Maryam Ahmad 2023

When the Mask Fits

WEEK 2

“I am so sorry to hear that,” I say during my second week of medical school to my not-real patient with not-real chest pain in front of my small group that is seven people too big. My mouth feels stiff and my lips are moving slowly and everyone is watching me and this is not coming out right at all.

We had a demonstration last week, but that was a real doctor talking to a simulated patient so it didn’t feel as much of a dress-up game that I am doing now.

Show your patient that you care, the physician at the demo lecture said. You need to communicate to them that you are in this together.

My not-real patient goes on to talk about the trouble she is having breathing and a hysterical urge to laugh rises up in my throat and I have to control my expression and make it be blank because the only thing worse than saying a stumbling sorry in front of all my classmates who all know what they’re doing and sound genuinely concerned for their patients is to start laughing.

But I can’t help wanting to laugh at my own ridiculousness. I’m an actress in this strange facade, pretending to be a medical student that I’m not. I guess the secret that I don’t really know how to talk to patients is not so much of a secret anymore.

I pull my lips into my mouth from behind my mask so I don’t accidentally smile. Paying attention to what she is saying helps me drag my thoughts away from the fact that laughing while someone is talking about pain is the opposite of empathy.

By the end of the excruciating five minutes that is my patient history, I’m worn out. “How did you think you did?” my facilitator asks.

“I don’t know.” I’m too embarrassed to tell her I know I did not do as good as my six classmates who went before me.

She acknowledges some of the positive things in my patient history and that makes me feel a little bit better. At the end, she says, “One thing you could work on is your emotion. Your words are all there, but your facial expressions...” She trails off. “You can show a little more emotion. Let your face feel it.”

My face heats up. I’m sure even my forehead is red so the mask isn’t really hiding anything anymore.

“That makes sense.” I try not to crawl under my chair and melt into the floor.

WEEK 4

The day of my second not-real patient visit, I am not at the front of a room in front of all my classmates. Instead, I knock on a door to a clinical suite and walk in to find my not-real patient sitting at a chair, massaging his head.

I ask him if there’s anything I can do at the moment to ease his pain because my facilitator suggested we always try to make our patients comfortable. He says no. I take a deep breath as he tells me about his headache, and I say, I’m so sorry you’re going through this.

Let your face feel it. My ‘empathy’ still feels stilted coming out of my mouth, but I say it because if there’s one thing I’ve learned in my very short time here, it’s that everything needs practice to get better. Especially this.

“What would you like feedback on?” asks my simulated patient after we’ve finished practicing the visit. He is now just his normal self, Sam, a retired science teacher who does this in his free time. This is a lot easier. We’re not in a play anymore. I can talk freely.

“How is my…empathy?” I ask. My face is turning red again. I’m not sure what I’m looking for. Unlike the list of things to do when taking blood pressure that I memorized last week, I know there’s no set procedure for showing empathy. I can’t follow steps one, two, and three to guarantee that my patient will feel that I do care for them.

“It was good,” Sam says. “I felt like you were responding to my pain.”

I stare at him. Is he saying that because I’m really getting better? Or is it because I’m a first year first semester medical student whose white coat is too big for her and he is a kind fifth grade science teacher?

“Did it feel emotionless?”

Sam reassures me that his answer is still the same. I don’t know that I feel that I thought my empathy was coming across, but I also need to ask him if I had organized my questions correctly so I move on.

Later, I watch the recorded video of myself doing Sam’s patient visit. I hear myself say the words I’m so sorry. My voice is too high pitched. I can hear the part of me that is trying so hard to get this right but getting it wrong anyways. I don’t really recognize this person, this tone coming from her mouth. She sounds hesitant, unsure if she is doing the right thing.

I lay in bed that night, unable to sleep. I moved here three hours away from home and I have an apartment with a roommate with a lease until next June. I can’t drop out of med school now. But maybe I’m not cut out for this. Maybe the admissions committee meant to pick someone else who was good at patient visits instead of me but just forgot their name. Maybe I accidentally

said something in my interview that made them think I’d be just fine at this, and somewhere out there, they’re regretting their decision right now.

I flip my pillow over and try to think about something else.

WEEK 6

I enjoy my bioethics class on Mondays over the lunch hour. My professor is an infectious physician whose tidbits of wisdom I sometimes note down on my laptop. During a discussion over an article about, we arrive at the topic of empathy. He asks whether showing empathy to patients can be learned or whether it is something that you must be naturally adept at.

I start to get nervous. If I have to talk now, what am I going to say? I have no wise words of wisdom to tell the class about empathy.

To my relief, I don’t have to talk because the professor starts to tell a story. He tells us about a man who put on a mask of a person he wanted to be like. He kept the mask on for so long that when he took it off, his face had molded to fit it and now looked like the person whose face had been the mask.

I open the notes app on my laptop and type, it is okay to practice with the mask until you become the mask.

WINTER BREAK

I’m home for winter break. The last few days have been a whirlwind of emotions. I have never seen so many students hugging and congratulating each other, people they’d never met, people whose names they didn’t know, like I did after that last exam.

As I am waking up from the longest sleep I’ve had since med school started, my mom comes into my room and tells me she wants to talk to me.

“I need you to help me get an appointment with a psychiatrist,” she says.

When I ask her what’s wrong, she tells me about the crisis she’s been having the past couple of months. It started out with stress about work, then erupted into full blown tinnitus in one ear, which led to anxiety and now insomnia for the past couple of weeks.

I help her make an appointment for the earliest date that is available, Tuesday. I go with her on that day and sit in on the appointment, listening to my mom recount her sleepless nights and her anxiety that this is all it ever will be, that she’ll never want to eat or live again.

She cries during that appointment. I cry. My mom has always been stoic. She will face life and she will not back down. It’s almost unbearable to hear that she doesn’t want to do this anymore.

Afterwards, we sit in the cold car in the parking lot. It is dark outside. I reach in the glove compartment for the box of tissues I keep there for cold winter nights like this and hand her a few.

“It sounds like it’s been really terrible,” I say quietly. The guilt is weighing heavy. I wish I had known earlier. I wish I had checked in with her, or asked my sister how my mom was doing. Maybe I could have done something to prevent it from escalating. “I’m sorry it’s been this bad.”

Some reflexive part of me cringes at those words. Is that me? Or is that what I’ve been practicing in school?

Or maybe - is it both?

“It helped that you were there. Thank you for coming with me,” she says.

We talk for a while about the psychiatrist and her feelings about the medication he prescribed. She’s simultaneously hopeful but trying not to get too ahead of herself in case it doesn’t work and we have to go back to try another dose or another medication.

But thankfully, by the time I am packing up to make the drive back to school, she tells me she is getting better. My mom and I don’t hug much, but that day the occasion definitely calls for it.

WEEK 2

I’m back in front of the room. We’re doing an “emotional” patient today. That label on my class schedule makes it seem like all our patients will be either divided into “calm” and “emotional” patients. I’m not sure I understand.

My friends and I debate before class starts about who will get the patient who is sad and who will get the patient who is angry. I’m terrified of ending up with the person who is angry. I haven’t practiced that one yet. But I realize that is obvious. I know that this is all of our first times. None of us have practiced with a patient who is angry before.

In the end, I end up interviewing the sad patient. She is heartbroken over being ill for so long that it has prevented her from seeing her new grandchild. She is worried that she has something incurable and she might transmit it to her family if she visits them.

I’m still freshly homesick. It’s not been too long since I came back to Iowa, and I miss my family. I miss my mom and I worry about her. I wonder how my patient feels about not being able to see her family, and at such a momentous time as the birth of a new baby. It must be crushing.

“That sounds awful, not being able to see your grandchild and your family all this time,” I say. “I’m glad you came in so we can try and find out what’s going on.”