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Student Notebook

Choice words

By Armand Russo

When I first heard the oft-repeated fact that my vocabulary would more than double during my first year of medical school, I took it as a warning. I was worried that I would have to relinquish some of the finer features of speech and thought in order to learn this second tongue. Could a heart still ache or long? Could a breath continue to ripple or a glance fall? Or would all words and phrases such as these need to give way to precise clinical terms?

It had been challenging enough to master one dictionary to describe all the possible combinations of people, places, memories, and emotions. I was doubtful about the benefits of adding another.

Precision: Clinical language is serenely accurate; it streamlines thought. With some free time and a fertile imagination, one could, I suppose, string together conversational words to describe a nodular thyroid. But in the clinic, precision and efficiency are the rule; instead of groping for words of the heart, doctors (and doctors-to-be) necessarily turn to words that are to the point.

The Student Notebook essay offers insight or opinion from a Dartmouth student or trainee. Armand Russo is a second-year M.D. student at DMS, as well as a member of Dartmouth Medicine magazine's Editorial Board. He majored in biology and religion at Swarthmore College, and he has an identical twin brother, John Peter, who is also in medical school, at St. George's University in Grenada, West Indies.

But partway through my first year, I found a reprieve: the need to understand patients. Medical vocabulary is astounding in its deficiency at doing this. Its emotions are shallow breaths. An ultrasound-guided thyroid nodule biopsy does not require a description of the patient's shapely forehead, of the way his legs cross at the end of his dressing gown, or of how he looks from under his brow at the doctor standing above him. Yet I see no reason why these features should go unnoticed. These are beautiful in their own way. Struggling with a new medical idiom should not stifle these finer descriptions.

At about the same time that I met my first patient as part of On Doctoring, a course that Dartmouth medical students take during their first two years, I met another patient, named Mohun Biswas, on the pages of V.S. Naipaul's novel A House for Mr. Biswas. He, I knew, would be a challenge to treat. He was unhappy, ferociously sarcastic, untrusting, and well informed. For a man with an empty belly, four children to feed and educate, and a wife to keep happy, he spent a lot of time reading.

Exacting: As I got to know Mr. Biswas, I wondered how I might evaluate him in a clinical setting. His life and host of medical problems seemed too complex for a clinical write-up, which, as I learned during my first-year studies, is an exacting format, limited to essential details and clean prose. But if Biswas had appeared with the problems Naipaul described, and it was my responsibility to evaluate him, the resulting clinical description of this patient from Port of Spain might read something like this:

Mr. Mohun Biswas is a 40-year-old male working as a journalist. He has a two-week history of sudden-onset panic, characterized by fear of people and the market, thoughts of violence toward his children, an intense desire to be alone, fatigue, and racing thoughts. He has not been sleeping well. He has eaten little for lack of appetite. He also complains of intermittent pain in the abdomen that is diffusely spread on the umbilical perimeter and of indigestion. For this he uses Maclean's stomach powder. He has had diarrhea since childhood. His mother recently died in old age without any known medical conditions. He drinks until drunk upon occasion with friends but uses no other addictive substances. He lives with his wife, four children, mother-in-law, and sisters-in-law and their children and husbands in a domicile of questionable cleanliness.

This write-up attempts to describe Biswas and his complaints and to outline his relevant medical, family, and social histories. But there is so much more to Biswas than the small sliver in this hypothetical medical history. If Biswas were to read it, he might wonder, save for his name writ large at the top, who it was about.

In a single passage of the novel, Naipaul tells us much more—including what I hope to understand about my patients..

Window: In a single passage, Naipaul tells us much more—including what I hope as a future physician to understand about my patients. He explains who Biswas is by describing a game he loves, the scenes and smells of his most prized memories of youth, and his loneliness. He provides a window on a world parallel to my precise, clinical write-up:

As much as the game he liked the making of the sticks. Designs were cut into the bark of the poui, which was then roasted in a bonfire. . . . There was no scent as pleasant as that of barely roasted poui: faint yet so lasting it seemed to come from afar, from some immeasurable depth captive within the wood: as faint as the scent of the pouis [his father] roasted in a village like this, in a yard like this, in a bonfire like this: bringing sensations, not pictures, of an evening meal being cooked over a fire that shone on a mud wall and kept out the night, of cool, new, unused mornings, of rain muffled on a thatched roof and warmth below it: sensations as faint as the scent of the poui itself, but sadly evanescent, refusing to be seized or to be translated into a concrete memory.

I want to hold onto my literary sensibility even while doubling (or maybe tripling) my vocabulary during medical school, so that I can learn about my patients with this depth of feeling. Fortunately, my white coat has two pockets—one for my clinical notes and the other for a personal journal. Or, perhaps, a Naipaul novel.

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