Ugly Cells

The pathologist’s cursor cruises over the cells, brilliant pinks and purples magnified on the slide. She highlights cellular anatomy, drawing on knowledge I’ve long forgotten from the first year of medical school. Graduation is in a few weeks, and the pathologist’s voice droning on about biomarkers and stains fades as I think about moving to Boston for medicine residency.

“You know these cells are cancer,” she says, and I snap back to attention. “Look how ugly they are.”

I vaguely remember something about cellular markers and basement membrane disruption, cancer creeping in.

I remember B.’s blood counts vividly. When we first met, she was young, no more than 10 years older than I was as a fourth-year medical student. She had been feeling tired, so she went for a blood draw. I’ve done this countless times, only to be started on iron pills, counseled to eat more meat. She was not as lucky. With dangerously low cell counts—pancytopenia was plastered all over her chart—she was admitted to the hospital, assigned to my care on the general medicine service. Yet, B. is friendly and pleasant. She teaches special needs children and is always feeling run-down, so she didn’t think much of her fatigue and weakness. B. tells me about her daughters, how they are adjusting to having a baby brother. Her husband is thrilled to finally have a boy, she says, laughing.

“I thought I was pregnant again,” B. recalls.

I trace the familiar routes I was taught and had practiced before. A breast exam is like mowing a lawn, one of my mentors once said. I think he meant to emphasize the systematic approach that we use in so much of medicine; reading EKGs and interpreting acid-base disorders apply here as well. But this didn’t feel mechanical. I try to hide the concern on my face as my fingers make contact with the mass in the left outer quadrant of her left breast. I can’t meet her eyes. Instead, I focus on the cards her children made. She told me she hopes they can visit after school today. Her daughter has drawn a cat in pink crayon.

“I’m still breastfeeding my little one, so I didn’t think anything was unusual,” B. continues. She begins to cry, “I should have known something was wrong. I should have come in sooner.”

I pull my chair to her bedside and take her hand in mine. “You did nothing wrong. I’m glad you are here now.”

I hold her hand as she is wheeled in for surgery. The OR is cold. I feel intrusive and clumsy as I help her slip out of her hospital gown, uncomfortable with her bare breasts exposed, goosebumps spreading and nipples hardening. I cover her with a heated blanket, knowing that the blue surgical drape will not be enough to keep her warm while she is asleep. I suppose being cold is the least of her issues as the surgeon inks her initials on the left breast. I try to mentally prepare myself for questions the surgeon will ask me during the procedure: the data for axillary dissection, sentinel lymph node biopsy, TNM staging. I keep thinking about her daughters and how they got their names, how good they are with their baby brother.

In the pathology lab, the breast slips through my hands, unrecognizable from its natural form after its preparation for the wet lab. The technician clamps down on the tissue with a pair of tongs. These are great for cooking, you know. My stomach twists in knots as she slices thin cuts and places them on slides. The tumor looks like a streak of gray to the naked eye and feels stiff, a contrast to the rubbery tissue around it. I think back to every breast exam I’ve ever done, reconstructing the cross section into a mass my fingertips would recognize. As if a systematic approach like mowing a lawn could recreate this. I think about B. and wonder whether she knows how ugly her cells will look under the microscope.

A few days later, the pathology is back. B. asks whether she will be able to breastfeed her son once she starts chemotherapy. All I can do is watch her face. I can’t hear the oncologist’s answer, but her crumpled expression and quiet tears are clear.

I think about how much easier it would be to hide behind systematic, analytical thought—a place where I can mow lawns, drawing clean clinical lines between my patients and me. How much more comfortable it is to detach personhood from patienthood, to break patients down into their constituent parts. To talk about skewed blood counts, diseased organs, ugly cells.

B. was discharged home with close follow-up with oncology. I finished school, celebrated graduation, and held 4 years of medical school condensed into a diploma in my hand. As I started residency, I continued to think about B. and all my patients like her. I don’t have a good answer for how to maintain the clean clinical lines I found refuge in as a medical student without distilling my patients into their component parts. Maybe there is no clear answer. Maybe it’s learning to live with the discomfort of reconciling those ugly cells with the big, beautiful, messy, complicated lives of the people they create.