Here is a short story I wrote for a Humanities in Medicine elective I recently took. Thought it might be nice to share.
To see a gecko in the sand
Sam Brunwasser
“Right there! He’s sitting on that big rock. Mira. Look where I’m pointing.” I strained my eyes to follow the direction of my Uncle Sam’s finger. And then I saw it. First the eyes - two little black beads on a diamond-shaped head. As I continued to focus, I began to see the rest of the creature. Small rows of dark spots on a yellow body. And then, just like that, it bolted away as fast as I had seen it.
“It’s called a leopard gecko,” my Uncle Sam explained. Another one of the myriad critters and plants my uncle showed me as we explored the Arizona White Tank Mountains together. His encyclopedic knowledge of these deserts always amazed me. He would sprinkle our hikes with varied facts about these magical lands - pointing out a creosote bush, showing me how it smelled like rain when you crushed its spindly leaves between your fingers, identifying the various species of cacti that littered the mountainside, spotting animal droppings and somehow knowing whether it came from a deer, a javelina or some other creature, showing me the holes that housed rattlesnakes and warning me to stay away from those, and teaching me practical things like what kind of trail mix to eat on a hike to have energy and how to walk in a level way on the uneven rocks and dirt to prevent yourself from twisting your ankle.
These were my uncle’s favorite mountains, and he imparted his knowledge to me with love. He was one of the oldest of 12 brothers and sisters, growing up in poverty in a family of farm workers. He and his siblings often had to skip school to pick cotton so that the family would have enough food to eat. They had grown up in an area called Litchfield Park - a remote region hidden in the shadow of the mighty White Tanks on the outskirts of what’s referred to as the Valley of the Sun encompassing the greater Phoenix area. This was the westernmost edge of the Valley, which at the time had not yet caught up to the rapid development of the Phoenix metro area and even to this day still lives in a much more quiet existence. A place where you would not be surprised to see your neighbors on horseback passing by, where many of the roads are just gravel and farm plots stretch as far as the eye can see. But towering above this land are the White Tank Mountains, which provided the backyard of my childhood home. I spent many evenings alongside Uncle Sam, watching sunsets of brilliant orange and purple casting their pleasant glow on the White Tanks’ mountaintops - a sight which still entertains me from memory many years later.
I had a special connection with my Uncle Sam, notwithstanding our shared first name. We also shared an intrinsic love of learning. He managed to escape the poverty of his youth through education, obtaining a full scholarship at the local state university and then at Stanford Law. His relentless pursuit of scholarship inspired my own journey into higher education in medicine. But even at that young age, I think we shared this passion for learning through our regular hikes in the landscapes of the White Tank Mountains where he would share his boundless knowledge of these deserts with me. I would collect various tokens of these deserts. I had an entire file cabinet drawer of rocks I had found in my backyard, which I somewhat comically presented to all of my family with pride. None of these stones were particularly valuable, but they hearkened my fascination with the natural world and eventual love of science. The most prized possession of my collection came from Uncle Sam himself. One Christmas he gifted me a geode he had found while hiking in the mountains - a beautiful, glistening explosion of crystals hidden inside a rock that had been burst open. I treasured this curio, so much so that I gave it a special drawer of its own in the rock file cabinet separate from the others.
I also collected books and encyclopedias on desert wildlife. I had an entire book of leopard geckos, which was one of my favorites because these small little guys were all over our backyard. As my uncle had taught me, you had to look carefully or you might miss them. In the harsh deserts of Arizona, these critters had learned how to survive by hiding. Though at first they might look like part of the rocks and gravel of the desert surroundings, this was just the way they had learned to cope in the extreme conditions of the desert. But if you observed closely and patiently, you could begin to see them, training your eyes to spot them over time by learning to look past the initial appearances of the desert floor. I couldn’t have known it at the time, but eventually this skill would become extremely valuable to me as a physician in training.
“Get the fuck away! Get out now!”
It was my third week on the internal medicine rotation, and frankly I was exhausted. This rotation had pushed me to my limits - the hours, the patient volume, the smells of fecal matter and fetor hepaticus.
This rotation coincided with a challenging time in my personal life as well. Over the past few years, my Uncle Sam had struggled with several bouts of non-Hodgkin lymphoma. It had always seemed to us like a cruel twist of fate. He was one of the healthiest people I knew, having been a competitive marathon runner his entire life. For example, I remember him telling me to put either butter or syrup on my pancakes, but never both because that would include unnecessary calories. His cancer had first presented itself in his lungs, which is what baffled us all the most. He was a man who had never smoked a day in his life. But thankfully he remitted with chemotherapy. At first, it was difficult to see him at family gatherings for Christmas. The tall and toned marathon runner I had spent many years hiking with now looked much weaker, his hair thinner, always wearing a mask to protect his weakened immune system. But over the years, as he battled cancer again and again and received more and more chemo, things almost seemed stable somehow - as if this was how things were going to be forever. I became used to seeing him in his weakened form every Christmas when I would return to Arizona on break from medical school in another state. There was a rhythm to these annual appearances, and I eventually lulled myself into an illusion that he was suspended in stasis. But the cancer did come back in my third year of medical school, and somehow it seemed different this time. He was admitted to the hospital because he was significantly weaker and had difficulty eating anything. My mom was at his bedside every day and I called her as much as I could to ask how he was doing and get any updates on his medical care. He was very weak, but I would talk to him on the phone whenever he had the energy for it. As the only person in the family to go to med school, I felt a strong responsibility to know everything going on with him and translate the labs and updates for everyone. But I also felt incredibly helpless because I was in another state and could not know the minute-to-minute events at his bedside in Arizona.
I was completely exhausted, torn between the anguish of watching my uncle’s critical situation from a distance and managing my own responsibilities on the internal medicine rotation. I was on a floor that primarily saw patients with chronic liver disease. Many of them were addicted to drugs or alcohol, and many of them were unhoused. In just the past two weeks, I had witnessed more patients die than during any other rotation in my medical training. I felt that the grim reaper was in lockstep behind me and as Uncle Sam’s condition continued to deteriorate, I couldn’t shake the feeling of a dark cloud suffocating me.
In full disclosure, this dark cloud had affected my ability to feel sympathy for the patients on my floor. In stark contrast to my Uncle Sam’s unjust fate, I grappled with anger towards these patients; had they not willingly forged their own paths into addiction and despair? Why was his lot cast among these people?
For my own sanity, I had become a leopard gecko. Camoflauge. A mask I put on as soon as I entered the provider work room and started my pre-charting. Phrases I had rehearsed like “Yes sir, we will work on that right away.” A mask I even wore for myself, telling myself things like:
I’m okay. Don’t worry. Everything will be fine. Just get through the rotation.
I turned off all my emotions because I was afraid I would implode if I didn’t. We held vigil over one of our patients with his family on what everyone knew would be his last night before death. I held back tears because I knew if I let them come for this patient, a flood would be behind them for Uncle Sam.
Hold it together. Don’t allow yourself to feel.
It was amidst this emotional milieu that I admitted the most difficult patient I had encountered thus far in my medical school training. He was a 45-year-old man with a history of HIV, IV drug use, and prior history of a gunshot wound who presented with shortness of breath, fatigue, and poor nutrition in a state of withdrawal from opiates. As soon as he was admitted, he refused to talk to any staff. Anytime someone entered his room or attempted to touch him, he would scream at them and refuse treatment. Naturally, I was hesitant to enter this patient’s room. I steeled myself and knocked on his door. After hearing nothing, I entered.
“Hello. I’m Sam, a medical student part of the team taking care of you.” I recited as I walked through the open doorway.
There was no reply. I saw a man in a ripped sweatshirt lying in the hospital bed, hunched over. He wasn’t stirring. “Hello!” I said, a little louder this time.
Still no reply. I walked closer and put a hand on his shoulder, giving a gentle shake to wake him up.
“Go away,” he said.
“I need to ask you some questions so we can start taking care of you, sir.”
“Not now. Come back later.”
Come back later? I was baffled. This was a hospital. Not a hotel room service. My mind wandered to a story a friend of mine had told me about her experience in medical school in Russia. When she went to see a patient, they refused to see her and asked for a male doctor. She reported back to her attending, who then came in and said, I heard you’ve refused to see the doctor. In that case, you clearly must not be sick anymore. So we can go ahead and discharge you! I’m ashamed to admit I wished I could say something similar. But this wasn’t Russia. And I was just a med student. So I called the intern I was working with for help. She tried to talk to him too, but also to no avail.
“Come back later.”
We knew we’d have to recruit our attending physician next. Excellent - now we have the big guns. He’s going to have to talk to us now. And then we can be done and move on and maybe even go home. When he gave the same response to our attending, I was prepared for our attending to lay down the law. But I was surprised when instead our attending said, “That’s okay. We’ll come back later. When would be a good time?” after which our attending and the patient negotiated that we would come back in an hour.
I was stunned. That would keep us for an additional hour for nothing, and then we would still need to write our notes and prepare any intake orders. And if he needed any imaging, we would have to wait on that. I was frustrated, to put it mildly.
When we left the room, our attending leaned in as he often did to signal that he had a lesson he wanted to impart to us. “For a patient like this, patience is the key. I think for him we need togive him a larger degree of flexibility and freedom. I am hopeful that he’ll open up to us more if we try that approach.” I was stunned. There was absolutely no way that approach could work. Even in my brief experience as a med student, I knew that patients didn’t change overnight. I was convinced that the best approach would be to have a strong backbone and not let the patient bully us around.
Nonetheless, we tried out my attending’s approach over the next few days. We bent backwards to accommodate this patient’s timeline and desires. We let him go on walks and smoke breaks whenever he wanted. He told us that he did not like to be disturbed in the evening, so we negotiated with nursing staff to consolidate all vital checks and interruptions to specific points during his waking hours. And whenever I spoke with him in the room, I tried with all my remaining reserve to be patient, sympathetic, and listen actively to whatever was bothering him that day.
As we continued to treat him for opiate withdrawal and work up the cause of his presenting symptoms, we eventually discovered that he had chest x-ray signs concerning for PJP pneumonia, a serious complication of HIV AIDS. In addition to immediately beginning treatment for fungal pneumonia, we would need an induced sputum sample to confirm the diagnosis.
The respiratory technician had some difficulty obtaining sputum from the patient. “This guy’s just not going to do it,” said the technician, implying the patient was just not willing to do it.
“I know. Just give me a second. Let me try to talk to him,” I said.
I proceeded to talk with the patient for a long time. I wanted to make sure he understood how serious this type of pneumonia could be, and how important it was for us to confirm it so that we could treat him appropriately and make sure he could feel better as soon as possible. To my surprise, there was a shift in his body language. His eyes rose to meet mine and he almost seemed to nod in understanding. “I keep trying to cough up stuff for you but nothing is coming out.”
“That makes sense. And maybe the medication is already starting to help a little bit, which is why you don’t have as much of that stuff in your lungs. Maybe I can give you some time to rest for a bit and I can send the respiratory therapist back in a couple hours to try again. Would that be okay?”
He agreed.
I let the respiratory therapist know, who seemed a little annoyed because it meant he would be here later than he had planned. I apologized to him nonetheless. “We’re just really trying to work with this guy,” I said. And then I picked up a conversation with him about football that we had started earlier to attempt to lessen the tension.
A couple hours later we got our sputum sample.
As soon as my shift ended, I got in my car and called my mom.
“How’s he doing?” I asked.
“It was unbelievable!”
“What happened?”
My mom proceeded to tell me about the day’s events.
Earlier that day, while I had been fighting for a sputum sample, the security staff at my uncle’s hospital had entered his room, demanding to search his belongings.
“They wanted to raid his room and search for drugs!”
My mom was in the room when it happened, and she was shocked. Her shock quickly gave way to anger. Like my uncle, she had also trained as a lawyer and many times I had seen her stand her ground like a bull when it was necessary.
She refused to let the security guards search the room, and they continued to press. They argued back and forth and the situation nearly escalated when finally one of the doctors intervened and ordered the security personnel to leave.
“That was totally, totally uncalled for. He was being judged for something that is so remote from his lifestyle. Just because he’s Hispanic doesn’t mean that he’s an alcoholic or a drug user.”
Tensions had been mounting over the several days since he was admitted to the ICU. His initial admission labs had shown elevated liver enzymes. He had grown out his hair after the last round of chemotherapy, and in addition to his brown skin and emaciated appearance, it seemed that the doctors had pegged him for someone with more of a rough lifestyle. Multiple doctors had asked him on multiple occasions how much alcohol he drank, despite him telling them the same answer every time that he did not touch alcohol. They did not know that he was a pastor, having taken over sermon duties every week at his family’s small Mexican community church for the last several years. They did not know that he had been such a health nut before that, always counting calories and in a state of perpetual training for the next marathon. And they did not know until much later that his cancer had metastasized to his liver and this was the most parsimonious explanation for his liver results.
In addition to the issue over explaining his labwork, there was an ongoing battle with the doctors about his caloric intake. His gastroenterologist had been pressuring him to increase the amount of calories that he could eat, threatening to place an NG tube if he could not eat more than 3000 calories a day. It is not hard for me to imagine that this doctor had assumed my uncle was willfully refusing to eat, just another difficult patient who did not care about their own health. The reality was that he was steadfastly trying to increase his caloric intake, recruiting my mom to help him keep a diary of all the calories he consumed with the studiousness he once used to calculate calories for his running diets. Even with these efforts, he could still only muster enough strength to consume 900-1000 calories at most. Only later would we learn that his cancer had metastasized to his lower esophagus too, creating an obstructing mass that made it nearly impossible for him to swallow food.
It was extremely unfortunate that these metastases had not been discovered earlier, or even considered in the differential. When I learned of them, I was angry. How could he have received such poor care? It was hard not to conclude that he was treated differently because of his appearance. I wish his doctors could have seen past that, that they could have seen the man I knew - a man who hiked mountains, ran marathons, read voraciously, and studied at the best law institutions in the country. A man who taught me how to see geckos hidden among the desert.
“Patient refusing AM labs,” read the nursing note.
It was the following morning and I was pre-charting on my patients for the day.
No surprises there, I thought.
I finished reviewing the overnight events, new lab results, and vital signs, chugged another big gulp of coffee, threw my stethoscope over my neck, and headed down the hall to check on my patients.
Might as well start with him, I thought as I stopped in front of the familiar hospital door.
I once again steeled myself to enter the familiar door, anticipating a string of yells to be hurled at me. But as I entered, no curses or angry statements were levied my way this time. To my surprise, he was sitting in a chair by the window.
“Good morning,” he said warmly and met my eyes directly.
“Good morning,” I said back, trying to hide the surprise in my face.
As we continued talking about overnight events and the plan for the day, it felt like I was talking to a completely different patient than the one I had become acquainted with over the past few days. He was much more talkative and was even smiling.
“Hey doc. I just wanted to say I appreciate how you guys are treating me. I know you’re doing your best to help me. Like thanks for talking to me so much yesterday. Nobody had really told me what was going on before you did that.”
To hear this man say these things to me felt like an otherwordly experience. But I was very happy to see he was doing so much better, and I told him as much.
He then told me that this morning the nursing staff had barged in to his room unannounced and treated him very roughly in trying to get him to comply with morning labs.
“I could tell by the way she was looking at me that she thought I was homeless. But I’m not. I have a place. I have a job too. I’m doing well for myself. I think people just assume things like that about me. But they don’t know my life and they don’t know what I’ve been through. They don’t know me.”
And there it was.
I felt an immediate pang of shame rise up hotly within me as my mind jumped to my uncle and how the hospital staff had treated him based on their assumptions - ignoring how much pain he was in, disregarding his laboratory findings and symptoms, and assuming he was an alcoholic or just a difficult patient.
They don’t know me.
It was true. I knew nothing about this patient. Even though he had thanked me for taking care of him, I still felt it was undeserved. I was only doing what my attending said to do. If not for that, I was just as bad as the health care team who had treated my uncle.
My uncle passed away a couple weeks after that ICU stay. Like many cancer patients near the final stages of their illness, he had had enough. He had finally reached a point where he felt that the medical care he was receiving was not worth the suffering, and he wanted to die on his own terms in the comfort of hospice care.
My mom shared with me later that right before that decision, he had asked her for permission to die. She said no; that he still had too much he needed to do here on earth. It was too soon to give up.
As if my attending had somehow perceived what I was going through, even though I hadn’t shared a word of it to him, he suggested I follow along with the palliative care team, in a goals-of-care discussion with the family of one of my patients whose death was impending. That conversation enlightened me to the realities of hospice care.
Hospice was not giving up. Quite the contrary, hospice was one of the greatest dignities that could be given to a human being. It was the opportunity to be with family on a patient’s own terms, and to be allowed to die with dignity and respect. It was the opportunity to be seen in your last moments instead of hidden away.
As physicians, our job is to recognize patterns, often from very little information, and to do it as quickly as possible. We hike through arid desert environments and have to identify the creosote bushes, the prickly pear cacti, and the diamondback rattlesnakes that walk through our hospital doors. But these skills of pattern recognition can also be our greatest weakness. We may think we see a rock because we’ve seen a thousand rocks, and might miss the leopard gecko hiding on that rock.
Our patients come to us at some of the lowest points in their lives. They appear emaciated, in distress, fatigued, hungry, without appetite, and in overall sickness. We must realize that all we get is a small window from which to make our judgments. And importantly, we must recognize that our patients might be wearing camouflage to survive the harsh conditions they find themselves in. Errors result when we make medical decisions solely based on these small, camouflaged windows.
What we don’t have the privilege of seeing is the time before these windows. We see words in a chart like “gunshot wound” but not the life situations that led to that injury. We see diagnoses like “HIV” and make assumptions about choices, lifestyles, and behaviors, but we will never know the full story. What we don’t see is the marathons our patients ran, the mountains they hiked, the calories they counted, the sermons they gave, the families they led, the children they raised, the institutions they attended, the life’s work they produced - all the points in time that preceded the moment of camouflage on a desert rock, dying in the hot desert sun. Nonetheless, the nature of the physician-patient relationship requires that we expose the layers underneath that camouflage.
But while we have the task of recognizing the disease and treating it, we also have a responsibility to respect the person who contains all those prior moments. It is important for us to hold deep respect for the lives our patients have lived so that they may have dignity both in life and in death. We can only do this when we train ourselves to truly see our patients, looking past any layers of camouflage and observing them as a sum total of the person before us and the myriad experiences prior.
In reflecting on this lesson, I couldn’t help but laugh. Not only had my uncle tried to teach me this lesson as a boy spotting geckos in the desert. But now even in his death he was still teaching me. I wouldn’t be surprised if he was laughing too, watching me from somewhere in the orange sky above the White Tank Mountains.