By David Weissmann, MD When I quit teaching English to apply to medical school, a psychiatrist friend helped me write my application essay. He said, “Nothing fancy. No quotations from Shakespeare or T. S. Eliot. Imagine that the least cerebral, down-and-dirtiest urologist in the hospital will be reading your essay.” So now, after two years of sponging up facts in a lecture hall, I’m finally in the wards. On this, my first on-call night, I’m not just green — I am flamingly iridescent Kelly green. Except to shake hands when introduced as an observer, I’ve never touched a patient. Right now I’m trying to catch some sleep in an on-call room, worried about bed bugs and scared I’ll have to do a procedure that I’ll screw up. As I’m drifting off between the not conspicuously clean sheets, mired in a bad dream about a patient who refuses to stop bleeding, my beeper goes off. I call the number and speak to a mysterious muse of medical mishap — who is this lady who knows what’s gone wrong everywhere in the hospital and exactly which wrong is mine to repair? An elderly male cannot urinate. I’m told only the room number. When I arrive, the distressed patient is shifting uneasily in his bed. He’s a poor historian (medical lingo — he doesn’t remember why he can’t pee), and I have no idea what to do. I must have dozed through the old-man-who-can’t-pee lecture. Actually I do have an idea: call the intern under whose aegis I function and tell her to get over here and solve the problem. The problem is that she has a lot of problems like malignant hypertension or chest pain or airway compromise — seriously grim scenarios. Her advice is, “Just do something. Don’t bother me!” I say I have no idea what to do. She explains by hanging up. This was pre-Internet; I couldn’t Google “old man who can’t pee.” Luckily (actually it’s not luck — no on-call medical student walks the wards unequipped) in the sagging pockets of my stained and humiliatingly short white coat (attendings and house officers get to wear long lab coats while medical students are stuck with castratingly short ones) I have my top-of-the-line Welch Allyn otoscope and ophthalmoscope with power handle and optional nasal illuminator, a tuning fork and safety pin, a reflex hammer, a cheap stethoscope, and multiple spiral bound guides to the diagnosis and therapy of all ailments known to humankind. Fully loaded my jacket weighs about the same as a Kevlar vest (7.4 to 15 kg depending on how many body parts you’re bent on shielding). I say a short prayer that one of my guides will deal with old men who can’t urinate and dive in (to the guides). It seems there’s a procedure called “straight catheterization.” Here’s how it works: you get a special-purpose plastic tube with a collection bag at one end and start smearing the business end with as much K-Y jelly as will stick. After donning your latex gloves, you grab the patient’s flaccid (presumably) penis (“grab” is maybe the wrong word) and purse the urethral tip to maximize its caliber. Next comes the tense part — as carefully as possible you thread the greased tube into the urethra and begin slowly coaxing it deeper and deeper, all the while administering “OK” anesthesia (this non-drug-based mode of pain control consists of murmuring, “Ok, ok, ok” to reassure the patient that the procedure has not, as of yet, gone off the rails and that his pain, no matter how bad it feels, is tolerable). Inevitably inserting the greased tube will cause some “discomfort” (great weasel word, that), but hopefully the pain will be minimal or the patient will be stoic. You say another short prayer (not actually part of the directions), this time that the urethral obstruction is not impenetrable scar tissue. You want that greased tube to slide into the bladder like Ty Cobb stealing home (54 times, a lifetime record). And as the tube at last waggles freely within the vesicle, urine should gush through it to fill the collection bag. The ordeal will be over. Except you’ll have to withdraw the tube, which can be just as painful. You mean this is what I have to do, with no training or experience, at 2 AM in a dim, slightly smelly room, to an old man who doesn’t know me (or himself, really) from Adam? Yes, it is. So I do it. In fact, the hardest part is overcoming my inhibition against grabbing another man’s penis. The patient is a sweet old fellow who tolerates without a murmur my hesitant shovings and adjustments until at last — eureka! — the urine streams forth. He is so relieved he doesn’t even whimper as I remove the tube. Awash in gratitude, he cannot stop repeating what a fine doctor I am. For a moment each of us is to the other the most significant person in the world. And I realize, a little choked up, this is why people want to become doctors. It’s the most meaningful thing I’ll learn in medical school. Several weeks later a surgical team will order me to straight cath a patient prepped on the OR table, hoping I’ll flush and fumble while they snicker. Medical student extraordinaire, I show ’em how it’s done. Maybe urology wouldn’t be such a bad fit after all. But in fact, after confronting my chronic uneasiness in the wards, I will reluctantly decide to forgo the satisfactions of direct patient care and train as a pathologist. This was not the outcome I had in mind when I was busy wiping Shakespeare quotations from my application essay; but it is, at least, the product of informed consent. David Weissman is a reformed English teacher who relatively late in life got tired of critiquing society and decided instead to plunge into it via medial school.
