Today I got my grades from the psychiatry rotation, back at the beginning of the year. Could someone please explain how I could score ninety-eight percent on the SHELF exam, without believing a word of it? I had to fight myself all the way through that test, not to to write an essay in my head for how each question was crazy, not to spend the time speculating about what I would say if I really met a person like that; and I must have missed only one or two questions. Without believing it. I wish I could do that well on subjects I do believe! 

My overall score was considerably lower, thanks to my clinical evaluations. Which is sort of disappointing, but I would have had to score fives in every single subjective area to come near that SHELF score. Moreover, I got a higher grade from the outpatient doctor, in whose office I sat still and attempted not to scowl at her recalcitrant schizophrenics, than from my inpatient attendings, in front of whom I at least spoke every now and then. I guess the more opportunity they had to see my skepticism, the lower I scored. That part’s logical.

Medicine really is about believing things. I’m learning a faith, and my profession is supposed to be to act on that faith. I’ve never seen a virus; but they tell me they do amazing things; and they also tell me some medicines fix that. I have actually never yet seen a person in DKA (diabetic ketoacidosis) (although I sure hope I do before I graduate) but they tell me they exist, and that their electrolytes go up and down, and one ought to do thus and so about it.

In fact, as far as I can know anything, I know that most of the medicines we prescribe will only help sixty to seventy percent of people. But I’m learning to hand them out with the authoritative statement that “this will cure what ails you.” I don’t know that; I’m told to believe it. I feel like the world keeps sliding in and out of perspective. Most of the time I’m solidly inside of this conspiracy, this Matrix, and everything is smooth. But every now and then the frame shifts, and I hear the ridiculous things the doctor is saying, the ridiculous things I’m supposed to say, and I don’t know how anyone believes us.

I’ve learned a lot about how a doctor ought to look and act this last month. Back at the beginning of this year, I think I expressed some concern about the possible dishonesty of pretending to know all the answers when I don’t. My preceptor does a beautiful job of this. He responds to every question with the exact same expression of polite concern and certainty, whether it’s a sprained ankle, new onset atrial fibrillation, his favorite allergic-rhinitis-that-needs-an-antibiotic, or some puzzling syndrome of muscular weakness. Sometimes the answer is obvious; even I can recognize it, once he’s said it. But sometimes we get back to our charting station, and he shrugs his shoulders, and says, “I don’t know what she’s got; she does that all the time.” And I would never have guessed it from his authoritative explanation and instruction to take this or that medicine. There is no correlation between any puzzlement that he lets on to me, outside the room, and his confident manner in front of the patients. I suppose that’s proper and necessary. After all, there will certainly come a day when you face a serious puzzle, one that will certainly turn into cancer, and you can’t discourage the patient by raising your eyebrows and saying, “I never saw that before.”

I’m rambling on about this because I noticed, especially over the last month, that I’m getting good at this, too. I no longer look as surprised at weird rashes, or ominous symptoms. I speak confidently, assure the patient that my preceptor will know exactly what to do about it, and step out of the room decisively. In this office I didn’t often tell the patient, even when I was sure what it was, because I had such a bad habit of disagreeing with my preceptor, and I hate to look foolish when he decides to prescribe the expensive, high-powered antibiotic that I just explained was unnecessary. <grinding teeth> But I have not yet achieved his comfort level with ordering medications, even not antibiotics, in all directions, and assuring the patient that that will fix everything.

This is why I need to do something surgical. Surgery fixes a visible illness – I’ll know for myself that it’s there – and the results are immediate and visible. I can’t wait for my ob/gyn rotation; I sure hope it’s not this disillusioning. There is no way I could be happy practicing modern American medicine. It’s all smoke and mirrors and paperwork.

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