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Little Miss Perfect: a portrait

LMP, the other residents called her. In medicine, the acronym LMP usually means last menstrual period. In this case, it stood for Little Miss Perfect. This was not a compliment.

Lakshmi gave every appearance of being perfect. Her marks in undergraduate medical school were exceptional. She was intelligent, well prepared, charming and efficient.  Always beautifully dressed, her hair was professionally blown out, her nails never ragged or chipped. Unlike the other often frazzled and sleep-deprived members of her resident cohort, she never looked flustered, exhausted and overworked. Lakshmi presented well and had a strong medical database, She had done well on all the tests. We put her on the top of our “pick list” when we chose our new residents.

The cracks in this perfect façade began to show when she started in her family medicine clinics. Her primary preceptor was an excellent teacher. A proud IMG, he had given up a lucrative job in medical administration to struggle back into clinical medicine. He was not impressed by our Lakshmi.

“There is something wrong with her,” he confided to me one day over coffee. “She does not seem to want to get to know the patients, to understand their lives and needs, and I think she is lazy.” His shocked tone was that of a man for whom 12-18 hour days were standard.

“Lazy, how? In what way?” I queried.

“Well,” he replied, “She seems to pick through the charts, trying to pick out the least complicated cases. I’ve noticed that she seems to always leave the more marginalized patients for me to see.”

“Is she just insecure about seeing them, perhaps?” I countered; lazy did not seem to fit into my image of the poised, high-achieving Lakshmi.

“No, I don’t think so,” he said. “The other day, we had a very busy walk-in, and I noticed that she had not taken a patient for over 20 minutes after the last patient had left. So I went to the room and opened the door. She was just sitting there looking at the screen. She clicked off when I came in, but I saw what she was looking at. It was purses!  Perle, she was on a shopping website looking at purses in the middle of a walk-in clinic! Not acceptable!

I took the preceptor’s comments very seriously, but I wondered if this was just a personality mismatch. In those days as a site program director in a preceptor-based residency, I described part of my job as making 12 arranged marriages every year.  I tried to match the resident and preceptors’ interests and personalities so that they both got the most out of the program, but sometimes that did not work out. Every once in a while, the residents had to be moved, and preceptors changed.

At her six month review, I took the opportunity to chat with Lakshmi about herself, her plans and desires for her career.

“Well, you know, I am really into cosmetic medicine,” Lakshmi told me, “I plan to do a family medicine derm fellowship and do fillers, Botox and veins. I like that kind of stuff.” I was frankly a bit shocked, I could not think of anything that was less like how I envisioned the career of a family doctor. I reminded myself that it took all kinds of people to do all types of work in the wide medical world, but Oy!

She was not too happy with her preceptor. “He is so demanding,” she said, “and some of his patients are so difficult! It’s not fair.”

I looked at her, puzzled. “We all have difficult patients,” I said to her. “You can learn a lot from your preceptor.”

She raised a skeptical eyebrow.

I asked her how she decided to go into medicine. “Did I have a choice?” She laughed. “My parents are immigrants, I was a good student. This is my fate.”

“What would you have chosen?” My curiosity was piqued. Was this an explanation for her attitude in her preceptor’s office? “What would you have chosen?” I asked her.

“Oh, I would have gone into the fashion industry, for sure. Maybe a designer, I like accessories, in particular, you know shoes, purses.” She pulled out her phone and showed me her extensive Pinterest boards.Animated and happy,  this was very different from her usual reserve.

Medicine is not for everyone. In fact, if you don’t love it, it can be a terrible job. Unlike the white-coated, intellectual young sex gods often depicted on TV, most residencies are long hard, and people complain to you all day. There is a lot of contact with other people’s secretions and people for whom bathing is an infrequent event. There is also the responsibility, the fear of making a life-threatening error.

Many years ago, I knew a woman who had kind of fallen into medicine. She was brilliant, and the first two years of medical school went well. When she started doing clinical rotations, she realized that she hated it. She tried to quit at that time but was persuaded to stay. “Maybe you should do pathology if you don’t like clinical medicine,” she was advised.

When I met her, she was a chief resident in Pathology. She was miserable. What she had discovered was that what really disturbed her was taking the responsibility of deciding on a diagnosis that would materially affect peoples’ lives. It terrified her that if she was wrong, someone could die. It was pathetic to watch her struggle. She would describe the slide to her preceptor, perceptively and accurately describing every finding.  Her preceptor would very gently ask her, “What is the diagnosis?” She would turn pale, start to stutter and sweat. She would refuse to answer. She also began to not come in – missing days at a time, coming in dishevelled and looking hungover. Finally, 3 months before the end of her residency, she quit. Many years later, I ran into her at a bank where she was now a loans officer. She looked terrific: happy, fit and clear-eyed. “Leaving medicine saved my life,” she said.” I would have died if I had become a pathologist.”

I worried about Lakshmi. She felt that being a doctor was “her fate.” I worried that she would end up like my pathology friend, unhappy to the point of suicidality.

I had already moved her to a different practice. This was a practice of two older women, both excellent teachers with a more upper-class clientele. Perhaps Lakshmi was not cut out for the diseases of the poor.

Then it happened, Lakshmi failed her Emergency Rotation. “I just can’t pass her,” said the ER’s Teaching Lead. “She knows her stuff, but she just does not DO it. Working with her is like working alone. Every time you turn around, she is not there.”

So we started the stressful, frustrating and tedious job of remediation. We marshalled all kinds of resources to help Lakshmi be a better physician, private tutoring, simulations, and reading lists. Just before the whole program started, she came in with a note from her doctor saying she needed 3 months off for burnout leave. “Oh good,” I thought, “let’s just delay things.” It was not her skills and knowledge that needed remediation but her attitude. I had no idea how to fix her. So Lakshmi went off to Mumbai to visit some relatives and “rest up.”

When she returned, she was glowing with happiness. She was even more exquisitely dressed and made up than before. On her finger was a spectacular ring. The ring featured among many brilliant gems, a large yellow diamond, the size of her thumbnail. ”I met the most wonderful man in Mumbai. We fell in love instantly, and now I am engaged!”

“Congratulations,” I said. “So, what’s the plan?”

“Oh I am going to finish my residency,” Lakshmi said gravely, “It would be too shameful to not finish. Steve wants me to be a doctor, but of course, I won’t practice once I am married. He promised me that he would help me start my own fashion line. Purses, I think. I do love purses!” She was glowing with excitement.

A change came over Lakshmi, she now attacked her remediation program with gusto, finishing early. Back in the regular residency program, she worked really hard, completing her tasks with energy and precision. She wrote her family medicine exams and aced them. She was perfect.

Lakshmi lives in Mumbai now, with her financier husband, two perfect children and her growing and popular line of purses, scarves, jewelry and other accessories. She seems very happy.

I have never met Steve, this Deus ex Machina, who saved Lakshmi from her “fate,” but I am grateful to him. I think he helped make Lakshmi’s life a good one, one that was more suited to her personality and talents. Sometimes, however, I think about the “not Lakshmi,” the student who did not get into medical school because she did. The person who may have been a little less perfect but wanted it more. What happened to them?