A medical student in therapy

On TV shows, therapists decorate their rooms with leather lounge chairs, throw pillows and organza curtains that let in the light.

But Dr. Hassan’s office is in the clinic basement. The fluorescent lighting is sterile. She has a gray metal desk — I think every doctor I’ve shadowed as a medical student has had that same desk.

But I’m not here as a student.

I’ve been anticipating this appointment for a month. In March, I started to take an online physiology exam for school but instead spent twenty minutes staring motionless at the computer screen. I eventually input the answers and passed the test, but I’d stopped caring.

A week later, I had a panic attack while riding the 6 train through Midtown Manhattan at rush hour. I’d already been feeling trapped by the tightly scheduled lifestyle of a medical student, and getting sandwiched between strangers inside an underground tube of concrete didn’t help.

In late April, I scheduled an appointment with my school’s counseling program. An attending psychiatrist did my initial interview: She was warm, and we spoke for over an hour in her well-lit office before she referred me to Dr. Hassan, one of her residents.

Dr. Hassan’s soft voice makes me aware of the silence surrounding us. I hear no coworkers rustling about outside her basement-office door, no printers whirring in the background. Her movements are slow and deliberate.

This appointment feels different from my meeting with the attending. I feel like I’m repeating a step. The idea of reiterating what I’ve already told the attending makes me feel like a fraud — like I’m reciting sentences from a play, mouthing words that don’t belong to me.

I notice my hands clasped in my lap, my slumped shoulders and crossed legs: classic signs of “discomfort.” In my first year of medical school, I’ve been taught that these are indicators of an anxious patient.

That’s a bit simplistic, I’ve thought. Patients wouldn’t betray their apprehensions so easily. But now, I feel ridiculous.

Quietly, I make myself lean back in my chair and uncross my legs. I force a smile.

Dr. Hassan looks up from her notepad. “Any trouble sleeping lately? Or too much sleep?”

She’s assessing my depressive symptoms. Next, she might ask me about feelings of guilt.

It may seem strange, but I’m not used to opening up to doctors. For the past few months, the only doctors I’ve spoken to have been my teachers, whom I’ve approached solely with the aim of getting better grades or networking for a better career.

“Well,” I respond, “I’ve been lying awake in bed for hours in the morning.”

That wording is a little too textbook-perfect, maybe. Am I telling the truth, or just reciting the symptoms of an illness I’ve studied?

“Any loss of motivation?”

Yes.

“I don’t know,” I say.

I’ve lost a lot of motivation, I reflect, but I doubt that it’s enough to warrant complaining to a doctor. I’ve seen patients with major depressive disorder huddled in psychiatric wards. I’m a somewhat-functioning medical student. Who am I to feel that I deserve the same level of care as those patients?

I keep smiling — wondering what she can see, wondering what I can control. Should I slump over again? Wring my hands? Do I want her to say that I’m depressed? What if she ends up telling me that I’m completely fine? Would I want that?

I don’t think so. There’s a comfort in thinking that I cannot hide or influence my diagnosis — that I cannot purposefully or inadvertently mislead the doctor.

Last year, I tripped on a sidewalk crack and sprained my foot. It wasn’t serious; but after a few weeks in a walker boot, I had a follow-up with an orthopedist, Dr. Cohen.

“So, an inversion sprain,” he said, writing something on his clipboard. “Do you remember anything else about how you fell?”

“No,” I said, trying to pull nonexistent details from my memory.

He continued to scribble. A few seconds passed. He still didn’t speak. I tilted my head a little, trying to catch his downturned eyes.

A minute passed. Two …

“Um,” I said, after at least three minutes. “Just a normal fall. It’s nothing new; I’m pretty clumsy.” I gave a short laugh.

I’m not actually that clumsy; I just thought the remark might make him smile.

“Oh, are you?” he said, then paused. “All right, I’m going to refer you to a physical therapist. I recommend seeing her for about a month.”

A month? I frowned. “I’ve actually been walking fine the past few days.”

“Yes, it looks healed,” he said. “But since you say that you fall pretty often, I recommend you see a physical therapist. They can help you with that.”

Feeling frazzled, I wondered if there was a credible way to take back my comment. After a week, I bailed on the unnecessary physical therapy, knowing that it was just a self-inflicted trap I’d set by fibbing.

This year my professors have emphasized that it’s no use knowing how to conduct a physical exam unless you’ve also perfected the interview: Most of a patient’s diagnosis comes from his or her answers to your questions.

But what if the patient lies?

As I’m finding out, it’s hard not to.

“Well, Kristen, what do you think has been causing you stress?” Dr. Hassan asks, placing her hands flat on her notepad. “Do you have any ideas?”

I feel anxious, knowing that something as unreliable as my own words will help to determine my diagnosis.

“I’m not sure. Not grades, thank God,” I say, forcing myself to stare at the middle of her forehead, a trick I used in high school when I was practicing presenting to a judge for math fair.

She doesn’t respond. Instead, she looks at me neutrally.

I don’t respond either. Two can play at this game …

At medical-school seminars, they’ve encouraged us to become at ease with silences. As one lecturer said, “Silence makes patients uncomfortable, which makes them talk.”

I’m not letting that work on me this time, I think, a bit defiantly. I’m going to be a doctor soon, too.

Ironically, the more I learn to build bridges with my patients, the more I want to construct barriers against my own physicians.

Finally, Dr. Hassan concedes.

“Since this is your first visit, I just want to get an idea of what’s going on in your life,” she says, more mildly and patiently than I’d expect.

I sympathize with her. I glance at her notepad; it’s mostly empty. She’s spent most of the appointment so far waiting for me to talk — and, unlike Dr. Cohen, listening before taking notes.

“I know, I’m sorry,” I say, letting my hands fold back together again.

She continues to wait, giving me a reassuring smile. I notice that she tucks her bangs behind her ears the same way I do.

I nod again and say, “I’ll take a few minutes to think.”

For me, therapy has been a fluid process. Nearly five months have passed with Dr. Hassan, and still, some days, I’ll sit quietly pretending that defying her gentle questions will somehow make me a stronger physician or patient. Other days, she’ll ask a question that hits me like a garden spade bursting open a pipe.

In some ways, I’m glad that it’s been a longer process. Dr. Hassan has gradually gotten to know me, and I’m no longer as scared that my answers will be twisted against me. I feel less pressure to say the most correct, most all-encompassing thing at all times. In that, there’s a certain freedom.

If I pretend that I’m my own patient, I can tell myself that I’m doing the healthy thing. I keep moving forward, so maybe I actually do believe it, too.

Kristen Lee is a medical student. This piece was originally published in Pulse — voices from the heart of medicine

Image credit: Shutterstock.com

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