No Apparent Distress: A Doctor’s Coming of Age on the Front Lines of American Medicine

In 1981, Pearson’s father cut off the tip of his index finger with a table saw while clearing land in the East Texas woods. His wife drove him to the hospital where doctors were able to mend the wound. Pearson was born two years later. He would point at Pearson and her brother Matt with the shortened finger and ask his wife how they would send them to college. He had stayed home and worked so that his wife could attend college, and it was important to him that his children have the same opportunity.

When Pearson was 11, the family moved to Port Aransas, Texas, a town of only 3,000 people. They lived in an RV while Pearson’s father and brother built a house: “If you can imagine living in a tiny camper in an RV park in Texas with thirteen-year-old and an eleven-year-old and two small dogs, I guess this tells you something about my family. We get along” (5).

Pearson was an awkward child with severely crooked teeth, which required braces. She also wore thick glasses. When she broke a pair, her father would solder them back together, causing the bridge of the frame to grow larger each year. Pearson made friends with other awkward girls, like Jennifer. Over a Christmas break, Jennifer’s family invited Pearson to go skiing with them: “The skiing trip was my first real introduction to how the other half lives” (6). Pearson sends a postcard home, giddy over the peanuts on the airplane, marshmallows in hot chocolate, and having Jennifer’s mom brush her hair.

It took a year to build the house. Pearson’s father worked at the Marine Science Institute, although he was creative enough to build robots and houses. He kept the Marine Science job for the insurance and told Pearson: “I never want you to have to work like that, not for insurance” (7).

Pearson and her brother are able to attend the University of Texas at Austin on scholarships from a now-defunct scholarship program. During her first two summers, Pearson went home to work with her dad renovating cottages: “That summer, my father started a tradition of cornering me in the evenings to have long conversations about my future” (9). He always encouraged her to take pre-med classes. Sometimes he talked to her about marriage, although she was only 20. She tells him that she wants to marry someone with an education like hers, then realizes that he might feel insulted when he is quiet. He tells her it’s okay, but that a man without a college education might surprise her. 

After her last year of college, Pearson works as a patient advocate at an abortion clinic: “It was abortion that convinced me that my dad was right, and I should go into medicine” (11). However, before starting at the clinic, Pearson wanted to be a writer and had been accepted into Columbia’s creative writing program in New York City. When she begins working, the clinic leader emphasizes to her that they are, above all, always kind to their patients. She starts in the front office, answering the telephone. She learns how to answer the questions of pregnant women, read from telephone scripts that are mandated by conservative Texas law, and how to respond to bomb threats, although there is never a threat during her six-month stint.

Then she begins working in the pathology lab, which is “where things grew more complicated” (13). The lab is where she learns what fetuses look like. Pearson begins to dream of driving on the road and finding it blocked by jars of aborted fetal tissue. She says that it was counseling that changed her path: specifically, learning to give women the mandatory counseling that they had to receive, according to Texas law, before getting an abortion. The stories of the women she spoke with changed her life, and the most influential stories were in Spanish, which Pearson was fluent in.

She counsels a woman named Nayeli, who is there in secret because her husband would never allow her to have an abortion, and he refuses to use a condom. She says it breaks her heart because she is a Catholic, but they will not be able to afford to feed a fourth child. Pearson tells her that God must understand her heart and that she is acting out of love for her children. Nayeli tells Pearson: “Yes. For them, I will go to Hell” (16).

A woman named Gloria tells Pearson that she wants to see the baby after the abortion. She asks if she can show Pearson why she is getting an abortion. She shows Pearson a huge wound on her thigh that has been stitched up. She says that she cannot give birth to a baby who will belong to the man who has tried to kill her. After the abortion, Gloria prays over the remains of the baby, which are held in a glass bowl.

Another woman, named Xochitl, tells Pearson she was born in Mexico. When she was four her family sold her to a family who needed help on a ranch; her parents couldn’t afford to keep her. After her boyfriend got her pregnant, she realized he was stealing money from her and no longer wants to have his baby: “I already left him. That was the first real decision I ever made for myself, and this is the second. The abortion. When I got pregnant, I realized I was in a trap. But here is the miracle: I can get out” (19).

At the end of the summer Pearson moves to New York. She goes to her writing workshops and care about her stories, but only briefly. None of the stories she or her classmates write feel as important as the stories of Gloria, Nayeli, and Xochitl: “I remembered the touch of Xochitl’s rough hands, and how instantly I had recognized her story as true” (20). She decides to go to medical school.

Pearson leaves the writing program in December of 2006. She enrolls in a pre-medical program in Portland, Oregon, and moves. She is happy at home, but lonely at school. Part of her feels that at heart she is still a writer. In one class she sits next to a student named Frank: “We were both in a sort of hiding, assuming that our true selves could never get into medical school” (23). Frank is trying to hide the fact that he is gay for the first time since Junior High. She and Frank become lab partners and study together at night. They begin discussing the problems they have with men and relationships. Frank expresses he wants to be in love, while Pearson explains feels love but has no idea how to apply it to a relationship.

Frank worries that he won’t be able to hide his homosexuality in a job interview, but feels that he must. He and Pearson become better friends as the semester progresses. By January, the continual rain and the pressure of studying for the MCAT have made Frank depressed. He sees a counselor and takes an antidepressant, but nothing helps. One weekend, he misses their first Sunday dinner in months. He misses a quiz, and then a test. Pearson calls Frank’s roommate, Dean, and asks him to go home and check. Dean does not call her back. When she arrives, Dean tells her that Frank killed himself. Pearson reads Frank’s suicide note. He had killed himself with caffeine—a lethal dose of NoDoz, which was an experiment they had joked about early in their labs while drinking coffee and studying too much.

For a few days, she is grief-stricken. She speaks with Frank’s mother and sits for long hours with her new housemate, John. When she speaks with her father, she says she wants to take a break from school. He discourages this, and says that this won’t be the last time she deals with a death. Then he reveals that he had been taking classes at college in Arkansas when a friend killed himself with a shotgun. Her father left college and never went back. He tells her that her grandfather was a Marine who fought in World War II and then led a happy life. Her grandmother had a double mastectomy and chemotherapy in her 50s, fought cancer for 20 years, and never stopped teaching: “These are the people you come from, and this is who you are” (30). Pearson stays at college.

She goes to Frank’s funeral in his hometown the next weekend. After, Frank’s mother says that she wants to sue the doctor who prescribed antidepressants for Frank, since one of the side effects can be suicidal thoughts:“If my mind grasped at any easy explanation, it was, This was your fault. You should’ve known. When he told you about depression, when you joked about killing someone with caffeine. Those were messages and you should have known” (32). 

Pearson interviews at several elite medical schools but none of them feel right to her. She likes the University of Texas Medical Branch (UTMB) on Galveston Island and applies. One week before her interview, Category Two Hurricane Ike hits Galveston and the entire town. The patients at St. Vincent’s Hospital have to evacuate, and 19 people died in the storm.

The first floors of most of the UTMB buildings were flooded. The student-run free clinic takes weeks to resume services. Pearson’s interview is rescheduled at a medical school in Houston, six weeks after the storm: “I did not know at that time how much the hurricane and its aftermath would change my medical education. I did know that the disaster, like Hurricane Katrina, would disproportionately affect the lives of poor people” (45). Pearson is accepted to the school and promised that the hospital will be fully operational again by the time she is in her third year. 

Pearson describes a head and neck surgeon named Susan McCammon. She feels lucky to still have her job, because after the storm nearly 3,000 employees had to be fired: “This luck, however, would have a silencing effect: those who now considered themselves lucky to have jobs at all mostly kept quiet about the changes at UTMB” (49). UTMB’s administration decided that the university could no longer afford to provide unfunded care. All of Susan’s cancer patients received a form letter stating that UTMB would no longer be able to offer them medical care. Susan did not learn about the letters until her patients began arriving at the clinic to ask about it. The letter had said: “Susan McCammon will be discontinuing her professional relationship with you” (49). She is appalled and unsure if the university is allowed to do this: “Not to cancer patients. Not to people who surely would die without care” (49).

One of the first things Pearson learns in school is how the bureaucratic hospital policies affect the poor: “The notion that the university could compel a doctor to abandon her patients was shocking, and at first, Susan didn’t believe it” (50). It turns out that the university is within its rights—the post-hurricane repairs were expensive, and it was a miracle that UTMB was still running at all.

Even if the finances made sense to Susan, the form letters did not: “It used her name. Because of that, her patients thought that she had chosen to abandon them” (51). The letter blamed Hurricane Ike for the abandonment of the poor patients. On the mainland clinics, UTMB’s paying patients had not been denied care. UTMB arranges for each abandoned patient to have one final visit, during which Susan does all she can for them.

Susan begins driving up and down the coast looking for her patients that she has not been able to reach by phone. They each ask her the same questions regarding what they should do: “She had to tell them that it was true: she would no longer be able to treat their cancer” (53). In each case, she commits to honesty and tells each person that they will die without care. She felt that these conversations had to happen in person, the opposite of the form letter: “Susan was in unfamiliar territory, beyond the guidelines of how physicians discuss death” (54). She continues visiting her patients to try and comfort them, even though she cannot treat them. Susan cannot abide the fact that it is bureaucracy and the lack of treatment it produces, not cancer, that is now causing her patients to die, starting in January. Susan is not religious, but she reflects on the dire circumstances:

She sees all her patients who have died very clearly; she imagines them all side by side in a high pew in the Government State Presbyterian Church in Mobile, Alabama, looking down. The upholstery there is gold and velvety, and the light makes golden dust motes. Susan’s patients are looking down and she can see their faces, and they have something to teach her. Though in these cases, as often, she is not yet sure what the lesson is (57). 

Pearson moves to Galveston the summer after that January during which Susan’s patients began to die. The student director, Margaret, takes Pearson to the clinic—called the House—a month before medical school classes begin. In a waiting room, Pearson sees a large group of uninsured people: “At that time in Texas, 26 percent of all people were uninsured” (60).

The first person Pearson saw that day needed a simple physical exam prior to beginning a job. She observes a third-year medical student giving the patient an interview about her health history. Pearson is astonished that the 26-year-old student has all of the questions memorized. The student tells her that this patient was an anomaly: “Most of the people you see here will be really sick” (62).

At the end of August, Pearson receives her white lab coat, preparatory to beginning her studies. The students also receive a gold pin that reads “UTMB: We Stop for No Storm” (62). All of the students take the same classes and have the same schedule. In a building called Graves, Pearson participates in small group discussion classed called PBL: problem-based learning. In PBL, the students discuss patents who had been seen at UTMB. In her first PBL class, they discuss a patient who needed plastic surgery to fix injuries he had received while trying to escape from the police. A white woman from Dallas says that because he’s probably in prison now he doesn’t deserve any medical care at all: “At first, all my classmates seemed like her: young, anxious, and conservative. There were women who woke up at seven a.m. and meticulously curled their eyelashes before a long morning of dissecting a human cadaver” (63).

When Pearson learns a new skill on campus, she visits the clinic to put it into practice as a volunteer. She spends most of her time out of clinic dissecting cadavers and studying. She expects to be disturbed by dissection but is fascinated instead. She gives the story of Vesalius, the most famous dissector in history. Vaselius lived in the 1500s. Prior to his intricate dissections, most physicians in Europe trusted the anatomical work of Galen, a Greek physician who died sometime around the year 200. Vaselius proved that Galen had made several errors. He often dissected criminals, because “[i]n some cases, to be dissected by physicians after death was part of the punishment for a crime. To dissect a body is to desecrate it—literally, to take away its sacredness” (66). Pearson’s view of dissection is practical. Bodies are useful objects of study to her, once the breath has stopped.

She explains that in modern times, cadavers come from people who have donated their bodies to science. But sometimes the donations occur because people are too poor to pay for cremation or funeral services: “Already in anatomy lab, we medical students begin by learning on the bodies of the poor” (69). She wonders if she should view the bodies of the poor, while they are still living, as victims of a symbolic death since they are slowly dying financially and are at the mercy of the medical system.

Pearson says that studying seemed to “obliterate the entire world” (70). She loses touch with old friends as she struggles to memorize thousands of facts. The clinic is her relief because it gives her a chance to focus on other people’s problems. She deals with patients who have schizophrenia, diabetes, depression, and more.

Her anatomy class ends with a challenging multiple-choice exam and a lab practical in which they answer questions about the body parts of random cadavers with only one minute each. The next day Pearson goes to St. Vincent’s. She is able to help a 55-year-old woman who has high blood pressure and prescribes the right medication for her with the help of a doctor. The woman hugs her, and Pearson feels that she has done a good thing, even though she does not know if she passed her anatomy exam yet. 

Pearson begins her Practice of Medicine (POM) courses, which will take two years. In POM classes she is able to practice on hired actors—called standardized patients, or SPs—who pretend to be patients with various symptoms and conditions. The encounters take place in a theater where students can be observed by their professors. The cases range from basic to complicated: “Lots of the complicated questions had to do with sex, because medical students are a virginal bunch—at least in Texas” (77). After each POM session, the students watch a video of their interactions, which always strike Pearson as a combination of embarrassing, horrifying, and occasionally hilarious.

They also perform POM encounters at the clinic, where they perform exams and take medical histories, but only after a doctor has done the very same thing. The first time she does a POM encounter in a surgery room in which a patient is being operated on, it feels like “a holy space” (79). She observes the inside of the woman’s intestines as the surgeons maneuvers a laparoscope inside her. Pearson watches as he removes the woman’s gallbladder.

POM students also visit Galveston’s prison hospital, which is “notoriously short on medical staff” (83). The first time she visits, all the shackled men moving through the hallways unsettles her. Pearson’s first POM patient in the hospital is a Spanish-speaking man in his 40s. He had fainted one week prior. He tells her that he wants to climb mountains when he is released but is worried that he won’t be able to if his heart is weak. Pearson tells him that diet and exercise are important for a healthy heart, and then follows a guard downstairs as they take the man to a cardioversion session—a procedure in which the heartbeat receives electric shocks to try and restore it to a normal rhythm. The man is terrified, but Pearson explains in Spanish what is going to happen, and he tries to relax. The doctors sedate him, begin the shocks, and Pearson leaves.

She knows that his options for self-care and medical care are limited in the prison: “All I could do was have a sort of human conversation with him, and hope that it mattered” (87). She is beginning to understand that technical competence can still be frightening for patients if doctors are unable or unwilling to demonstrate a “human touch” (87) while tending to them. 

In April, Pearson dissects a human brain in a neurobiology lab. As she walks home, she feels heavy:“This is not a symptom of depression, I realized. This is who I am. I have always wanted to die” (89). Later she does realize that she was depressed, which she says happens to a third of medical students at some point. She reveals that she has had fallings out with her two closest friends in school, but does not elaborate on details. Pearson’s dog Charlie seems to realize that her mood is different and bites her face when she is crying:“I was not actually (I say now) going to kill myself. I learned my lesson from Frank: It’s cruel. But the simple fact that I wanted to, that I was perfectly convinced that not-life was preferable to life, itself depressed me” (90).

Pearson says that three things helped get her through it: smoking, her brother, and the end of the school year. At the end of the semester she receives an offer to work with a family physician in Colombia for a month, but she turns it down: “I knew I was in no place for that, and I think the decisions I made was life affirming” (91). Instead, she spends a month in Chicago with her friends Ryan and Delaney. In the evenings, she resumes a children’s writing project she had begun long ago.

Pearson provides statistics about suicide among physicians: “Male physicians are about 1.4 times more likely than their non-physician counterparts to die by suicide, and female physicians are 2.3 times more likely” (91). Medical students seem highly vulnerable to depression, but do not like to discuss it. It makes students professionally vulnerable if they have to reveal to interviewers that they have ever been under psychiatric care. But this “drives a suicide-prone population away from the help we may need” (92).

When she goes home she is immediately depressed again. She is not a writer, but “doomed to be a medical student” (93). She dreams of Frank and he asks her how she could have made such a horrible mistake. She sees rats in her apartment and leaves, beginning school again two weeks later: “That was when I met Mr. Rose” (93).