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

“‘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.’”

When Pearson meets Xochitl in the abortion clinic, she understands the awe with which some people regard doctors. Xochitl is there for an abortion, but to be able to perform an abortion, safely, is to work a miracle. 

“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.”

Pearson is prone to guilt after Frank’s suicide, and this tendency will follow her into her medical training. It takes a long time before she can stop second-guessing herself when something goes wrong, and it becomes clear that this is a tendency shared by many medical students, which makes the discussion of suicide statistics among physicians more poignant. 

“Who is a surgeon without her operating room? What does a good doctor do, when the institution she works for compels her to abandon patients who need her help?”

Susan McCammon’s dilemma when she can no longer treat her unfunded patients is one of identity. She cannot feel as if she is performing her ethical duties, because an institution dedicated to healing barring her from treating her patients. She questions whether she is still a doctor and surgeon if she allows her patients to die because of bureaucratic exigencies.

“This is the precise strangeness of learning to see like a doctor. If you believe hard enough in the truths of biochemistry and anatomy, what surrounds them—people with their suffering, the politics of a society that lay this particular body into your hands—seems not to matter at all.” 

In anatomy lab, Pearson learns that many of the cadavers are donated by people who are too poor to pay for cremation or funeral services. And yet, as she becomes more fascinated with anatomy, and more driven to excel at medicine, she is able to compartmentalize the politics and treat the bodies as useful objects of learning, and little more. 

“Already in anatomy lab, we medical students begin by learning on the bodies of the poor.” 

Pearson learns that people donate many cadavers—or the families of people—who can’t afford to pay for a cremation or for funeral services. She uses this anecdote to emphasize how the healthcare industry relies on the poor to teach their doctors yet dismisses them when the poor cannot afford costly medical care. Pearson struggles with this realization throughout her training and career.

“This is not a symptom of depression, I realized. This is who I am. I have always wanted to die.”

Pearson’s thinking during her depression is so distorted that she can’t even remember that there were times when she was happy. And when she is locked into the grueling schedule of medical school, it is even harder for her to distance herself from her thoughts. She describes feeling “doomed” (93) in her enrollment. 

“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.” 

Pearson thinks constantly of dying during the POM stint of her studies. Even while she is learning to heal others, she is frustrated by her inability to desire her own continued existence. Thoughts of depression and suicide stay with Pearson throughout her training. 

“They say you shouldn’t treat your family, and that’s right.” 

When Pearson’s grandmother is sick, Pearson knows that she needs to be treated by someone more objective than she is, even if she had been a fully-fledged doctor and not a medical student. The detachment required for her to care for a sick body is not there when she examines someone she loves. 

“This was the first patient I had ever seen die. Guilt washed over me: I was only a medical student, but I was also a twenty-eight-year-old woman. I had loved my grandmothers. I knew better than to step away and let an elderly woman die.” 

Pearson is ashamed when she watches an elderly woman die in the ER. No one spoke to her or tried to comfort her. She commits to being more emotionally invested in each patient, even if they are unresponsive and beyond help. 

“I felt sick, like this tiny baby’s pneumonia was entirely my fault. I had caused it by trying to do what I was told instead of confessing to the fact that I had no idea what I was doing.” 

After Pearson botches the pregnant woman’s vaginal exam during the labor, she is embarrassed that she was not secure enough to tell Dr. Leucke. Even though she didn’t know what to do, he would have understood since she was still a student and had never delivered a baby. After, she vows never to let her ignorance override her judgment again. 

“The baby girl began to cry. A minute later, I was crying too. Some things in medicine really are miraculous; there’s no other word.” 

Pearson assists in a successful C-section delivery. Even though many babies are born every day, and medical procedures become routine, she can still feel that it is a miracle. Pearson balances the darker realities of some stories with uplifting anecdotes such as this one.

“Was second-rate care better than no care at all? What would it feel like to place your life in the hands of students, or of charity?”

After assisting Dr. Leucke at the free clinic in the church, Pearson worries that it might be a disservice to the poor. If the free monthly clinic did not exist, families might treat their children’s illnesses earlier and with more urgency, even if it meant traveling further to more expensive hospitals. This doubt parallels Pearson’s persistent self-doubt as a medical provider. 

“He loves his patients, but is it possible to do right by them this way?” 

Pearson is with Dr. Leucke. She realizes that the existence of a monthly free clinic might make people postpone their own care to a real hospital for fear of the bills, or of being denied service. Doing right by a patient ostensibly means providing the best care, or of informing a patient of who can perform the best care. Again, this mirrors Pearson’s doubt that medical care providers can consistently help their patients. 

“I was no longer the medical student on the neurosurgery service, but a live woman!”

Pearson enjoys herself during a blind date and realizes what a relief it is to be able to forget the hospital for a while. She later describes it as feeling human again, a condition she is not always able to sustain while at work. 

“Like my patients, I wanted desperately to be in this world. His heart beat fast against me when we kissed, and when I touched him I felt like I was flinging myself toward life, life, any kind of life.”

After Elias’s surgery, he loses the ability to talk, and Pearson struggles with the feeling that they never should have performed the surgery, since he will probably die anyway. She finds relief in the man she is now dating, and makes the connection that she feels more alive when she is out of the hospital, even though it is where she spends most of her time. 

“His family wanted us to be heroes, and we tried too long to play that role. It was easier for us at the time to put the blame on his parents for clinging to his life. But the fact is, we kept on doing the surgeries, even though we knew each one would leave him more devastated.”

Elias lasts for six months after the initial surgery Pearson witnesses. She wishes that his family would let him die, and that the doctors who had known that he could not be cured would have had the courage to refuse the series of devastating operations. No one, including the doctors, wanted to admit that there was no hope, or to cast the doctors as helpless in the situation. 

“Everything that had happened to my mother felt so unnecessary: the transfusion, the failed treatments, the pacemaker, the fear of death that had fallen over everyone in our family and which we could not shake. Medicine had caused this.”

When Pearson’s mother learns she has Hepatitis C, the experimental treatments she undergoes fail to help, while also ravaging her body and immune system. Pearson is frustrated with the medical system, which made promises to her mother it could not keep, and with how the entire situation could have potentially been avoided if the unnecessary blood transfusion after Pearson’s birth had never happened.

“My own response, too, had become bureaucratic. This could be a time for me to learn how to support a patient through fear and grief, but instead I would learn how to apply for financial assistance. Could this be what good doctoring is about?”

Pearson is unsure of how to respond to Vanessa’s grief when Jimmy is diagnosed. The only thing she truly has the power to offer is to help Vanessa wade through the bureaucracy of the financial process that might give her and Jimmy a break on the costs. Pearson knows that there must be something more effective she can do for Vanessa but doesn’t know what.

“More than anything else, I wish Vanessa and Jimmy had had a more experienced advocate than me. Not because I did a bad job. I did a good job for someone at my level. But I was just a student and there were many things I did not know. They deserved, as everyone does, a doctor.” 

Pearson is no longer afraid to admit it when she does not know things. But in Vanessa’s case with Jimmy, because of their financial precariousness, Pearson was still her best option, despite still being a student. Pearson maintains how everyone deserves a doctor, including Vanessa and Jimmy, although a doctor was not an option for them. 

“If you are a patient at a private clinic—as I am myself—you can be pretty sure that most of your doctor’s mistakes have already been made. They were made on the bodies of the poor.” 

A patient who was initially hostile, given that she’d had medical students make mistakes with her care before, thanks Pearson. When Pearson proves to be empathetic and competent, the woman is grateful. Pearson realizes that she has never had to be grateful to a doctor because she has never had any expectation of her own doctors making mistakes in a private clinic.

“He always said that one is better than zero, and I always said that one is still an injustice when somebody needs five.”

Mr. Jackson says that even though St. Vincent’s can’t do everything—which would be a five—it can do more than zero, if that means only providing one small service for a patient. But for Pearson, her sense of outrage over a system in which someone who is dying can be turned away is more potent that her eagerness to provide minimum care for someone who needs maximal care. 

“Sometimes when you push and push and push, and you don’t give up—when you become that obsessive doctor who can think of nothing else—you actually save your patient’s life.”

Pearson is conflicted while watching Jacqueline’s tenacity in pursuing charity care for Gloria. Jacqueline is an obsessive doctor, and Pearson worries that she is missing out on living a real life. However, Jacqueline’s refusal to give up saves Gloria’s life.

“Your life is actually not about your own experience. It’s about serving this other thing.” 

Pearson tells Julian about Cicero, whose grief over the death of his daughter was seen as weakness by other Romans. He detaches himself from society to grieve in the country, where he has the solitude necessary for his writing, which is highly influential. Pearson likens their detachment as doctors to Cicero’s fleeing to the country to hide his emotions.