Issue 5, April 2010
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Robert Isenberg
I’m lying on a cushioned table, and five people gather around—two men, three women. I stare at the ceiling panels to avoid eye contact because my gown is pulled up and bunched around my neck, exposing my chest and belly. I’m self-conscious about the curled matt of hair that smiles along my pectorals. I feel a little muffony around my belt-line. My farmer’s tan is exposed, so that everybody sees the brown of my arms and the bone-white of my torso. But I can’t see it; the mound of gown has blocked my view.
The light is low, and a laptop beams quietly next to me. The unit is like any other laptop, except for its extra-thick body and the dials that flank the keyboard.
This is nameless company. The people in the room haven’t bothered to introduce themselves. They’re just heads, bobbing in and out of sight. They lean forward, fall sideways, jerk suddenly to toss hair away from lashes.
“I think I need more lube,” a man says.
The man looms over me, holding a plastic rod in the air. It’s about the size of an electric toothbrush, except that the tip splays out, like the head of a hammerhead shark. The man is tall, broad-shouldered, and his eyelids droop. His meaty hands grab an arrow-shaped bottle, and he squeezes blue gel across the head of the probe. The fact that this is called a “probe” makes me anxious, and I can’t help but think of flying saucers, bright lights, extra-terrestrials, ripping sounds—
The man presses the probe against my ribs. He does this slowly, so my skin can warm the cold gel, but then he pushes it firmly. Two ribs ache from the pressure – I think how rare this is, that my bones are forced against an object. The ache evolves into stabbing; I can feel the skin depressing and squishing against my tubercles.
The man’s face doesn’t even twitch. He looks bored, even. Another day, another ultrasound. “I can’t find it,” he murmurs.
Juan has appeared. His is the only name I know. He’s an odd-looking man—his face looks like mashed putty; his brows and cheeks drip into each other, melted, a visage of ongoing concern.
“Let me see,” Juan says, and he takes control of the probe. He presses harder than the other man did, and my teeth grind, my eyes go back. There’s nothing I can do; this isn’t even the part that causes discomfort. Just wait for that.
I look sideways because movement has registered on the laptop. The screen is grainy, black-and-white. I’ve seen this image hundreds of times before, but always of other people, always women, expectant mothers. I’ve seen this image pasted against refrigerators and flaunted around offices. People have sent me this image by e-mail, along with captions and exclamation points. But now the image is mine. Me, a 29-year-old male, some red-bearded guy lying on a table, half-naked, now remembering that my navel is probably packed with lint, how embarrassing. But what does all that matter?
I’m looking at my own heart.
It’s a vague outline, a soft triangle, but each beat is a powerful throb—like an animal wrapped in a bag, punching in every direction at once. The grays of its surface are darker here, brighter there, but even in this grainy rendition, the muscles look smooth and soft. The ache feels trivial now—a tiny price to pay for a glimpse at my most essential organ. I consider how much this muscle has done—how it has pumped each platelet of blood through my body, once through my circulatory system per minute; it has beat since before I was birthed. This bulbous monster, flexing manfully on-screen, has so often accelerated for joy, burned from loss, gone nearly silent on cold winter nights. It has knocked in my temples through every migraine; trilled in my wrists after sprints. It has alerted me in moments of panic, quieted for sleep. And now I see it, an anonymous friend, a pen pal standing at my front door.
“There it is,” Juan says.
We’re called “standardized patients.” The idea is that every patient is controlled, or standardized, so that students can practice precise skills.
When I describe it to friends, the explanation is simple: “I help train doctors in bedside manner.” This gets the message across, but it’s a little more complicated than that.
In the old days, med students became physicians without ever seeing a live patient. They learned biology, anatomy and physiology; they learned the name of organs and tissues and types of cells and the systems that tied them together. They learned all kinds of medical practices—CPR, surgeries, transplants—and slowly, after thousands of hours of classroom learning, the students mastered their knowledge of the human body and how to preserve it.
Years ago, I interviewed a doctor about simulation techniques. He described simulation as essential, because a doctor who has no hands-on experience can be more deadly than no treatment at all. He used the example of intubation: Doctors often have to insert a tube into a patient’s throat. This is a common practice, used for all kinds of situations, and nearly every doctor in the world may resort to it. But the human throat is a sensitive place; there are many delicate muscles at play, and the tissue is vulnerable to puncture. It doesn’t matter how soft or flexible the plastic tube is; if a doctor has never tried intubation, the tube could rupture the esophageal passage, and the patient will choke on his own blood. There are plenty of safeguards—doctors are trained in the Cormack-Lehane grading system to predict the ease of intubation—but the bottom line is that a new physician would at one point lose his intubation virginity, and for decades, doctors had to practice on live patients.
Today, almost every medical student in America practices on a synthetic body—a realistic-looking dummy with vinyl plastic skin and polyurethane muscle. The head is designed to tilt back, with exactly the arc of an authentic human neck. The throat offers the same texture and resistance as an actual person’s, so that medical students can practice over and over without ever threatening a live patient.
There are countless other examples, and nothing beats a real specimen of Homo sapiens. But modern medical training now relies on simulated patients to create a safer, bloodless version of the O.R. experience. In this standardized environment, doctors can make endless mistakes. And as everybody knows, making mistakes is how we learn.
But mannequins can’t teach everything. Doctors can master every cell of every organ and still be terrible doctors. Doctors must know their patients, as human beings. They must prepare for strange back-stories, weird habits, ugly relationships, destructive urges. Most precarious of all, doctors must haggle with human emotion. So many doctors are bookworms and valedictorians, the children of privileged families; they’re not “people” people. They may not flinch at the sight of third-degree burns, but they’re clueless in the presence of a grieving spouse. They might massage a stopped heart until it beats—a miracle of cardiology—but the suicidal stress of a broken heart baffles them. Medical students prepare for exams and rotations, outfitting themselves for the pressures of a non-stop 48-hour shift in the E.R. But if they can’t explain their procedure in plain English, frightened patients may struggle, scream, try to escape. This is one way people die.
So here’s where we come in.
When I met the doctor in the lobby, he introduced himself only as Juan. Not his last name, just Juan. Then he said, “This is your first time?”
“Yes.”
“Well, the needle will only hurt for a minute,” he said flatly. He held his forefinger and thumb in the air, splaying them as far as they could go. “The needle is only this long.”
I squinted at him. Needle? Nobody said anything about a needle. What are you talking about? Do I need to call somebody about this? Is this—
“Only kidding,” Juan said, and patted me on the shoulder. “This won’t hurt at all. Really, you just have to lie there. The students do all the work. Most people fall asleep.”
After some corridors, I stepped into an examining room. I’ve seen a lot of these lately. I’m surprised how different they are—as diverse as closets and cubicles—but always containing the same accoutrements: a bed, a few work-stands, mysterious drawers, a canister of sanitizer by the door. I recognized the box of latex gloves, the trashcan stenciled “biohazard.” This room at least has windows; of the three blinds, two are fully closed, the last half-drawn, revealing a view of Oakland; the rooftops of houses; the pale blue sky.
“And what is your name?” Juan asked.
His voice was gentle, and he awaited an answer, but I wasn’t sure what to say. We didn’t cover this in training. For the past two months, I have been a number of people—most recently Ken and Tom—but do I need an alias here? Does anyone care who I am? Will they bother to remember my name? Then I considered running into Juan in real life—at the supermarket, or worse, in a café or bar—and I wondered whether this man would saunter over, say hello, ask what I thought of the ultrasound?
“Robert,” I said. It slipped out. These thoughts occurred in a millisecond, and my lips just dripped. I would never make it as a spy, or even a therapist. I can’t keep a secret to save my life. Not when the secret’s mine.
For now, I’m probably safe. These students are too advanced, too close to graduating medical school and moving on to internships and residencies. But secrecy is precious. I can’t make this mistake again. Even a first name, broadly known, could blackball me forever. As a standardized patient, I can be a hundred different people. But for as long as I work on hospital grounds, I can never be myself.
The ultrasound is unusual. Usually I do Medical Interviewing. It’s a required class for all first-year medical students. This is where the real acting happens.
Students are divided into groups of ten. On class days, each group is stationed in a different classroom. Each standardized patient is assigned to a different group. We’re given a name, but also an entire dossier of other information: age, occupation, medical history, temperament, family background, current medications, and sometimes even pets and unusual habits—literally, the story of our lives. We spend hours memorizing these details, because every detail is important. If a topic isn’t listed—such as, say, my grandfather’s name—and a medical student asks, we must make this up on the spot.
Here’s how it works: Enter the room. See the students. They mill around. They look at me. I don’t look at them. Find a chair and sit. A facilitator speaks. She is a physician, or R.N., or social worker. I sit in the back, but I don’t doze. I watch the facilitator write on the wipe-board. When eyes flash toward me, I look away. I stay mysterious. I’m invisible. Pay no attention to the man behind the curtain!
Another S.P. is seated across the table. She is warm and freckled. She glances at me and smiles. Her nose crumples. Isn’t this fun? she seems to say. But we don’t speak to each other. The facilitator discusses Important Business. I can’t interrupt. My voice is forbidden here. Until I’m simulating, I’m flat. Dead. Non-existent. The students mostly ignore me. This makes the process easier. I half-listen to the facilitator. It’s a mini-lecture about what I’m covering.
“Remember non-verbal supports,” the facilitator says. “Nodding, keeping eye-contact. Also verbal responses, to show interest. Huh, or, That must be difficult. You don’t want to lose your patient. Stay focused…”
A second facilitator nods from the table. “That’s right,” she says, agreeing. The two facilitators stop speaking. They wonder what to do next. “Should we divide the room?” one says.
“Yeah, let’s do that.”
“How do we want to divide up?”
The ten students stay seated. They wear white lab-coats, but they look too young. The facilitators break them into two groups, five and five. They pull dividers out of the walls. They slide along a track, unfolding accordion-like. When the dividers meet in the middle, they click shut. My fellow S.P. is lost behind the new wall. Five students have vanished with their facilitator. Now it’s just me. No spotlight. No stage. Just the corner of a classroom. A chair. I sit down.
The chair must always face the door. This way, the students see me as they “enter.” But they don’t “enter.” They don’t even step outside. Everything happens inside this classroom.
“Who wants to volunteer?” asks the facilitator.
The students wait. After a silence, they titter. They trade glances.
“I guess I will,” says one.
He goes to the door. He shakes out his arms, like an athlete. He’s nervous. First-date nervous. Bungee-jump nervous. I want to assure him, Dude, it’s cool. But I can’t speak. I’m blank. I stare at the floor, arms on armrests. My ankles cross beneath me. I wait for the knock. The student will knock, and then the scene begins. Lights, camera, knock!
He knocks. “Mr. Wheeler?”
It’s always the last name. Always “Mr.” Do I even need a first name?
“Come in,” I say. Mr. Wheeler doesn’t mind strangers.
The student “enters,” but he pauses. This is the weirdest part. He must introduce himself, but also sanitize. He turns to the anti-bacterial gel. It hangs by the door. He presses the knob and transparent gel squeezes out. As he rubs his hands together, citrus scent abounds. Then he turns to me. He smiles.
“My name is Udayan Ghosh,” he says.
I extend a hand. “Mr. Wheeler,” I say.
But Mr. Ghosh pauses. He wipes his hands on a pant-leg. He mumbles, “Sorry, my hand’s a little gross.” Then he shakes my hand. I wonder: Why anti-bacterial gel, if he wipes on his pants?
“Do you mind if I sit down?” Mr. Ghosh says.
“Uh, I guess not,” I say. “Are you the doctor?”
This is my personal touch. I want him to explain himself. These early med students often don’t. Why are they here? Who are they? This is important. Patients want precise information. They want confidentiality. They won’t just talk with anybody.
“Oh, no,” Mr. Ghosh backs up. “I’m a medical student at the university. I’m taking a class in medical interviewing. Could I ask you a few questions?”
They all say this, but I’m not satisfied. I want him to sweat. “Any particular reason?” I say.
“Oh, yes, of course,” says Ghosh. He bows slightly. I want to laugh, but my expression is “confused.” Ghosh gushes: “I was hoping to practice my medical interviewing skills.”
“I see,” I say. I shrug. “That sounds fine.”
“Thank you,” says Ghosh. We both sit down, in cushioned chairs. We sit opposite, like morning-show hosts.
“So what brings you in here today?”
And cut.
Consider these rituals. Knock on door. Wash hands. Introduce. Shake hands. Explain. Get permission. Sit down. It sounds so simple, but it’s not. This is the med student’s first week. They’re terrified of these simple rituals. They may know every gland in my body. But they struggle to say their own names. Med students have broken down and cried. They convulse with fear. But I don’t blame them. They’re being watched. A facilitator and five students sit in a ring. They are the audience. They will offer their advice and support. But they also scrutinize. This is a kind of audition for them, too. They are showing “people skills.” And for years and decades, this will recur. Hello. My name is. May I ask you? This is as vital as any incision.
I think about all this as a woman takes the probe.
I noticed her in the corridor—how could I help it? She is fit and petite, and her caramel skin smoothly envelops youthful curvature. Her black hair is wrapped into a ponytail, the simple style I’ve always loved. She presses the probe between my ribs, as before, but now I’m ignoring it, because my chest is puffed out. On the monitor, my heart’s thrumming has quickened. I’m conscious of my long breaths, which have grown deeper—oxygen flooding me, carbon dioxide escaping past my chapped lips. I notice her lips—a thin line, the mouth of a serious doctor-to-be.
“I can’t see past his lungs,” she says. “Could you stop breathing?”
Everybody chuckles.
“I mean…” She shakes her head. “I mean, could you exhale for me, and then hold your breath?”
I’ll do anything for you, doc.
I exhale, as advised, but now the simple task of holding my breath—something I could do anytime, anywhere—is a physical feat. When her brow furrows, I try again, and succeed. I hold it all in, what remains of my air, and I stare at the ceiling. I can’t look at her. It’s painful. Her eyes are cool but piercing. I try with all my might not to gaze at the neckline of her scrubs, where a silver necklace bears two tiny, interlocked rings. But how could I see this if I’m not looking? You’re looking! You idiot! Don’t notice the subtle shadow of her clavicle, the way it intersects with the serene line of her neck! Don’t examine her delicate cheekbones, set high and proud in her silken cheeks! Stop it, goddamn it!
And then I stir. I’m old enough to resist a full reaction, but I can feel myself inflating, rolling sideways. Even through my boxers, I can feel the gridded texture of my zipper. I stare at the florescent light until it becomes a blue blob that burns into my retinas. I try to think of anything but this woman. I try not to hear her sparrow-like voice, the way she rolls her Spanish R’s, the naked confidence of her tone—
“Okay,” says Juan.
Juan to the rescue.
“Try the other side.”
“The other side?” the woman says.
“Over here,” says Juan, pointing to the opposite side of my ribcage. “This is probably the most difficult place to examine.”
“Oh, I see.”
But I don’t see—not until the woman leans over me, her chest grazing mine, and her arm wraps around my side, then presses the probe into my bones. Oh, I get it. It’s hard for her because she has to reach across me, I think. It’s hard for me because this is goddamned torture.
“Just breathe normally,” she says.
Fat fucking chance.
The breath that streams from her nostrils tickles my chin, and I try to look away, now that she has blocked my view of the ceiling. I look to the side, where her spare arm is bent; her hand is locked against her waist. She looks like a colonial horse-rider, one arm akimbo, the other grasping the reins. Except that I am the horse.
The woman moves her free hand. It flashes from her waist to the examining table. She is clutching the end of the bed, and her wrist touches my shoulder. But no, it’s not her wrist – it’s her hand; she is touching my shoulder, using it for leverage, but softly. Now everything has spun out of control, because this is not what a medical student should do. Touch, yes, but not in this familiar way, not with unnecessary fingers, unnecessary contact. It feels as if an invisible wall has cracked, a wall built by thousands of years of codes and oaths and ethical treatises. Knowing my given name is one thing, but for our bare skins to conjoin—the whole of Western Medicine implodes. In this world of barren white walls, disposable gloves, chronic scrubbing, we are now a breath away from anarchy.
Then she’s done.
“Okay, gotta run,” she says, and flies out the door. And that’s that.
The big man takes the probe, and more students enter. The room is even busier than before. They hover around, eager. They all want a shot at seeing my innards.
One student presses hard against my solar plexis. This is real discomfort—the part Juan said would hurt a little—but I’ve prepared for it, hypnotized myself against it. They dig the probe along the bottom of my ribcage, daring me to struggle. Suddenly it tickles—I’m very ticklish—but I bolster myself against it. This is not real pain. I imagine hot coals, broken limbs, fractured skulls, torn ligaments. This is nothing.
At the very least, I’m flaccid again. Thank God.
A woman with papery skin and curled blond hair steps into view. She runs the probe along my stomach.
“I can’t find the heart,” she says.
I take a chance: “My ex-girlfriend was right,” I say.
All heads jolt my way. I haven’t spoken this entire time. They’ve never even heard my voice.
“What’s that?” she says.
“I guess I don’t have a heart.”
She giggles. Prettily. She glances at the screen, then sighs. “No, wait—there it is.”
And we’re both relieved.
A male doctor leans in. His haircut is prim, his face dusted with freckles. He nods firmly at the screen, then to me. He strives to make eye contact. He says, “You have excellent anatomy.”
“Thank you,” I say. Because what else can I say?
I have a personal stake in this business. A few years ago, I had a memorable check-up with Dr. Schultz.
Dr. Schultz was a beanpole with a sandy mustache. His glasses were large and round. He shook my hand with bony fingers and asked me to sit down on the edge of the examining table. The paper sheet rustled beneath me, the only sound. The room was sleepy with florescent light. As Dr. Schultz sat down in a cushioned chair, I noticed the poster above his head.
ABSTINENCE IS 100% EFFECTIVE
In the waiting room, several portraits of Jesus Christ hung on the wall. Wearing a beard and toga, Jesus smiled to his flock of followers as Elysian light shot through the clouds. A quote from Psalms floated above; I couldn’t understand the Jamesian verse. Half the magazines were issues of Watchtower, the publication of Jehovah’s Witnesses.
This was not a role. This was my actual care center: The free clinic in East Liberty, one of Pittsburgh’s more underserved neighborhoods. The clinic was surrounded by acres of parking lot, where the concrete was broken and grass tufted from the cracks. The building was flanked by long-closed outlets and nail salons; the windows were shaded and splattered with graffiti.
This was my first check-up in 10 years. Friends and family begged me to go, “just in case.” It felt absurd. Suppose I did have lymphoma or something—what the hell was I supposed to do about it? Cross my fingers? Light a candle? I didn’t even have time for a support group. I had completely given up on affordable health insurance. One broken leg could mean eternal bankruptcy. So I just stopped thinking about it.
Finally, someone told me about the East Liberty clinic, where I could arrange a check-up for a measly $15. This was a good price, even by my miserly standards. I could weather a little biblical imagery if it meant some one-on-one time with an actual physician.
Dr. Schultz’s voice was pinched, and his long nose-hairs were distracting, but he moved swiftly through the medical interview, learning about my habits and history. When he learned my weight—195 lbs—he knitted his puffy eyebrows, then shook his head.
“You really could stand to lose a few pounds,” he said.
This was strange advice to hear—I had always been svelte, and I only gained a few pounds in the winter months; the fat was usually shed in the first weeks of spring. When I consulted Dr. Schultz’s chart, I was shocked: For my height, 195 lbs is not overweight. It’s obese.
“We should really do something about that acne on your back,” he said, clucking his tongue.
Not since high school had I even noticed the acne on my back. I craned my neck to see it, and suddenly my back felt flabby and blistered. All the adolescent shame of disrobing for the public pool rushed back, blushing my cheeks. Except that when I was a teenager, I was also thin.
“Are you sexually active?”
“Yes.”
“But you’re not married.”
“Uh, no.”
Dr. Schultz leaned back in his chair and sighed loudly. “You know, a lot of people are anxious about getting married. But it’s really a very smart decision. There are lots of benefits. Taxes, for example.”
I squinted at him. Say what?
“I’m assuming you’ll want to start a family one day,” Dr. Schultz continued, “and if you find yourself committed to someone, you should probably consider making it official.”
In moments like these, I wish the room was bugged. Is he really saying this? Is marriage counseling part of his contract? Or does he just do this for fun?
The interview bumbled along, but Dr. Schultz’s one phrase echoed in my mind: I’m assuming you’ll want to start a family one day. As in: I’ve known you for five minutes and feel confident guessing how the rest of your life will unfold. As in: Jesus and I were talking, and we’ve decided you’d better start planning your nuptials before somebody gets knocked up.
It wasn’t all the New Testament iconography that bothered me. It was Dr. Schultz’s condescending tone. Here I was, visiting a doctor under the best possible circumstances, and Dr. Schultz had made me feel incompetent, impious, out of shape. But more than anything, judged.
I paid the $15 to a smiley receptionist, who told me to have a good day. But the afternoon felt nothing like a good day. I wandered the shattered streets of East Liberty, feeling heady and judged—and obese. I cursed everyone who had convinced me to come here. What had I earned, besides a pleasing blood-pressure report? I was in good condition, except for an occasional cold. No STD’s, no blood disorders, only a couple nicks and scars. I’d even avoided tattoos. Aside from going vegan and jogging five miles a day, how could I possibly be healthier?
I met with Dr. Schultz three years ago – and for the next three months I ate like a teenaged cheerleader and biked more fanatically than usual. The interview had lasted only 20 minutes or so, but Dr. Schultz’s words continued to haunt me. Why was marriage so important to him? Aside from my physiology, what stake did Dr. Schultz have in my romantic life? Had he been my family doctor, someone I had known and trusted my entire life, I could imagine chatting about “the future.”
I think about this as I pass med students in the corridor. When they converse, ignoring my presence, I steal glances at their young faces—so energized, so intelligent. In the corridor, they gab about their tests and techniques.
“Can you believe that anatomy final?”
“Dude, don’t worry about it. They’re totally gonna scale it.”
“I fucking hope so.”
“Not gonna lie—it freaked me out, too.”
In the corridor, they’re just ordinary people, college kids, awkwardly outfitted with lab-coats and nametags. But one day, they’ll pass their boards, and some of these people will get dumped into a dumpy free clinic. And I’ll be damned if any of them transform into Dr. Schultz.
“Thank you, Robert,” Juan says, and he shakes my hand. This would feel so much more comfortable if I hadn’t just taken off my gown. It’s so rare to be standing indoors, shirtless, shaking hands with another man, who is fully clothed and even wearing a tie. I can’t remember a single other time this has happened.
I struggle back into my shirt, and when it fits against my skin, I feel the globs of lubricant dampening the fabric. I spend a few seconds hastily dabbing the gel from my body, but still I feel moist, slathered. I have officially sold my body to science, which always sounded noble. But after stripping, lying down on a strange bed, staring at the ceiling, getting lubed up by unfamiliar hands, and then watching others scrutinize my body, I can’t shake the grimmer associations.
I walk past the receptionist, feeling a little dizzy, a little unsure of my feet. I take a wrong turn, toward the restrooms, and have to turn around, because I completely missed the two beige elevator doors. In a kind of tunnel vision, I see the elevator button, but another hand reaches in front of me; a finger presses the button; it lights up. The hand is soft and brown. It connects to a set of green scrubs, and when I take in the full person, I see that it’s the woman with the Spanish R’s.
We are standing together. There is nobody else in the lobby.
She nods to me, her lips pressed firmly together. I nod back, but the nod takes control of my entire body, and I feel as if I’m bowing to her. I wait in silence with this strange woman; I don’t know her name, and yet she knows exactly what my liver looks like. When the door opens, we both shuffle in and stand on opposite sides; we stand as far apart as two people can in a 50-square-foot elevator. When neither of us presses a button, she mumbles, “The ground floor is M.”
I press the M button with the star next to it. “Thanks,” I say.
The sun welcomes me. The fresh air hasn’t tasted so sweet for a long time. I am 29 years old, perfectly healthy, and I’ve spent the past two months floating through hospitals. Today, before taxes, I’ve earned $52.
In a few days, I’ll have lymphoma.
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