow-up for several years. Now, in his mind, I was the doctor who would put the pieces of the puzzle together. The next day, I got a page from the nursing staff. His blood pressure had dropped, and he had become tachycardic overnight. His hemoglobin was low, and his platelet level did not look good either. He received a blood transfusion and was placed on fluids. I rushed to the bedside to assess him. “¿Cómo está? Tiene dolor?” I asked even though I knew what his answer would be. He mumbled “no,” and shook his head. His body was completely edematous, and I could feel his abdomen was distended. There were no obvious signs of shock or a stroke. I ran the differentials with my team, but everyone was puzzled. He was deteriorating right in front of my eyes, yet he said he had no distress. I was the one who felt distressed. I felt hopeless. I felt pain. I felt burned out. I felt like a failure and an imposter. But I hid it from my team. He later died, and I had lost everything. Statistically, I was not supposed to be wearing the white coat. My patient's story is an example of phenomena outlined in the paper, “Understanding the Hispanic/Latino Patient” by Enrique Caballero, MD. (Am J Med. 2011;124[10 Suppl]:S10.) He described machismo, which creates the notion that enduring pain is necessary and that visiting a physician is a sign of weakness. Machismo, he explained, refers to positive qualities expected of Hispanic/Latino men such as having a strong work ethic, being a good provider, and protecting their families as well as behaviors thought to prove manhood. Perhaps subconsciously or due to ancient traditions, this is why my patient did not admit to pain. Societal stereotypes and the expectations of health care providers to mask their emotions in front of patients or other first responders can lead to burnout and feelings of hopelessness. Dr. Caballero also described personalismo, the expectation that a Hispanic/Latino person will develop a relationship with his health care provider. Language and culture have proven to be key mediators in creating a sense of personalismo and a stronger therapeutic alliance between patients and providers. My hope is that stories like these humanize and normalize feeling emotions as health care providers. Let us change the narrative by challenging the status quo. Let us continue to promote diversity within the workforce by funding pipeline programs and mentoring underrepresented students. Together, we can continue to bend the arc and fight for justice for all.
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