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Student Notebook

Categorical denial

By Sarah Dotters-Katz

During my first two years in medical school, my professors continually repeated an adage that is familiar to anyone in medicine: "Treat the patient, not the disease."

I thought I knew what they meant—that the same disease might affect five people in five different ways. For example, the flu could cause a fever and a headache in one person, but a hacking cough and a runny nose in another. As a result, the patients would likely be offered different treatments, even though the same virus was causing their symptoms.

Then, early in my third year at DMS, I had two experiences that gave new meaning to my mentors' advice. One of them began with a phone call from home, and the other one was a direct outgrowth of one of my clinical rotations.

Lump: The call from my parents came during the second week of my pediatrics rotation. "Sit down," they said. "We need to tell you something kind of bad." My mom had found a lump in her breast. Her mammogram confirmed it, and an MRI showed a small mass. Later that week, she had surgery—a lumpectomy. The doctors said it was an aggressive type of breast cancer. They had caught it early, but she would need chemotherapy and radiation, too.

I didn't understand: How could my mom be sick? She epitomized health. She ate more than eight servings of fruits and vegetables a day, and she would only eat meat if it was organic. Her HDL (the good kind of cholesterol) was 70 and her LDL (bad cholesterol) was 90. She swam four days a week and rode her bike to work. People like that weren't supposed to get sick.

Two weeks later, a few days before my mom started chemotherapy, I went home to visit her. I needed to see for myself that she was okay—that even though she had cancer, she was still my mom. When I caught my first glimpse of her at the airport, my immediate thought was that she looked the same as always, and she certainly didn't look sick. During the course of that weekend, we swam together twice, got pedicures for my birthday, and worked on a quilt that she was sewing for a cousin's newborn—the same sorts of things we always do when I go home for a visit.

Scar: In my head, I knew she had cancer; I had seen the scar from her surgery. But I kept thinking to myself, "She looks the same, she acts the same. How can she be sick?"

The next week, back at school again, I had another experience with people who were supposed to be sick. For the outpatient portion of my pediatrics rotation, I was fortunate enough to work as a member of the medical staff at Camp Carefree, a two-week overnight camp for children with diabetes. Most of these kids are the only ones in their school with diabetes, so it's invaluable for them to have the opportunity to meet 120 other kids who are just like them. For once, they're not "the sick kid."

My job was to help the counselors monitor the kids' blood sugar levels. With four scheduled daily checks, plus shots to correct their sugar levels as necessary, each camper got at least five needle sticks every day. Yet they also canoed, swam, did archery, and played dodgeball. It was just like any other summer camp. And that, I realized, was exactly the point. The purpose of the camp was to teach these kids that although their pancreas did not work as it was supposed to, they were not different—and they especially were not sick.

It's easy to lose sight of that fact when you're a medical student; we're handed endless lists of diseases, bacteria, and viruses to memorize, and eventually categorization seems like the only way to survive. I had even started to apply categories to people. People with diseases were not engineers or teachers, or blondes or redheads—they were patients. Someone with a sore throat was sick. When that person took antibiotics and the sore throat went away, then he or she was no longer sick.

Categories: These two experiences during those few weeks made me pause and reflect on my use of categories. My mom might have cancer, but she was still a doctor and a swimmer and a mom; her disease was just another part of her, not what defined her. My campers might have diabetes, but they didn't want to talk about low blood sugar; they wanted to talk about archery and dodgeball. At their checkups, of course, they would have to talk about sugar levels, but it was just as important that they discuss school. If school was going well for them, then their diabetes was more likely to be under control.

It can be easy for patients with diseases to have their lives consumed by a diagnosis. They have to call to ask questions about changing symptoms; they have to change their work or school schedules to get to doctor's appointments; their appearance may be affected by the medicines they take. But they still have other identities, as mothers or students, for example. Having a diagnosis does not make a person sick. Even more importantly, although a disease is yet another way to categorize a person, it is neither the only thing nor the primary thing that defines who that person is.

And that, I have come to realize, is what my mentors meant when they told us to "treat the patient, not the disease."

The Student Notebook essay offers insight into the activities or opinions of students and trainees. Sarah Dotters-Katz, a third-year student in the M.D. program at Dartmouth Medical School, grew up in North Carolina and Oregon and did her undergraduate work at the University of Pennsylvania. She is one of the student members of Dartmouth Medicine magazine's Editorial Board.

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