“Welcome to the profession!” Big smile, clean-shaven, and with big bright diamond eyes I stood beside my colleagues excited, but nervous, to pursue a life-long dream of mine. My white coat was crisp and embellished with the David Geffen School of Medicine at UCLA logo just like a newspaper hot and right off the press. I am no longer “Rigoberto Perez Hernandez, pre-med”; my new white coat reads: Rigoberto Perez Hernandez, Medical Student. Now, as an MS IV about to begin more specific training into the specialty of interest, that memory seems so distant, but at the same time, so close to my heart. First year. Community health fairs, interest group meetings, my first OSCE, and a pandemic to top it all off. I barely scraped by on my first ever midterm of medical school –I was not proud of my 76%. Imposter Syndrome? Nah. Second year. Social isolation, record high cases of COVID-19 infections, the era of “Zoom University”. I remembered our “well-being lecturer” saying approximately 50% of medical students develop burn-out. Was I feeling burnt out? Maybe a little more tired, anxious, and sad than usual. Nah. Third year. Pushing near the 80-hour week duty hours every week, multiple shelf exams, and dealing with life and death situations. Am I good enough to be here? Statistically, I was not supposed to be wearing the white coat; I was supposed to be wearing chains. The odds were against me. Luckily, an education allowed me to break free from these shackles. Though I worked hard to push through the first two years, nothing had prepared me more for the wards than the resilience I developed from growing up as a first-generation Latino. Soon enough, I was about to be responsible for the lives of others. Reality quickly set in as I was about to see my first patient on my internal medicine rotation.
My team was called down to the ED to see an elderly gentleman with concerns for “failure to thrive” and an ensuing mass encasing his kidney and large vessels. He had a history of non-Hodgkin’s lymphoma and had been in remission for quite some time. The concern was that it had returned, as it seemed that he was lost to follow-up. His name was reminiscent of a Mexican origin, so I was the first to go down and see the patient. Past the buzzing monitor noises, painful cries, and teams running codes in the nearby trauma bay, I finally arrived at my patient’s room. He was not a standardized patient from the OSCEs. He lay on the gurney with his spouse by his side and dressed in a hospital gown with lines and wires as convoluted as the confusing nerve plexuses from anatomy. They were desperate to hear what was going on. In English, I introduced myself as the medical student, and astutely began to gather a history as we were indoctrinated to do so. They both looked at me with looks of confusion and anxiety. “¿Hablas Español?”, they asked. “Claro que si. Por favor permíteme empezar de nuevo”, I responded. The look of relief immediately usurped their faces. I was just as nervous as they were, but somehow, speaking in our native tongues set ease to our encounter. “¿Tiene dolor?”, I asked as I pressed on his belly. He denied any pain. His face stoic like a statue. I explained the next steps and told him that he will be admitted to the hospital for further work-up. “¡Gracias doctor!”, they said to me. I was no superhero or doctor. I was just another medical student rotating through, but to them I had become their doctor.
I saw my patient early the next morning. “¿Tiene dolor?”, I asked as I examined his body. He seemed uncomfortable as I palpated his abdomen again; though, he denied any pain. I finished with my exam and explained what we knew so far about his condition. We had suspected a recurrence of his malignancy, so we needed to proceed with a few biopsies for confirmation. Aside from the plan for today, I had purposefully made extra time this morning to get to know him personally. He was originally from a small town in Mexico and had just returned from the festivities of Las Posadas (an extended religious festival celebrated in Mexico and other parts of Latin America). It seemed as if he had forgotten everything I explained to him because he began to smile from the memories he had from his time back home. He would describe the celebrations, dances, singing, and scenery as if they were straight out of a Disney movie. He was the first from his family to emigrate to the United States and was proud to have created a life for his extended family here. He was a cook for several years and was the primary “breadwinner” for the household. He was a true “Macho-Man”. Taking days off were no option for him –at least not until lymphoma put the brakes on his life. He had begun therapy, and, ultimately, underwent stem cell transplantation. He later went into remission, and, unfortunately, was lost to follow-up for several years –something not uncommon as I’ve come to experience as a trainee. Now he lay in front of me, in his mind, I was the doctor that would put the pieces of the puzzle together.
The next day, I got a page from the nursing staff about my patient. He had developed a drop in his blood pressure and became tachycardic overnight. His hemoglobin was cruising in the low range, and platelet level did not look good either. He received a blood transfusion and was placed on maintenance fluids. Immediately, I rushed over to bedside to assess him. “¿Cómo está? Tiene dolor?”, I asked even though I knew what my answer was going to be. He mumbled “no” and shook his head. His body was completely edematous and I could feel his abdomen was distended. There were no obvious signs of shock or a stroke. I ran the differentials with my team, but everyone was puzzled. He was quickly deteriorating right in front of my eyes, yet he denied any form of distress. Internally, I was the one who felt distressed. I felt hopeless. I felt pain. I felt burnt out. I felt like a failure and an imposter. I felt everything, yet I hid it from my team. He later passed away, and I had lost everything. Statistically, I was not supposed to be wearing the white coat.
My patient’s story is an example of multiple phenomena outlined by Dr. Enrique Caballero’s 2011 paper Understanding the Hispanic/Latino Patient. He describes the concept of machismo which creates the notion that enduring pain is necessary and that visiting a physician is a sign of weakness. More specifically, machismo refers to positive qualities expected of Hispanic/Latino men such as “having a strong work ethic, being a good provider, and protecting their families, as well as behaviors thought to ‘prove’ manhood”. Perhaps subconsciously or due to ancient traditions, this is why my patient did not admit to pain. At the same time, societal stereotypes, or expectations of healthcare providers to mask emotions in front of patients or other first responders can lead to burnout and feelings of hopelessness. Dr. Caballero also describes personalismo, or the “expectation that a Hispanic/Latino individual will develop a personal relationship with their healthcare provider”. Language and culture have proven to be key mediators of creating a sense of personalismo and a stronger therapeutic alliance between patients and providers. My hope is that stories like these humanize and normalize feeling emotions as healthcare providers. Let us change the narrative by challenging the status quo. Let us continue to promote diversity within the workforce by funding pipeline programs and mentoring underrepresented students. Together we can continue to bend the arc and fight for justice for all.
Share your "Welcome to the Profession" story in the comment section below.
Subscribe to the blog by entering your email in the subscription box below. Don't rely on Facebook to get notifications for new posts. We only email when a new post is published. No spam. If you are reading this on your phone, just keep scrolling down to get to the Subscribe box.
Give us some love by sharing the blog. Forward the blog to people you think would like it. Post the blog on social media. Like and Follow our Facebook Page. Follow us on Twitter. Follow us on Instagram
Rigoberto’s BIo is below keep scrolling
Rigoberto Perez Hernandez
Rigoberto Perez Hernandez is currently a fourth-year medical student at the David Geffen School of Medicine at UCLA. As a part of the Program in Medical Education -Leadership & Advocacy (PRIME-LA) Program, he will be pursuing an MPH in Health Policy at the UCLA Fielding School of Public Health for the 2022-2023 year. Rigoberto earned his B.S. in Human Biology, Health, and Society from Cornell University. In medical school, he is involved with the American Medical Association, UCLA PRIME-LA Council, and the First-Generation Students at UCLA DGSOM. He is passionate about mentoring others and will be pursuing a career in emergency medicine.