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Student Notebook

Trust fund

By By Debraj Mukherjee

"Anything you say, Doc. You know what's best." On a cool January morning, G.J.'s easy acceptance of his physician's advice was not in response to a suggestion that he get more exercise or adjust his diet. G.J. was in the hospital recovering from a left above-knee amputation (AKA), an operation that had been necessitated by uncontrollable lower-extremity necrosis, or tissue death.

During morning rounds on this particular day, the attending vascular surgeon had informed G.J. that he would probably soon need an AKA of his other leg, too, because of worsening gangrene. This second operation could very well confine G.J. to a wheelchair for the rest of his life.

Advice: How could G.J. so unquestioningly accept the surgeon's advice? In a nation where medical errors are thought to cause as many as 98,000 deaths per year, and in a litigious health-care environment where clinicians are often forced to practice defensive medicine in an effort to avoid being taken to court, G.J. had not even second-guessed the recommendation.

Over the next three days, I found myself quietly reflecting on this unusual and yet inspiring interaction. The conversation between G.J. and his physician had set wheels in motion that would soon find me in hospital scrubs preparing to observe the operation that would cut off G.J.'s right leg and alter his life forever.

But then I recalled the gentle manner with which the attending surgeon had broached the subject. He not only took the time to explain the intricacies of the operation and its possible ramifications, but he sat with and comforted G.J. during what must have been an extraordinarily difficult period. In much of popular culture, a surgeon is depicted as little more than gloves, gown, and a cold scalpel. But I had had an opportunity to see beyond that stereotype and was able to appreciate one surgeon's warm hands and warm heart.

Warmth: I was reminded of a line from the Hippocratic Oath, which I had recited four years earlier with my DMS classmates during our White Coat Ceremony: "I will remember that there is art to medicine as well as science and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug."

I was now seeing firsthand that it was indeed care and compassion— as much as it was the sterility of the surgical field or the precision of the operational technique—that was bringing G.J. comfort and a sense of calm and that was sparking his healing process.

Two weeks after the operation, G.J., now in a wheelchair, headed home with a remarkable smile on his face. His life had changed forever, and yet the care he had received had guided him across an ocean filled with confusion and doubt to a calm sea of acceptance. As I looked into G.J.'s beaming eyes, I reflected on what an honor and a gift it was for me to be a student of the art of medicine and to participate in his care. Practitioners of this most auspicious of arts had brought G.J.—in spite of all that he had gone through—the hope for a brighter tomorrow, as they had to countless other patients for over two millennia. Students of medicine today follow a long procession of those who have valued humanism in the practice of medicine—from practitioners of the Hippocratic and Aesculapian eras to Drs. Paul Farmer and C. Everett Koop. It is, in part, this fundamental tenet that has allowed clinical medicine to grow and develop to dizzying heights and has laid fertile ground for the advancement of biomedical research.

Connections: While I am constantly in awe and wonder of those giants in medicine, I am equally humbled by the trust patients place in me—a young, inexperienced medical student. Trust is indeed the most basic and, at times, the most beautiful of all human connections. During my time in the clinical setting, I have found that these bonds of trust seem to be especially necessary in times of need.

It is this fundamental trust that allows a baby in the newborn nursery to seek comfort in her provider's gentle caress. It is this fundamental trust that offers a marginalized teenager the freedom to openly talk about his problems with an unknown caregiver in an outpatient clinic. It is this fundamental trust that opens men and women up to discussions about chronic disease and comfort at the end of life. It is this fundamental trust that even allows a person to agree to an operation that may leave him wheelchair-bound for the rest of his life.

As medical students, we are taught that the four basic principles of biomedical ethics consist of autonomy (deliberated self-rule), nonmalfeasance (the avoidance of harm), beneficence (the doing of good), and justice (adjudication between competing claims). I have come to believe that these principles are grounded in the even more fundamental pillars of humanism and trust. While the basic principles at the core of bioethics may date back more than 2,000 years, I now see that the fundamental pillars at the foundation of the practice of modern medicine reach back even beyond the time of Hippocrates to the inception of social human history.

As I move forward with my training in this most wondrous of arts, I feel particularly fortunate to have come to realize the importance of the two fundamental pillars of humanism and trust that lie at the heart of medicine and the larger human story.

The "Student Notebook" essay offers insight into the activities or opinions of students and trainees. Debraj "Raj" Mukherjee, a fourth-year medical student, is a member of the Dartmouth Medical School chapter of the Gold Humanism Honor Society and currently serves as the Medical School's honor chair. He has a longstanding interest in global health and plans to do his residency training in a specialty within internal medicine.

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