An Uneasy Understanding

One month into medical school, I arrived in the ultrasound suite to join Dr. Braun for the afternoon. As the preceptor assigned to me for my first year, she would provide me with most of my clinical instruction in the first-year curriculum. Ultrasound was her only clinic time that didn't conflict with my class schedule, so I showed up prepared to learn about nuchal widths and intrauterine growth. Dr. Braun had reassured me that I would spend some time in labor and delivery as well. Still, in the sonogram suite, I fought gamely to hide my dismay that my first patient would be a moving image on a screen. So much for learning about the doctor–patient relationship, I thought.

We pulled our chairs up to a monitor displaying the ultrasound images of a patient in for a 16-week amniocentesis. As Dr. Braun looked at the captured stills, the sonogram technician related that the couple had said they didn't want to be told the sex of their baby. Dr. Braun was focusing intently on one image. She pointed out a blur at the base of the head, explaining it was an encephalocele, a hole in the skull through which part of the brain had protruded. I registered this detail—still only abstract terminology to add to my nascent mental dictionary—and searched with her through textbooks to find the mortality rates and outcomes associated with this condition. With a hole of the size we saw and with that much brain matter outside the head, the chances were not good that the fetus would survive the pregnancy, much less any time past that. Severe mental defects were virtually guaranteed in the rare event that he lived and survived the surgery that would be required to fix the encephalocele. We relayed our findings to the …