After the tumultuous 8 weeks of surgery rotation, I started 12 weeks of internal medicine rotation. In surgery, the issue pretty much boils down to the question of whether the patient needs a surgery or not. In inpatient medicine, on the other hand, the most important task is to make the diagnosis. (And treatment, of course, but we often need to know what the patients have before we can treat them.)

Unlike in surgery, where the medical record consists primarily of how a procedure went and how the patient is recovering from it, in medicine, we go through a process of coming up with a list of things that could be responsible for the patient's symptoms -- differential diagnosis -- and perform a set of exams or labs that may confirm or rule out a disease entity. 

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You will never forget the cases that you see as a student, and you will never learn the cases that you never saw as a student.

This was a piece of advice that my mom gave me when I started my clinical rotations.

Countless times have I heard that the patients are our best teachers. A few months into clinical rotations, I could not agree more.

On my second week in medicine, I was assigned to follow a patient with alcoholic liver disease. And a prototypical case at that -- enormously distended abdomen, bilateral leg swelling, and hemorrhoids. He was emaciated, with gaunt cheeks and sunken eyes that reminded me of a Medieval portrayal of the Crucifixion. He said he was in the late 50s, but the disheveled, white beard made him appear much older than his stated age. He had a daily dose of 8-9 beers for as long as he can remember. For the past week, the only thing that entered his mouth was beer. How could he drive his body to a brink of collapse this way? I asked myself, incredulous.

His labs were also consistent with alcoholic liver disease: elevated liver enzymes, low serum protein levels, low serum sodium levels, low urine osmolarity. Everything was screaming out to us that the patient was diluting his system with too much beer and starving himself of any meaningful nutrition.

It was fascinating to observe with my own eyes the classic findings of cirrhosis, the hardening of the liver due, in this case, to excessive alcohol consumption and chronic liver injury: fluids backing up from the hardened liver and accumulating in his belly (ascites) and legs (pitting edema); Caput Medusae, or engorged veins around the belly button that reminded someone of the head of Medusa, the mythical creature whose hair was made up of snakes; scleral icterus, or the yellowing of the white of the eye due to pigments released from damaged liver cells; and gynecomastia, or male breast enlargement due to accumulating estrogen that cannot be broken down by the damaged liver.

As I performed the physical exam and followed the patient's course of hospital stay, I made a conscious effort to find the appropriate balance between a curious medical student and a firsthand witness to suffering. It was the patient, and a fellow medical student, who pushed me to try and think harder. As he was being shuttled from one testing room to another, he felt he has had enough. "You don't understand," said the patient. "I just lost everything." The old man started to cry. He refused any further testing. While trying to convince the patient that the testing could be beneficial for him, I could not help noticing that the tears coming out of his yellow eyes were clear, just like ours. I was fascinated by that finding, and I felt ashamed.

We brought him back to the floors and prepared to send him home, as he wished. Then, a fellow medical student, who had heard about this patient, thought she couldn't let go of the opportunity to take a look herself. I was taken aback by her curiosity and fascination, not unlike my own but completely undisguised in her case. She insisted that she examine the patient before he went home. I told her he just had an emotional breakdown and refused his testing, but she was adamant. A genial, if not tactless, person she was. "Don't worry, I won't be insensitive," she said, with a smile on her face, and walked into the patient's room.

A few minutes later, she emerged from the room, with an even bigger smile on her face. "That umbilical hernia was so cool! I've never seen anything like that!"

I agreed with her that his was a cool case, and changed the topic of conversation. Something bothered me deeply about that fascination. And this is not something new -- throughout the surgery rotation, I struggled with the guilt over being fascinated by the dysfunction of the human body while I tried not to turn my eyes away from the suffering that it produced.

But it's the patients who raise the alarm and drag us out of the habit of objectification. They resist. This is my only second week in medicine, but this was not the first patient who refused further testing and treatment because he felt he has had enough of it. 

In a way, what this patient taught me is more than just the work-up of alcoholic cirrhosis. He showed me that, even as he struggles with increasingly dysfunctioning body, constant pain, and loneliness, his dignity matters to him, and certainly to us as well. Though it should have been apparent from the get-go.