What I Did on My Winter Vacation

The semester drew to a close in mid-December. Since then, I've made a deliberate effort to get out and see some of the New York nightlife and not to sit inside getting a head start on the embryology and physiology reading for next semester. The fiancee and I went out to what I was told was a "bar" on my first night off. The next day, I spent a luxuriously quiet morning and afternoon cleaning and organizing the apartment, followed by an early night watching the most recent disc of Carnivale delivered via Netflix. The next night, the fiancee and I met up with a med school friend and a couple of my buddies from college for a rollicking night of celtic rock in midtown followed by an equally rollicking, non-celtic rock extravaganza on the upperwest side.

And that was about all of the nightlife I could handle. The fiancee and I, along with the future in-laws, needed to kick back and spend a relaxing day visiting the Bodies exhibit at the South Street Seaport. Much less lame than cracking that physiology text, right? Right.

Before we saw the exhibit, the father-in-law-to-be voiced some ethical concerns about the show. Some folks claim the bodies on display were those of Chinese prisoners who were executed in order to feed a booming black market organ industry. One might guess that these people never gave explicit permission to have their bodies dissected and put on display for gawking foreigners. At the very least, the origin of these bodies is uncertain. The folks who run the exhibit maintain that "the bodies belonged to people from China who died unidentified or unclaimed by family members." You can read more about the controversy here and here, but believe me when I say that nothing takes the fun out of flayed corpses like nagging ethical concerns.

Undeterred, we marched on down to the South Street Seaport to get us a look-see. And we weren't the only ones with the idea. The place was mobbed with all sorts of people. The crowd comprised folks of all colors, ages, backgrounds, and views on personal hygeine. The young and the old walked hand-in-hand past men cut in half to expose their viscera ("Grandma, why doesn't the man have any skin?" "That's what happens when you write an inflammatory letter to the editor in the Shanghai Gazette, Timmy."). There were people who had obviously studied human physiology for much of their lives, and others who evidently had only a cursory understanding of the typical number of human limbs or the placement of skin relative to the rest of the body. But everyone appeared equally fascinated.

Grown men and women would walk up to a display of the preserved vasculature of the kidneys, they'd grab the little box with both hands, bring their noses right up to the glass, and squawk excitedly about how little the blood vessels are and how amazing it was that, without any of the surrounding flesh, those vessels still make two distinct little kidney shapes. You'd see a dozen people standing around a body that's posed holding a football, and every one of them would be reading the display while mimicking the motions needed to hold and throw the football. They'd be feeling for tendons in their hands and reaching around themselves to feel the movement of various muscle groups. Surrounding the display of a smoker's lungs, I could see high schoolers glancing anxiously at their friends, their hands migrating unconsciously to cover the box-shaped bulges in their pockets.

I no longer meet new people who aren't in my class, but I used to meet new people on occasion before I started school. Invariably, when those folks found out I was going to be a medical student, the first thing they mentioned was gross anatomy. "Oooh, are you going to have to cut open a dead person? I couldn't handle that," and less frequently, "awesome, I've always wanted to cut a guy." Either way, this seems to be the aspect of medicine that most universally intrigues people. Nobody's ever said to me, "Oooh, do you have to spend hours hunched over textbooks highlighting? That sounds gross," or "awesome, I've always wanted to slowly turn every page of a book flourescent yellow."

Of course, gross anatomy is one of the things that really excites me about this upcoming semester. I fully expect to be one of any number of students grabbing those kidneys with two hands, pressing my nose up against the retroperitoneum, and exclaiming, "look how kidney-shaped these little guys are!" Logistically, it only makes sense that this experience is usually reserved for medical students and communist prison wardens. However, it's apparent through the wild success of the Bodies exhibit, that there are lots of folks out there, folks of all ages, colors, and creeds, who've always wanted to cut a guy.

So, you know, heads up.

Your chart indicates that you've recently visited the hospital cafe...

Sitting through a few hours of lectures on biological molecules is no easy task. It requires a good night's sleep, a good magazine, and a good cup of coffee. Yesterday, I stopped by the medical school's cafe to pick up some coffee only to find that it had been shut down because of health code violations.

That's right. Our coffee shop, housed in the same building as one of the nation's top 10 hospitals, is no longer allowed to serve coffee because the Department of Health can't ensure that it won't make people sick.

Now, I'm no health inspector, nor am I a mathematician, but the cumulative score on the cafe's Inspection Report (which is displayed proudly on its door) was a negative 64. That seems bad, doesn't it?

The voices in my head want you to get the hell out of my office

In all fairness, I was warned that everyone else is crazy.

During my first day meeting with patients, I watched a doctor elicit a woman's family history. The patient had high blood pressure and high cholesterol, so the doctor asked if there was any history of heart disease in her family. The reply was quick, "Nope."

"Any high cholesterol in your family?"

"Nope."

"High blood pressure?"

"None."

"None? No high blood pressure or high cholesterol in your family?"

"Nope."

"Do you have any brothers or sisters?"

"Yeah, two brothers."

"Any high blood pressure or high cholesterol in either of them?"

"Nope."

Was he serious? Did the doctor think his questions were unclear? I was incredulous. I almost felt as if he were insulting the patient by asking the same thing over and over again.

"Your mom, does she have high blood pressure or high cholesterol?"

"Oh, yeah. She had real high cholesterol. I think her pressure was high, too. She had a heart attack last year."

The doctor nods, making notes in the patient's file, "what about your dad?"

"He passed from a heart attack 8 years ago."

What!?

Is it possible that this patient is so uncomfortable in an examination room, that the doctor has to ask the same question a half dozen times before he can get an answer? It's not really so far-fetched. This patient has just been told that she her body doesn't work properly, and then was asked by a serious-looking guy in a white coat, "Is there any history of heart disease in your family?" Should I really be surprised that she rushed to her own defense? "Back off, Doc, my family's fine. And I feel great."

The simpler answer though, is the one I've heard a dozen times from family members, employers, teachers, friends, cab drivers, space aliens, coworkers, and unicorns: Everyone else is crazy. And watch out for them. But once you hear that advice a dozen times from a dozen different people, it turns into a logic problem. I've come to believe that, perhaps, those aliens aren't as smart as they think they are.

It seems more likely that we all think in a way that is fundamentally incongruous with the way everyone else thinks. A not-so-insightful observation that, if true, would make patient care much more difficult than I'd imagined it would be.

We take two classes right now, a science class and a touchy-feely class. Last week in the touchy-feely class, a speaker came in to discuss his experiences as a patient. He's had a string of serious ailments that brought him in contact with a number of doctors and other health care providers over the last thirty years. One of the earliest doctor visits that he recalls took place during his first year of college. While showering, he felt a tender lump on his butt and immediately became anxious. He quickly dressed and headed over to the student health office on campus, where he was seen by an amiable, outgoing doctor. The doctor gregariously inquired about the man's ailment, and subsequently examined the affected area. The doctor declared that the lump was "just a hemorrhoid" and "nothing to worry about." He explained that hemorrhoids will resolve on their own. He suggested that the man try soaking in a hot tub and maybe eat more roughage. The visit lasted about 25 minutes.

I've tried to convey this story in a manner similar to the way I heard it from the patient himself. The only thing I left out were the patient's frequent references to the doctor as a "jerk" (though the description of amiable and gregarious comes straight from him). The interaction described above INFURIATED the patient, so much so that he still recounts this story - now thirty years later - with a seething, undisguised hatred. During his senior year, the patient came down with a horrible infection and refused to return to student health because of that doctor. He finally gave in when his temperature neared 105 degrees.

I heard this man's description of his trip to student health, and I thought the doctor sounded competent, professional, and engaging. All in all, this seemed to me to be a strongly positive doctor-patient interaction. All that's missing is the sticker.

The patient's impression of the doctor was that he was extraordinarily dismissive of the condition, and that he totally ignored the patient's intractable (though never verbalized) belief that the lump was a cancerous tumor. Furthermore, he never said how long the hemorrhoids would last and wouldn't prescribe any medication to make them go away.

What didn't came up during this visit, was that the patient was a recently-outed, gay man. He was coming to grips with his sexuality in the context of a) his new, autonomous life at college and b) his traditional upbringing in a religious, military family. His concerns about the lump on his butt didn't just come from hypochondria; he was terrified that he was being punished for his lifestyle and that this condition would make him less attractive to men.

The patient vehemently believes that it was the doctor's fault that a discussion of these concerns never took place. Maybe it was, I really don't know. I'm not retelling this story to investigate that question. All I want to do is point out that, although his impression of the interaction was drastically different than my own, the patient is probably not crazy. And that terrifies me.

I probably would have treated a frightened college freshman the same way that doctor did, because that's how I'd want to be treated. If I thought I had cancer, and I saw a trained physician who was absolutely certain that I had only a benign condition that would resolve itself with time, I would WANT him or her to tell me exactly that. It would freak me out more if the doctor dwelled on any possible diagnoses that were clearly not appropriate. And if I could clear this condition up without taking any drugs, all the better. Though I might be exhibiting some self-preservation here, I'd like to think that this position is also not crazy.

So we have two, ostensibly sane people considering the same professional interaction. One of these people is entirely satisfied that there's nothing wrong (absence of stickers notwithstanding), and the other is so wildly offended, that he has spent thirty years of his life railing against this doctor to audiences across the country. Is this just the nature of a profession driven by interpersonal relationships? Is there some way that a physician can account for all of the disparate personal needs, histories, and characteristics that walk through the door? Am I doomed to have any patient who doesn't think like I do leave my office in a fury telling people I'm a jerk?

Sometimes the science class is much easier.

What I really think of sick people

The other day, I was listening with my stethoscope to the sound of a patient breathing. Even though I have no idea what to listen for, a doctor will occasionally ask me to “come on over and listen to this.” So I do. I blindly mimic the timing and technique with which the doctor shifts the bell of his own stethoscope first to one quadrant of the patient’s back, then to another, then another, then back to the first, then to the last, then to another. Invariably, the doctor asks, “so what’d you hear?” Usually, I say something awkwardly vague like, “sounds lungish.” Sometimes I’ll try to vocally relay what I hear, “You know, sort of, hhhhehehhh-scschchhhhhh…. Hhhhhehhhhhh-schchschshhhhhhh.” But with this patient, I could actually make out some relevant noises. “The left side,” I said, “sounds a lot less lungish than the right.”

To which the doctor replies, “you’ll usually hear quieter sounds from the left side, because the left lung has only two lobes and the right lung has three.”

News to me.

He continues, “but this man also had one of the lobes of his left lung removed due to cancer.”

To which I audibly whispered, “Awesooome.”

Now, I hope it’s clear that I don’t think cancer is awesome. Nor am I in any way glad that this patient had a piece of him wrested from its casing. I just get giddy when I encounter some medical phenomenon that I can understand. I’ve heard of lungs, I have some understanding of what they do, and I can imagine what might happen if you lost a part of your lung.

This kind of thing seems to be happening more and more frequently – I suppose that’s to be expected over the course of a medical education. Even though my first semester has focused on molecules, cells, and other things that don’t really puss, bleed, or throb, I still occasionally learn about disease. Often, the diseases we learn about are really obscure things you might only come across in the movies. We started with a case study of xeroderma pigmentosum (remember the movie The Others, with Nicole Kidman? The kids couldn't be exposed to sunlight. That’s xeroderma pigmentosum) and moved onto osteogenesis imperfecta (remember Unbreakable? Samuel Jackson’s character “Mr. Glass” had really brittle bones that always broke. That’s osteogenesis imperfecta). Last week we studied something called maple syrup urine disease, a metabolic disorder in which the afflicted individual's urine smells like maple syrup. While I haven’t seen any movies about maple syrup urine disease, I’ve mentally classified this disease as fictional for two reasons. First, if you were the first to identify a metabolic disorder, wouldn’t you come up with a less ridiculous name? Second, if this condition exists, then it’s not a disease. It’s a superpower.

On occasion, though, our curriculum covers diseases that I might come across in practice. And when I see patients with these conditions, I try my best to conceal my unmitigated joy.

“So you were recently diagnosed with Hashimoto’s Thyroiditis.” Don’t say awesome, don’t say awesome… “That’s… VERY… nice. I mean, great. Really great. Super.”

It may be even more awkward when I get excited about the diseases afflicting people I know and love. There was a moment this Thanksgiving when I was discussing a family member’s recent bout with gout.

“So I just woke up in the middle of the night, with this excruciating paint in my toe.”

“Aw…awesoooome. Had you eaten a big, proteiney dinner that night?”

“Yeah, steaks.”

“Awesooome.”

Realizing my biochemistry texts appeared to be right about the existence of gout, I mentally shifted that particular condition back into the “nonfiction” category.

I suppose my excitement about disease is more of a benefit than a liability. If I get this excited seeing how things go wrong with people, imagine how thrilled I’ll be once they tell me how to fix these things.

“So, you’re telling me that you took those pills I gave you, and now your kidneys don’t hurt at all?”

“Nope, they feel great. Thanks, Doc.”

“Uh… sure. That’s great. Really super…” Don’t say I can’t believe that worked, don’t say I can’t believe that worked… “What I mean to say is, you know, that’s totally awesome.”

Incubating biologists

About five years ago at my first high school reunion, I took a tour of our new science center. It was pretty ridiculous. The building was equipped with things like a scanning electron microscope and, for reasons that aren't immediately clear to me, cooling towers. On the tour, we saw bio labs with water tables and a tropical marine aquarium, as well as physics labs that have high school-kid-sized merry-go-rounds. When we finished the tour, my buddy The Beav, a filmmaker and tobacco enthusiast, shook his head and said, "Man, if we'd had this science center when I was here, I'd've been a biologist."

Beav was lying, but that doesn't dissuade me from my belief that science education in America could be so much better. I don't think that it's tremendously nerdy to say that science is super dope. Even the simplest science demonstrations we saw on Mr. Wizard stick with us for decades (anyone ever see a hardboiled egg get sucked into a bottle? or celery stalks turn red? That was all much cooler than phonics lessons.)

Bill Bryson recently wrote a book called A Short History of Nearly Everything. It's described as Bryson's "journey into the most intriguing and intractable questions that science seeks to answer." The fiancee and her mom both read it (educators, the lot of them) and seemed to find the intricacies of our collective scientific know-how fascinating. And it is. The stuff we know about our world is crazy cool, and how we came to discover it is equally interesting.

I went into medicine because I wanted to know how the body worked. I'd like to think that the country's interest in medicine is reflected in the Nielson ratings of shows like ER and Grey's Anatomy (as it turns out, the human body likes to have sex with pretty people. Who'd've guessed?). I think that there's a lot of latent interest in the sciences, just waiting to be activated by a compelling curriculum.

The reason I bring this up is because I'm about to give you a hyperlink to a video that I think is awesome. I don't know whether or not it's at all entertaining for those of us without a background in cell biology, but I'd like to believe that stuff like this might make a high school biology class a little more tolerable. Or it may inspire those biology students to be filmmakers.

The Good Life

I returned to the fold this weekend by spending Saturday afternoon at Teach For America's "What's Next?" workshop. There, I met with Corps Members considering careers in medicine who wanted to know more about my decision to change careers and the process of applying to medical school. This, of course, was not my idea. The fiancee volunteered herself and "inadvertently" told a TFA New York administrator that her betrothed was ALSO an alum of the program. Apparently TFA had nobody else who was in a position to speak about medicine, because they overlooked the giant red flag waving menacingly atop my record and welcomed me with open arms.

The event was being held at the Association of the Bar of the City of New York (subtext: BE A LAWYER!), and began with a panel discussion by TFA alums with careers in various fields. The room where the panel discussion was held is enormous, with - I don't know - 100 ft high ceilings, and portraits of fancy lawyers in pretty suits covering the walls (subtext: BE A LAWYER!). The panel included a school administrator, a teacher, a TFA program director, an investment banker (or some such business-type guy), a lawyer, and a city planner. Guess which of these folks was the best dressed, most articulate, and most charismatic? Well, it was the banker, but the lawyer came in a close second (subtext: well, ok, be an I-banker, OR A LAWYER, just make some MONEY).

As a side note, I don't have any problem at all with the unspoken prong of TFA's mission. In a very real way, the schools and the districts in which we work don't have the infrastructure to support meaningful change. So while one prong of the mission is to supply failing schools with dedicated, smart, grossly underqualified teachers (who, I believe, do a fair amount of good in their own right), the second prong invites alums to try to rise to positions of power, from which they might be able to impact policy. The truth is that policy makers, for reasons that aren't entirely clear, seem not to listen to teachers. But they'll listen to a guy with a nice suit and an MBA from Columbia.

So I'm watching this panel discussion, and a girl asks a questions that sounds more or less like the following: "I've worked a couple of office jobs in the past, and I always found those offices reasonably quiet and comfortable. When I started teaching, I couldn't believe how hectic everything was. But eventually, I got used to my classroom always moving, and full of noises, and students stopping me just to hug me. Now I'm worried that I won't be able to go back to an office. So I guess my question is, how do you get used to the boredom of being back behind a desk?"

This was not a concern that I held as a teacher. I remember one day, during my second year of teaching, a friend and former teacher came to visit the school after spending a few months working as a paralegal (...CLOSER). Remember when you were a kid, and one of your buddies found out that his dad subscribed to a special channel, like channel 97 or 99, with naked ladies on it? And that kid was saddled with the momentous task of trying to describe this wildly wonderful and totally inexplicable thing to you and all your friends? Well, this was what it was like to hear Ms. G reporting on her new office job. She tried her best though, as a small group of us gathered around her in the halls after school let out. "I just... I mean. When I need to go to the bathroom, I can just, you know, leave my desk. And go to the bathroom. Literally, whenever I want. Except maybe when I'm taking an important phone call." Our eyes widened as we glanced back and forth at one another. "But that's not even... I mean... I sometimes leave my desk even if I don't have to go to the bathroom at all. We have a water cooler, with cups next to it, and sometimes I go there to get a cup of water. Sometimes I'll stop by a friends desk on the way back to my desk. And we'll chat. And when I get back to my desk, it hasn't destroyed itself while I wasn't watching."

But I didn't even need the luxury of all you can drink water and unrestricted trips to the john. During my second year, I was summoned to jury duty. For the week before my day at the courthouse, I was on cloud nine. I couldn't believe my good fortune, and neither could my friends. I was in court for a single day. I sat for some 6-8 hours on a miserably hard wooden bench, but I might as well have been on a beach in Acapulco. For those 6-8 hours, I quietly read a novel, and was only occasionally interrupted by some guy reading off a list of names that weren't mine. Simply glorious.

Anyway, the boredom of an office job was never something that concerned me. And from the looks in the eyes of the teachers gathered around my round table discussion about careers in medicine, it wasn't a concern that many of these TFAers shared. "In medical school," I said, and paused dramatically, "you're asked to sit quietly while scientists talk to you about science." The giddiness rolled in waves through the crowd. "And then, when they're done talking, you go home and read books about what they were talking about. Sometimes you highlight words in those books." A few gasp audibly as they imagine such a peaceful day. A few teachers raise their hands to venture questions:

"These scientists, do they swear at you when you ask them questions?"
"Almost never."

Gasp!

"Tell me, do these scientists pee on your floor?"
"I've never seen anyone in my medical school, either teacher or student, pee on anything that wasn't meant to be peed on."

Surely he must be kidding!

"Do these scientists become enraged when other scientists touch their pencils or look at them from across the room?"
"Almost certainly. But they bury their fury as bitter pellets of hatred beneath oversized lab coats."

How wonderful!

It was a nice way to spend my Saturday. And I got a free lunch out of it. Then I walked across the island and caught a train back to the medical library, where I unfurled my supermap of metabolic pathways and began reading and rereading about various metabolic pathways to prepare for what's become our weekly Monday exams. I probably should have been a lawyer.

A man's gotta do...

I wouldn't be surprised if the doctor I've been shadowing is growing tired of me. After a couple of rounds of ludicrously moronic responses to straightforward questions, one would think he'd throw in the towel.

D: "So tell me what jaundice and cirrhosis are."
M: "Yeah, those are... you know, problems."

D: "What are microsomes?"
M: "Small... somes?"

No joke. Unfortunately. So you would think that the Doc's patience may be wearing thin, and that might give you some room to interpret what he said to me when I was leaving his office yesterday: "Maybe next week I'll schedule a sigmoidoscopy. Usually they're done in the mornings, but I'll see if I can do one in the afternoon."

To which I (of course) replied, "a what?"

To which he responded, "You take a sigmoidoscope, the patient bends over, and..." he then demonstrated the universally recognizable mime of feeding a fiberoptic tube up a man's rectum. Or losing at tug of war.

Awesome!

This August, on the first day of our orientation, I was watching some presentation about the first year's curriculum. The dean stood in front of us and told us that we would, throughout our time in medical school, be interacting with "standardized patients." Remember the episode of Seinfeld when Kramer's hired to play a patient with gonorrhea for medical students? He was a standardized patient. The school pays actors to help us practice taking a patient's history and administering a physical exam. These actors can then give you feedback on anything from your examination techniques to your demeanor. And as the dean was discussing the merits of using standardized patients, he says proudly, "this ensures that the first time you give a rectal exam, it won't be on a real patient."

So I laughed loudly. Because that's a funny thing to say. Right? Surely we're not paying actors to allow our little inexperienced fingers to plunge their rectums. Surely this was all a joke, right? A joke by the serious looking man at the front of the auditorium who seems entirely unamused by my very loud guffaw.

Looking back on that experience, I feel that there were some lessons to be learned that day:

First, despite the fact that I'm five or six years older than many of my classmates, they universally surpass me in maturity by several years.

Second, apparently, most student doctors get excited at the prospect of learning any medical procedure.

ANY procedure.

Third, there are harder ways to earn a buck than teaching first grade in the Bronx.

So I'm leaning towards the belief that the doctor I'm shadowing is trying to help me out. He did seem genuinely excited to able to offer me this chance (or he has fond recollections of losing at tug of war). We'll just have to see whether he's able to shuffle the schedule around next week so I can dive in on that sigmoidoscopy. If he does, I predict that, by the end of the year, there's going to be one blushing actor who's amazed at the expertise and dexterity of the medical student standing behind him.

Applicable skills

Most of our first year curriculum is packaged together into a single course that lasts throughout the fall. This course encompasses biochemistry, molecular biology, and cell biology. These subjects, it can be argued, are important, but they just don't seem nearly as exciting or relevant as, say, cutting someone open and poking at their insides. Right now, all I know about the human body comes from little schematic diagrams in my text book. If ever a patient complains to me that the red Pac-man looking thing in their cytosol has a small blue triangle stuck in it, I might be able to recognize that they've somehow picked up a nasty, constitutively active Ras protein. I could verify this because there'd be a bunch of other colored squares on which the Pac-man would have left a bunch of yellow circles with P's in the middle.

Though all of this stuff seems very abstract (or even completely made up), at least it occasionally has some gravity to it. The first thing we learned was how proteins get folded into their appropriate forms. Proteins are comprised of amino acids linked to one another like beads on a necklace. What makes a protein particularly useful (or deleterious) is the way that it's folded onto itself. As it turns out, small errors in the way a protein folds can produce some pretty taxing conditions. Cystic fibrosis, for instance, results from one protein that's only slightly abnormally folded. The normal protein forms a tube through which chloride ions can roll out of a cell, the defective tube forms a tube through which ions pass a little less frequently. This small abnormality has some tremendous consequences.

The other day, we learned about a misfolded ion channel in muscle cells. In order for muscles to contract, a current runs down the length of a muscle fiber. The current is created by a bunch of charged particles moving from one side of the cell's membrane to the other. However, in a condition called myotonia congenita, patients have a channel that doesn't conduct one charged particle quickly enough. As a result, the cell can't properly compensate when a muscle is quickly and repeatedly flexed, a patient won't be able to immediately relax their muscle.

I tried to imagine the consequences. Would a patient just crumple into a ball and slowly crush his internal organs with his own muscles? If such a person gets too excited, does his heart contract pump all of the blood out, and then sit like a clenched fist in the patient's chest? As it turns out, people with myotonia congenita tend to find it to be pretty obnoxious, but they can certainly lead full and productive lives.

So why, we all wanted to know, is this particular condition included in our curriculum? When are we going to come across it? As it turns out, only about one out of a hundred thousand people worldwide has it, and if they ever walked into my office, there's no treatment I could give them. So where might an understanding of this condition come in handy?

Goat farming. It turns out, myotonic goats can't jump without cramping up and falling over, saving goat farmers a fair amount in the building and maintenance of their fences. Also, these goats are adorable.

What am I doing?

During the first meeting of a course ominously called The Medical Encounter, our small group of 10 or so first year medical students was asked, "As students, what are you able to offer your patients." The answer, I thought, was simple: precisely squat. I don't know anything at all about medicine and even less about being a doctor. I'm not kidding when I say that I often find myself believing that the causes and remedies of all sorts of conditions are absurd and nonsensical things. Like, oh, the skin on your leg's peeling off, haven't been drinking enough OJ, have you? Or, oh geez, I've been dizzy for a couple of weeks, I should have a beer or two before going to bed tonight. It seems I've come to subscribe to a strange, modern belief in the four humors. We all, I've come to believe, are little more than an amalgam of orange juice, coffee, beer, and water. And when that balance is skewed, havoc ensues.

I probably shouldn't be a doctor.

Nonetheless, I find myself every week, standing whitecoated and bestethoscoped, in front of dozens of patients. Patients who call me "doc." And they ask me questions. Questions about what's wrong with them. This doesn't happen often as I'm rarely left alone with patients, but when it does, I typically laugh and explain enthusiastically that I have no idea... Although, what would you say your daily beer and coffee intake is?

I don't mind pretending to be a doctor. I kind of like it. I'm even becoming convinced that it's an applicable professional skill. It's going to be a long time - much longer than the 7-10 years it'll take me to start earning a real salary - before I'll be able to get through the day without ever feeling as though I'm in over my head. During those times, I'll be expected to maintain a professional facade, finger my stethoscope diligently, thumb through esoteric notebooks from the pockets of my luxuriously white coat, and explain that "I'm not quite sure what's wrong with you Mr. Jones, it could be a number of things. But when I figure it out, you'll certainly be one of the people I tell."

Recently, I was visiting a patient who had been put through the ringer at a local hospital. She'd had a number of invasive tests to determine what was wrong with her, but none of them were conclusive. The patient, let's say Ms. Patient, was understandably distraught. The doctor listened to her worry and dither and weep, and then left the room to pick up some free samples of a particular pharmaceutical for her to take home. While he was out of the room, I found out that Ms. Patient was a teacher. I told her that, for a few years, I had been a first-grade teacher, too. We talked about her school, her students, and how her condition was affecting her work. After only a short while, the doctor came back in the room and explained how to use the new drug and how the medication might help. Ms. Patient had difficulty understanding his instructions, and she soon fell back into her pronounced, dewey-eyed, funk. The doc looked up at the ceiling, then over at me. Then he asked, "How's work going?"

She looked at me, then at him. "It's fine. You know. Same old."

"What grade do you teach again?"

Again, she looks at me, then at him. She looks more confused now than she did when she recounted those weeks she spent in and out of the hospital. She asks, "Why are you talking to me like this?"

And then, for a fleeting instant, I believed I might have something to offer this busy family practice staffed by one doctor who doesn't always have the time to heap generous amounts of conversation and compassion onto his patients. I thought, just maybe, I could provide a meaningful service that would contribute to the health, well-being, and happiness of a patient. This woman, I realized, was wildly deficient in orange juice, something the doctor had never even mentioned. Next time I'll be sure to bring a carton or two.