On Being a Team Player

 , September 05, 2014

By Rachel Hammer
For Texts and Contexts 

“Clumped metastatic gumballs floated in the thick pus that filled his abdominal cavity” – a masterful description of advanced colon cancer in a surgical case Anna Reisman scrubbed for while still a third year medical student on her surgery clerkship. The rich imagery of Reisman transports physician readers back into their medical youths. The craft of this particular analogy succeeds for the way it conjures memory through the novice eye. The seasoned physician sees metastatic cancer in terms of calcification and fibrosis; the medical student, green as a clean chalkboard, sees the problem in terms of gumballs. 

I recognize myself in the protagonist of Reisman’s essay “Team Player” in the January 2013 edition of JGIM (1), because my surgery clerkship was in September of this year. During my first days in the operating room, I filled parallel charts, a journaling technique from the practice of narrative medicine (2), with pages of my own fragmented gumball-observations: 

“Only in Florida do they use fish hooks in surgery,” a resident said as he struggled to secure the neck flaps like a rain fly, taut and away from an oozing slit in a man’s throat, a slippery, wet hole. 

A CT screen left open in the corner of the room lights up a slice of abdomen that shows a slab of light grey liver stained with dark blotches; it is as though the patient has damp spots in the body that just need to dry. I wish her cancer were as treatable as stained fabric.

The overhead lights transform the patient’s body into a coliseum, I am a hovering spectator of sport, the surgeons are the Fates with their strings and knives and cackles, watching what scuttles, pulses, and flows around the arena. 

A gloved hand hovers over the spot, signs language in string, and thread becomes knot. Like magic.

My presence at the operating room table may have been the nearest thing to having the patient there to witness the shock of the scene herself.  The morning following my first surgery, a ten hour-long case, I went to the bedside of the patient to see how she was recovering. I reminded her that I was a medical student and delivered Reisman’s same line, “Think of me as part of the team,” but added my own disclaimer, “more like the waterboy than the quarterback.” 

The woman offered a kind smile and welcomed me to sit. “Were you there, during my surgery?” she asked, eyes wide with awe.

“Yes, ma’am.” 

“Please tell me what it was like.” 

While I described her body as the coliseum I had seen, using several words and phrases that I could recall from what I had written the night before, she nodded, as though the dramatic scene was just as she had imagined. 

The role of the medical student, learning aside, is to serve as a novice witness to expert work and to see it—to interpret it—with fresh eyes. This, too, is the fundamental role of the writer.

In Reisman’s story, the medical student narrator discovers that an important conversation with the patient has been missed, twice. Busy managing medication changes, monitoring ins and outs, assessing daily labs, opening and closing flesh, completing checklist after surgical checklist, hours on end, the surgical team forgets to inform the patient that he has metastatic cancer. In this story, the medical student, who often feels an outsider to the medical team, uses that which she has in common with the patient, being an outsider, to recognize a deficit on the service and advocate for his standard of care. 

The essay speaks to the problem of distance in medicine, on several levels. Reisman demonstrates the many barriers that contributed to the error: language barriers, the difficulty of hierarchical team dynamics, the challenge to be thorough and present when faced with attention-scattering urgency in the setting of an ever-stringent grid of time with limited work hours and many hand-offs. When the team finally gets around to informing the patient that his cancer has spread, Reisman writes the “lid of uncertainty that had capped his roiling agony was gone.” As a medical student, her professional veneer still tissue-thin, Reisman witnessed this transformation in the patient, and could see it plain as film. I do wonder if the others on the team could also still see such things—does distance travelled in medical training correlate with callus, with cataract? 

The genre of confessional writing by physician writers has become a rocky narrative domain. Physician error made public by those within the profession might seem like colleague-betrayal, or self-righteous profession-splitting into good doctors and bad doctors with the author usually self-locating on the side of good (3). Confessional writing often prompts a tense inquisitional tribunal conducted by the medical ministerium of professionalism, and at its worst, confessional writing exposes ugly facets of physician perspective, insidious biases that stain the conscience of medicine, building higher and thicker the barrier wall between doctor and patient. Reisman’s shrewd choice of narrator in this piece that might seem confessional shifts her power as doctor-author, and in so doing, changes the message.

Instead of pointing the finger at busy surgical services for fumbling patient care, Reisman implies that medical students’ sensitivity to moral injury must never be dismissed as naiveté; their observations and confessions are vital perspectives in medical practice. Doctors who can tune in to their pre-medicine, nascent selves are likely the nearest among us to the bedside, nearer to the patients the profession is privileged to serve. The sensitive skin of medical students can create this potential space where connection occurs in terms of humility, which is to say, common humanity. Students remind doctors of who they once were before medicine became them and, with candor and novice, prompt others on their team to see things fresh. But students need courage to share their unclouded visions. 

I shared the writing in my parallel chart one evening with the attending surgeon on my service, expecting somewhat to be told that my creative writing was a waste of time or irrelevant to the work at hand. Instead, he told me in sincerity, “It is not very often that I meet someone who can call out the subtle but real link between medicine and poetry. My advice to you, Rachel, is don’t change anything. Keep seeing what you see.”

Perhaps my words in some way returned to him the joy he first felt on the day it must have occurred to him that surgeons’ hands really do look like those of magicians. 

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We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

T.S. Eliot -- "Little Gidding,” Four Quartets (1943)


Works Cited
1. Charon, Rita. 2006. Narrative Medicine: Honoring the Stories of Illness. Oxford University Press.
2. Reisman Anna. 2013. Team Player.  J Gen Intern Med 28(7):976–7. 
3. Hammer, Rachel. 2012. The God Complex. Acad Med 87(6):775.