You are at the beginning of your clinical rotations. You have already come to dread the emergency department. You don’t like the way it makes your learning feel like schadenfreude. But there you are, meeting your patient in the exam room. The computer lists the triage complaint as “neck abscess.” You smell him before you see him: drunk and homeless. You feel a vague stirring in your area postrema. He is curled up under a sheet on the gurney, wearing dirty white tube socks, dirty white briefs, and a ratty knit 49ers hat. The rest of his clothes lie in a stinking pile on the floor next to his bed, the pants still holding form from where he stepped out of them.

You can see beneath the hat and above the sheet, his grey beard, thick and unkempt, and his ruddy cheeks, the kind that come from exposure to the elements, like you’ve seen on mountaineers. He is mumbling, incomprehensible. You realize you’re a little bit afraid of him. When you introduce yourself and offer your hand to be shaken, he grips it tightly, pulling into the handshake and toward you, maybe leaning in to hear, or maybe because he’ll fall out of the bed if he let go. You don’t understand what he’s saying, so you assume he didn’t hear you, and before you pull your hand away, you tell him twice more your name, and that you’re a medical student.

Once you start asking him questions, you begin to feel more comfortable. You can’t figure out how long he’s been on the street, but it seems that a kind restaurant owner lets him sleep under the eaves of his building. He tells you he drinks; he had half a bottle of Jim Beam before he came in. He has a strange way of talking – not so much an accent as an unusual pattern of ordering his words and choosing his pronouns. He has spent his whole life in San Francisco. Even though no one you present to will care, you ask, for some reason, if he is married, and it surprises you to hear that he was, though she’s gone now. You realize that at some point, to someone, he was very lovable. Because he no longer is, his alone-ness strikes you.

When you examine him, you find scrapes and scratches all over his arms and legs, at different stages of healing. He tells you he falls a lot. He has a firm, golf ball-sized lump on his neck, right where his strap muscles meet his clavicle. It doesn’t look or feel like an abscess, but it hurts him, and he just wants it to go away, he says. As your hands disappear into the scruff of his overgrown beard, feeling for lymph nodes, he begins weeping, and he thanks you. You’re surprised, not sure what just happened.

You and your attending call the county hospital and his records there include a CT showing a supraclavicular mass concerning for likely malignancy. He has missed recent follow-up appointments with Surgery, and you get him rescheduled for more. When you go back to tell him the plan, he is sleeping, out like a light even before you’ve given him anything for his pain.

Gathering your things at the end of your shift, you overhear snippets of competitive storytelling at the workstation: “you should have seen…!” or “listen to this one!” You see your attending and the ED residents laughing. You head home.

You have spent years learning about the different ways a body can decline and fall into disease. But just recently have you started to see the way that loss fixes to illness like a shadow. You have never doubted the pain of dying, but you have some sense now of this pain of living: the hurt of letting it go.

You are in the hospital almost every day. Before the end of the year, you will think the stories told by a certain CT scan, a set of lab values, or the malignant ascites bathing a patient’s peritoneal cavity are the saddest you’ve ever heard.

Over the next few months, you pick up the abnormal findings. You hear an S3 and an S4. You hear a diastolic murmur, subtle and never normal. You feel an enlarged liver and a 25 cm spleen. In the OR, you hold a patient’s pancreatic tumor between your thumb and forefinger as his beating heart pushes his diaphragm against the dorsum of your hand. You see the double dip of a patient’s JVP at his mandible from 20 feet away, through the glass outside his ICU bed. You see a woman who could have been your grade school classmate on the operating table, prepped for her second surgery for metastatic colon cancer. She doesn’t flinch when you wipe the tears rolling from the corners of her closed eyes. She has so many mets that you have to record them in a table.

The hospital is hard on you. You want to feel normal again. You want to go home. You want to eat a leisurely brunch with friends at a sunny outdoor table talking about anything but medicine. After weeks wearing scrubs, you want to wear clothes with zippers and buttons. You want the people you work with to care who you are, or at least, to act like it. You don’t remember the feel of generosity, and you wonder if this is why you’ve found it a new challenge to be kind. You see an inverse relationship between an extra conversation with a patient at the end of the workday and a conversation with a loved one before bed. At the end of the day, preparing a polished presentation for your team by the next morning feels more pressing than the need to remind your patients that yes, they are being cared for.

You feel like you are just getting by, that you have a tenuous hold on your own survival and even your identity – barely enough sleep, barely enough time for meals and laundry. You’re afraid that an unplanned conversation with a patient might make you feel something. One moment of acknowledging your patient’s suffering could throw off the carefully constructed balance that holds you together. You imagine a little lid sitting in your suprasternal notch, there to keep the tears down when they well up. It’s not fail-proof, but sometimes it works, at least temporarily – until you find yourself at home again, or in an empty bathroom, or in the rare company of someone who sees you and hears you.

You have occasionally recurring moments of clarity, usually after some stretch of more sleep and regular meals, when you remember that being in the hospital at three in the morning as a patient will always be worse than being there as a trainee. Your survival doesn’t compare, you realize, because your patients are actually ill, in pain to the point of tears, despairing to the point of suicide, wobbling on that razor edge separating their life’s continuation from its end. Patients come to be taken care of, to be attended to, expecting that on this day, maybe the worst day of their lives, someone will help them. Of course, you think. Of course. That’s what a hospital is for.Screen Shot 2016-08-29 at 8.39.26 PM

You remember your patient, the one in the ED with the “abscess,” not knowing if he’s better now or if he’s dead. You are glad that there was something – whatever it was – that made him feel like saying thank you. And you remember how lucky you are to be there in the hospital. You remember that this job is remarkable. You remind yourself that sometimes even painful things are worthwhile. And you feel grateful.