Thursday, January 29, 2015

To Miss the Mundane

The attending swiftly went room to room checking in and managing all the patients I had seen. He asked, “What’s important?”

I replied, “Making sure that he doesn’t have septic arthritis,” when we saw the patient with the swollen big toe.

We went into the next room, “He asked again, what important to you?”

I replied with this patient, “Making sure that he doesn’t have AAA,” as we saw the patient with back pain and vascular risk factors.

We returned to the computer station, and he clarified, “What I meant was, what is important to YOU the most?”

I was completely focused on the patients, trying not to miss any details, and confused that he reentered our previous conversation ten minutes prior where we were talking about career choices and how he became an emergency medicine physician. I failed to catch on that he was continuing that conversation as we saw patients.

He proceeded, “I have a friend who became a surgeon. He was happy with his choice, but one day he told me, ‘If my son walked into this room today, I would not recognize him.’”

Though an extreme example, he continued, “You have to figure out what matters the most to you in your life.”

The night faded away as we proceeded with task after task, seeing patient after patient, performing procedure after procedure.

As I was driving home after the shift into the early hours of the morning in the quiet/stillness of my car, no talk radio, no news, no music, as I often did after seeing patients for the day, reflecting on the people who I interacted with, I realized I never answered the question that Dr. B asked me. It didn’t feel natural to answer. It felt more rhetorical and something to ponder.

I got home and crawled into bed after having four shifts that were 3-11pm. I pealed Anthony’s hand away from his side of his body and crawled under his arm, bringing as much of my existence as close as possible to his. I felt homesick for him. I could hardly believe it! I thought, “How silly, Sarah, how can you be homesick for someone you live with!”

I thought about the last couple of days and how opposite of schedules we had, and then I thought about the last couple of weeks and how much I was not present in the day, even when I got half a day with him on a Sunday, I couldn’t let my mind free in the moment, thinking about the future of having to go to work later in the afternoon, or when I got home after working on a Saturday, too tired to fully enjoy being out to dinner with him and friends. I hadn’t had two days off in a row, and I felt completely un-refreshed, labored, and unappreciative of the beauty of life, barely present in whatever moment I was experiencing.

I thought how easy to answer Dr. B’s question as I laid under the pressure of Anthony’s heavy arm, him grumbling, recognizing I was home, exchanging our “I love you’s” and him slipping back into his dreams that I interrupted (and hopefully was a part of).

I realized how much it really mattered to me. How much it really kept me healthy to return home every night to Anthony. To run together at the gym, to eat dinner together, to do work side by side on the couch on our laptops watching our TV shows, to lie  next to each other in bed, to participate in the mundane that we mindlessly participate in every day. I actually missed it. I missed the mundane.

I briefly flashed into the future and thought how much more difficult it will be when it’s not only Anthony who I don’t get to see every night but when it is our beautiful children. Our children who I won’t be able to check their homework, to make them dinner every night, to nag them to make sure to brush their teeth after ice cream, to chase them to their bedrooms to settle down for the evening, and to stroke their beautiful silky hair away from their eyes as they fall heavy into sleep, lying on my chest listening to bedtime stories or reading to me their favorite, as I once experienced with my mom and dad and cherished doing with my younger sisters as they grew old.

I realized really how much I valued the mundane and that maybe the mundane isn’t so mundane. The nightly routines that close the day, that wrap their arms around us with their soft, gentle embrace, easing us into the next day, are something I find great comfort and value in, even contributing to my identity.

So as high as I scored in a survey directing me to emergency  medicine as a specialty and as much as I loved the experience of working in the emergency room, the balance between using your mind to diagnose, making critical decisions quickly and using your hands to perform procedures: intubating, suturing, reseting fractured bones, drawing blood, giving chest compressions; performing a cricothyrotomies, commanding diagnostic tools like ultrasounds, x-rays, and CTs interpreting images before the radiologists can make their official reports; providing health care access to those who have no place else to go; serving the poorest of our society; and helping those who, like of all us, have had accidents in our lives where we need emergent care; I could not let go of the mundane. I deeply love the mundane and would miss it too much, being homesick for the routines that Monday through Friday, the 9-5pm schedule offers and creates orderliness to the busy-ness of life, weekends to anticipate and plan, and opportunities to clear my mind of work-ly tasks and create enough space for the chance to look forward to the following week reappearing.

Loving the mundane, appreciating the mundane, experiencing the mundane, makes it absolutely far, far from being anything close to mundane.

Monday, December 22, 2014

I've Been There Too

“This next patient has never been here. Why don’t you go in and start the history and physical,” said the efficient attending, pointing to the medical chart on the packed computer screen filled with visits for people coming in for asthma checks, sicks visits, well visits, medication refills, referrals, and injuries.

As I entered the room, I introduced myself as the “Student Doctor Sarah” first to Ricki, who was sitting on the exam table ready for his physical, and to his supporting cast of mom, sister, brother and aunt who were hip to hip on the couch that looked like it belonged in a Willy Wonka’s chocolate factory with its curvy back rest. As I sat down at the computer facing mom and family, I asked if it was okay if I gathered some information about Ricki and  if I did a physical exam before the attending came to join us.

As soon as I said this, Ricki's mom released, “We have had issues with his insurance, and he hasn’t been to the doctor in a really long time, except for his visit to the emergency room a few months ago when he had appendicitis. He has osteogenesis imperfecta. Was diagnosed when he was a baby-had the blue sclera, bone problems. I think Ricki has autism, he’s a smart kid, high IQ, he also has difficulty with his weight; he is short of breath when he walks a block. His sister has lead poisoning. He doesn’t though. His lead levels are below three…”. 

His mom continued to rattle off his numerous concerns in what seemed like one large exhale as I tried to keep track of everything, charting each illness and back-tracking to ask more questions and to sort out what symptoms went with each illness as she and we jumped around trying to get everything from the last years that were missed with his care.

And when she talked about sensitive issues for Ricki she would lower her voice almost to a whisper or mouth the words of what she was talking about. Such as when she would say, “Ricki doesn’t really have friends. He plays a lot of time alone,” or, “He has weight problems. He even has breasts.” His mom continued to talk while Ricki's two younger siblings crawled under the head of the exam table testing their what they could get away with during this new environment. And his aunt sat watchful, supporting what mom was saying and trying to help keep the other children entertained and inline.

I periodically confirmed details with Ricki. He was 12 years old; old enough to provide his own history. I continued to listen to mom get out into the air everything that she had on her mind about her son until everything was floating around in the room waiting to be grounded in her mind with diagnoses or next steps.

When mom was done, I shifted my feet, moving the swivel chair 45 degrees to talk with Ricki, a purposeful distinction that it now was “Ricki's time,” whether he was interests or not.

Ricki laid on his back on the exam table in his black comfortable t-shirt and black silky gym shorts with sneakers, bored by the details of his life that we had been talking about, completely checked-out from the conversation. As I called his name, he barely reacted, I wondered what he was thinking about and where his mind had drifted all those minutes. I can only imagine where my mind would have drifted having a stranger, my aunt, siblings, and mom all there while my health and flaws were placed on display, out in the open for why I didn’t have friends and was overweight.

Ricki, “I gently met his dangling foot with my foot to nudge him back to the room.
“How are things going for you?”

He shrugged, and I tried to approach the topic of school, “Are you excited for 6th grade?”

“Not really,” he replied.

“Why not? What’s going on at school….”

We continued on back and forth going over things that were happening with Ricki with his physical health and his emotional health. I was in no rush, discussing at length what was going on with them as the attending managed all the other patients for the morning swiftly, never behind for a minute, yet having mastered the art of giving adequate time to each child.

When I felt comfortable enough to leave the room, having gathering as much information about Ricki as I could in order to help him, I reported back to the attending who was already reading what I had wrote in the chart on the computer.

“Let’s go in together and examine him and sort out how to best care for Ricki.”

As we started to examine Ricki, he was resistant to us even touching him. He started crying when he was told that he would have to get into a gown or even just lift his black t-shirt to listen to his heart.

“I don’t want you to see my chest,” he begged.

He was embarrassed of his weight and desperately wanted to hide from the world what so many of his peers made fun of him for.

The doctor leaned into Ricki revealing his own secret, “You know Ricki, I used to be big too when I was your age. My mom didn’t take me to the doctor, and we didn’t know that I had asthma. Once, I was diagnosed with asthma, I was able to run and play easier.”

Upon hearing the doctor’s story, Ricki's chin lifted from his chest. His eyes brightened, and his saddened face lightened up, easing the resistance to the physical exam. It was just enough, just personal enough to offer Ricki some understanding for why he struggled with running the mile at school or even walking down the block to his aunt’s house, getting short of breath.

The attending smiled at Ricki and said, "I’ve been there, too.”

Saturday, November 29, 2014

My Love Seppy

Dear Seppy,
I have spent my entire day with your friend snoopy at my side: napping, watching football, reading and recovering from the hustle and bustle of this time of year. Anthony, Snoopy and I were at the park this morning playing catch when you were put down. I wish I could have been there to pet your back and whisper into your ears how much I love you, but I am selfishly grateful to not have seen you as sick as you were.

We can’t begin to describe how perfect of a dog you were. Aunt Betsy brought you into our lives when JoJo was just 5 years old and so sick after suffering from brain damage. JoJo came home from the hospital unable to communicate words she once knew and run and take steps like she used to do so effortlessly. You were hope, you were life, you were a ball of fuzzy brown energy that helped JoJo so much with her recover: helping her laugh, play and find smiles. You grew up sleeping at the foot of JoJo’s bed, on-top of her dirty clothes in front of her floor vent. You really were JoJo’s dog; although, we all loved you just as much as JoJo. You helped to carry us through this really rough time in our lives. You were something positive in the midst of all the negative and uncertainty of that time period.

You comforted Joe being the only other male in our family. We named you after him, giving you the name “Seppy” short for Giuseppe. You managed to survive in a house of seven females!

You continued to grow-up, and we continued to love on you.  You were such a family dog. I loved you so deeply. I ran with you through-out high school and when I came home from college. I cherished these runs together, looking forward to coming home to you. Until one time I came home and mom said I better not run with you anymore because you were getting “too husky!” Every time I came home to visit, you were my morning alarm, waking me with your huge head propped up on top of my body ready for a walk. Last Christmas, you woke me for morning presents. Visitors couldn’t sit in our house without your enormous head stationed on their laps. You made everyone love you, including Anthony, who loved to play with you. We took you everywhere. You became a true lab up-north at the cabin running up and down to the lake to fetch your bumper. You couldn’t stop, year after year, you loved that bumper and being up-north. And no matter how many baths you got, you always were such a stinky pup.

I am heartbroken with your passing. We have lost a member of our family today. I have lost a great friend and companion. I will forever cherish all the memories we have of you, our great beast. You were truly a perfect dog. Christmas will not be the same without you around, waking us for presents and being front and center all the time.

I love you my little, 150lb Seppy. My heart and all in our family’s are heavy, and we weep from your passing. You will lay to rest up-north, under the beautiful canopy of pine trees joining our former family dog “RB” in the endless peace and serenity of our cabin that you enjoyed so greatly. And you will rest forever in my heart.

I will love you my Seppy. Until we meet again....
Your Sarah

Monday, June 30, 2014

Thread by Thread

I remember the first time someone called me “doctor.” I was not sure if the person was talking to me or if there was someone behind me that he was referring to. I felt my heart start kicking my chest wall when I realized the person had locked eyes with me and was pointing directly at my body. I quickly, immediately, reflexively, deferred the role, putting myself rightfully at the level I was at, pointing to my school ID, “Oh, I’m not a doctor, I’m a first year medical student. Do you need me to get a doctor? I can get a doctor.” I didn’t even inquire what the person needed. Perhaps just a glass of water, perhaps advice on some complex medical issue, perhaps he just wanted to talk. I was not confident enough to explore the encounter and the “doctor” role. I was caught off-guard. I was scared of what I didn’t know and lacked confidence in conveying what I did know. I couldn’t even recall by memory what fasting blood glucose should be below, was it 100 or 126mg/dl?

I left that day thinking how incredibly powerful a white coat could be. In the morning, slipping each arm whimsically, mindlessly, in each sleeve, covering up your clothes, and hiding your identity below, you create a new identity. It was like a magical cloak of superpowers: regardless of your age, experience, or training, you just had to know the answer to what anyone asked you. And, there was an assumption of trust, immediate trust, silly trust, unearned trust, like the trust that a dog gives its owner no matter what the circumstances.

In addition to being in absolute awe of these new responsibilities, I was incredibly humbled and motivated by that experience. That day it was emphasized even more just how important it is to get things right. How important it is to fill your brain with every fact you possibly can. How important it is to try your hardest. How important it is to give this opportunity absolutely everything you have. Because, at the other side of this classroom, for what at times seemed like we are stuck in a never ending rabbit tunnel, someone exists who may be really sick, who depends on your help, who is going to place her life in your hands, who will lean on your judgment and expect you to have the confidence, composure, intelligence, and experience to be able to answer her question or find the answer to his question and guide him through to the next steps.

I don’t know what’s going to happen in a couple of days. I don’t know how my first day will go on my very first rotation. I may get lost trying to take a sample to the lab. I may get a parking ticket for parking in the wrong spot. I may fail to answer a question correctly when asked by an attending. I may forget to document a detail in the HPI. I may forget which drug belongs in which class of medications.  I may have to return a couple times to a patient’s room after forgetting to ask important questions.

But one thing I do know is when I hear someone call me “doctor,” I’m not going to stop in my tracks afraid of what I don’t know yet or nervous that I can’t remember every detail that we learned in medical school. I will step up and embrace the responsibilities of a third year medical student listening to someone’s story, sifting through the details with that person, combing out and deciding which are important and relevant medical details, recording every bit of their history, laying my hands on the person to examine them, offering advice when appropriate, looking up answers, knowing what my role is, knowing when I need to seek help and when I can tease out more information, and most importantly, learning from and respecting all the medical professionals who have come before me and what they can teach me.

I am ready to embrace the enormous amount of authority, leadership, uncertainty, fulfillment, and accountability that comes with wearing a white coat. I also know every day is not going to be perfect. I’m going to make 100s if not thousands of mistakes both small and inconsequential over my career and, I hope, not large and consequential.

So when we have what we think is the worst day of our lives. Everything seems to go wrong, we continuously are in the way, can’t stop being used as a punching bag by everyone higher on the totem pole, fall into tasks where we feel we aren’t learning, stuck in what seems like a jail rather than a hospital when we have a shelf exam the next day, burrow your head into your pristine white coat, close your eyes, take a deep breathe, and try to remember a part of your training. Any beautiful moment when you felt that you deserved the gravity of this white coat. I don’t think I have proven that I have answered that tall order. But maybe when I dare to speak up when I notice an error that will affect a person’s life, or when I research and present eloquently a topic that no one knew anything about. Maybe when I get a diagnosis right, or even more importantly a large enough differential. Or, maybe when I take the time and don’t interrupt a patient and just listen, just be in their stillness for longer than I should taking in their whole story. Maybe these little moments, maybe these small victories, I may just earn thread by thread, pieces of my white coat. And maybe one day that white coat will get a little longer. Maybe it will come past my hips. Maybe eventually one day it will hit my knees. And ultimately may be one day, I won’t even wear it anymore because everything that that white coat symbolizes will be a part of me and how I live my life.

So, today we wear the white coat. We wear this white coat with compassion for those who are ill like we will all become one day, admiration for others who have devoted their whole lives to caring for the sick, and  humility for all that I have learned and will have to learn as part of this vast medical and scientific community. We celebrate our small and large victories here in the classroom. But, not afraid to go forth and earn our coats, earning every piece of thread that makes up that white coat and continuing to lengthen it. We will turn around with confidence when we hear someone call us “doctor” and be prepared to navigate that bumpy experience, embrace the awkward turns and with each person we come in contact with on our journey, we will smooth the ride out a little more.

Today I am proud of myself. I am proud of who I have become. But, importantly, I hope that I am proud of that same person two years from now when I graduate wearing that white coat; two years from then when I am a resident wearing a longer white coat; two years from then when I still may be a resident; two years from then when I still may be a resident. And, two years from then when I may finally just be Dr. Jorgenson…maybe wearing no white coat.

Oh and one more thing, the fasting plasma glucose – fasting being eight hours – should be under 126 mg/dl for a healthy person.

This essay was written for our white coat transitional ceremony: "boards to wards" reflecting on entering clinicals my third year of medical school.

Wednesday, March 12, 2014

Getting Naked….at the Doctor’s Office

I got you to click on this post. I knew you would after Jessie Gruman, President for the Center for Advancing Health, crafted this catchy little title: Our Preference in Health News: Uncertainty or Naked Ladies? We got a lot of reads.

But, I have a more serious message than just getting you to click on a “Getting Naked” title: when we are patients, we need to wear the ugly, crunchy paper towel gowns at the doctor’s office. Though we are the experts of our own bodies and may notice abnormalities, we may miss subtle signs deemed medically important: swelling in our legs, suspicious looking moles, a rash, an enlarged lymph node, faint pulses, loss of sensation, funny heart sounds, marks, abnormal skin colorations, infections and the list goes on. That’s where a clinician’s request for the patient to wear the gown comes into play determining what may be medically worrisome or indicate a potential disease versus what is harmless. Clinicians need to see, hear and feel what is going on under those tight skinny jeans, blue work uniforms, baggy sports sweatshirts, and that blouse that defends you from the outside world.

Yet, I’ve seen visits where patients rarely undress, where the patient never puts on the gown. Clothes are maneuvered from side to side on the patient’s body to get as good view as possible of what is going on. Stethoscopes are placed on top of clothing to listen to the heart even if it’s not as clear as placing the cold metal directly against the person’s bear chest. Shoes are never removed in heart failure patients or diabetics. The physician places his hands on the stomachs through the clothing never seeing a scar that's been there for years.

I can imagine a number of situations where wearing the gown may be helpful:
  • What if that was abuse? The toddler walking with bowed legs. It is probably not anything to notice, but normal for someone who is just learning to walk, but what if there are “loop marks” from being hit with a cord under that toddler’s clothes interfering with her ability to talk? What if there are “donut” burn marks on her legs, like the one’s we saw in our abuse lecture that haunted my thoughts for weeks whenever I turned on the shower testing with my hand how hot the water was flashing back to the image of the child, across our large lecture hall’s projector screen where all her lower extremities were burnt saving only her butt which weighed heavy on the cool surface of the tub, leaving a “donut” burn mark as she was held down in scalding water
  • What if it was heart failure? The man who had a major heart surgery. The proof was the scar running up and down his chest like railroad tracks, the diastolic and systolic murmur you could hear swooshing inside of his chest wall, and the noticeable scar on his right leg, where possibly the surgeons robbed his leg of an artery or vein in order to save his life. His foot throbs, and he pulls up the leg of his pant to give a visual of the scar. Learning in classes along-side of podiatrists, all I could think about was getting him to take off his shoes so I can see his feet and look for swellings, feel the pulses, test the sensation, and look for signs of diabetes such as unhealed sores, while thinking still about this man’s damaged heart. 
  • What if it we misdiagnose, mistreat, or just miss something? The women with the bed bugs in her house and presents with little red bumps on her flexor surfaces: the front of her elbows, the back of the knees. The color of her shirt is shifted side to side. We examine her with her tight jeans shimmed up her body. Her sleeves rolled-up. What else are we missing though? A better view could occur if the patient would just wear the gown.

Is this good care?

I remember sitting at my doctor’s office on the exam room table staring out the window cloaked in the disposable gown doing my best to make it as comfortable and chic as possible, tying the strings around my waist as tight as possible, making a Diane von Furstenberg wrap with the gown, even though I knew I blanketing my body from the outside world from nothing more glamorous than “Brawny Man” paper towels used to soak up spills. As uncomfortable as it was wearing it (and especially waiting for the doctor in it), I would feel like I didn’t have the full appointment if I wasn’t in it. How could my doctor notice anything abnormal through my clothing or subtle signs of disease?

I do understand the possibility of preserving the comfort that clothing provides. There certainly is no reason to make a person jump into a gown if they are getting a medication refill, but yearly check-ups, I am less inclined to let people off that easy. Being a patient is uncomfortable, and you are vulnerable. Wearing the gown, just reinforces this relinquishment of control over one’s body that often accompanies illness.

But, the benefits outweigh this brief period of being exposed.

I recalled the day we had the complete head to toe exam that we performed in our clinical skills class. How easy it was to listen to the person’s heart and lungs, look for swelling in the lower extremities, and examine the abdomen, when the patient was in a gown. New parts of the history were revealed, too:

“What’s this scar on your knee from?” I’d ask.

“Oh, I forgot, I had knee surgery years back,” the patient replied.

We miss part of the patient’s history, health, illness, and story without the gown.

So, I’m sorry. I know how uncomfortable those crunchy paper towel gowns are (especially when we make you wait in them), and how baggy and awkward the light blue cotton gowns that will forever have that “hospital smell” even after thousands of times being sterilized. However, I’m going to have to ask you to “get naked.” It’s for your health.

Thursday, February 6, 2014

The Memories We Had

I lie on my back staring up at the white peppered speckled panels on the ceiling watching the fan spin round and round, as I bring the cold, thin, hospital infused smelling sheet closer to my neck imaging all the sick people who have come before me and wrapped themselves in this same sheet, in this same way. A tear sneaks out of the corner of my eye and slides down the side of my face landing on my plastic pillow case. My mind drifts back to just two weeks prior standing at the side of my dad’s bed watching his tears take the same path down the side of his face.  

My dad was a healthy man, a lot healthier than I have ever been. A slender, 150 pound, eighty-year-old man, of good stature with no health conditions. It seems like yesterday that I was visiting him in Puerto Rico for the holidays. We drank mom’s coquitos on the porch and discussed life. He asked a lot about my two girls and the grandkids, wishing they were here now and forever. I tried to convince him and ma to move to move back to America and live with us. We told a few stories about the past, but mostly, we were present in that moment, together, sharing time as father and son making up for the lost moments we had apart over the years, in separate worlds, land and ocean apart but under the same dark night sky. He shared things I never knew about him, and being home with mom made me feel like I was a little boy being cared for again….

“John, are you awake? May I check on you?” I heard with a light tapping on the door, as I broke away from my warm memories and was thrown back into my cold hospital room reality. “I want to check your vital signs. How are you feeling?”

“Fine. Just very tired,” I replied.

She was a warm nurse, extremely diligent and bright, ever so gently and meticulously placing the blood pressure cuff around my arm. I didn’t mind her. She was thoughtful and respectful of my privacy, unhurried and unrushed, quite different from the doctors who entered when they pleased, whether convenient or not, talked in what seemed like foreign languages amongst themselves as if I wasn’t present, poked and jabbed me with every instrument they could get their hands on and every test they could order with their pen, and then they left almost as quickly as they scuttled in.

“Are sure you are doing okay? You look a little shaken up,” she persisted.

I guess being in the hospital so closely following the death of my dad was hard for me. I barely had time to grieve before I found myself unable to walk, weak in the knees, swollen from my knees down and unable to drive to work or put on my shoes. I knew I wasn’t as healthy dad, but I didn’t think I was as sick as some of the people whom I see stumbling through the halls, thin and frail, pushing their medications beside them on poles, not to move again for the day after doing a lap around the ward. 

My reality came crashing down on me.

I hadn’t really taken my diagnosis in 1997 of diabetes very seriously. Sure, I had given up eating less of some of my favorite foods, but I didn’t make any substantial or consistent life changes. Except for a year ago, December, my motivation peaked, and I got my weight down to 230 pounds. I was eating a lot of vegetables then. But, life marched on, and I fell back into my old routines. 

I lie here wondering if I will reach with ease the age my father died at. My reality feels numb today and the last few days. I am saddened, confused, and in disbelief that I will never see my dad again. I stare up at that white peppered ceiling and cry. I cry for the man the world lost. I cry for my mother who will sleep beside an empty pillow tonight and every night that follows. I cry for my grandchildren who will only remember pictures of their poppy. And I cry selfishly for myself: for future untaught lessons that I will never learn from him, for the silence on the other end of the phone when I call to talk to him, and for the end of sharing coquitos on warm evenings telling and making stories on the porch.

The nurse interrupts my thoughts as she reaches over and holds my hand. I let the tears pour down. She comforts me, assuring me that I am in a safe place. And, I release the sadness that I feel.

This essay was composed for my Clinical Reflections course exploring narrative medicine. I was to write a patient’s story in ordinary, nonmedical language and tell the story as if I was that individual. 

Monday, November 18, 2013

I Don’t Know What It’s Like…

I don’t know what it’s like to not be able to pay for your medications, even if it’s a drug for high blood pressure and is on Walmart’s $4 drug list. I don’t know what it is like to describe having left-sided weakness and numbness, vision loss, and tingling possibly indicating having had a stroke a few months ago on top of having unmanaged diabetes, blood pressure and, and hyperthyroidism and not having health insurance to seek regular care. I don’t know what it is like to get out of jail only to find out that your prostate cancer has metastasized to your spine, pelvic bones and lungs. I don’t know what it is like to have your foot run over by a car and not seek care for four months for various reasons, limping up and down the stairs of your three story apartment as life marches on as a mother of three children. I don’t know what it is like to have a mental illness and have trouble getting care and continuing your treatments. I don’t know what it’s like living on the streets, having marks all over your body, and needing pain medication. I don’t know what it is like growing up or living in a neighborhood blanketed in poverty, streets stricken with bullets and contaminated with fear.

So as I sit three feet across from you leaning in and listening to your story and your illnesses, there is nothing that can fill that space: that gap of differences in experiences between your life and mine.

What I do know is that I have been without health insurance at times in my life and understand the deepest fears of getting ill. I have seen someone I love have the same look on their face as the one you have today, worried about his future with the illness and depleted fighting what ails his body. I have avoided care because of fears of costs and medical bills just as you have. I have felt the pangs of being so ill to the point that you curl up “feeling like you are going to die,” which is how you have placed yourself on the examination table today. I have had troubles navigating the health care system, too, and getting the care that I or a loved one needs.

I do know, like the other people caring for you today, we have had ourselves or have cared for someone who has had the same anxieties, troubles, and ailments that torment you today. We care deeply about your health, week to week re-seeing you, coordinating your care, managing your medications, and helping you to get services, including health insurance, and the referrals that you need to see other doctors. We cast aside our judgments as best as we can, knowing that our lives are also far from perfect, and work to deliver care that will help you live longer and improve the quality of your life. We think about you long after we have left the four walls in that examination room, when we are walking our dog, at the gym working out or making dinner at home. We worry if you picked up your medications on time and if you are taking them properly, if you are well enough to go to work and if you got a ride to the appointments with the other doctors that we scheduled for you.

I sit here today, reflecting on the difference between your world and mine, how that three foot gap between you and me will continue to grow as I continue on my path to becoming a health professional, as my life gets more comfortable, more cushy, and the worries that keep me up at night may never be exactly perfectly the same as yours. I think of how only a few miles away from my doorstep, not cities, not oceans, not continents away, I see your face and your body as you struggle with your health and health care and ponder how I can continue to care for you and to be a part of your path to getting you better and maintaining your health: to allow you to see the doctor when you don’t have a dollar to your name, to prevent another abdominal aortic aneurysm, to help you manage your diabetes, to get you the mental health care services that you need in order to keep you off the streets, to provide the prenatal care to your first daughter,  or to keep your blood pressure under-control.

You have brought your family to me. You have welcomed me into your life, into your world, to care for you. I am up for the challenge. We are in this together.

This essay reflects on my clinical experience in a low resource community for an elective course for medical school, specifically working in a federally qualified health care center which provides care to the uninsured and allows people to pay on a sliding scale basis.