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Academic Medicine:
doi: 10.1097/ACM.0b013e31829e1995
Teaching and Learning Moments

Oh, Mrs. Muramoto

Henneberg, Christine M. MD, MS

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Author Information

Dr. Henneberg is a graduate of the UC Berkeley–UC San Francisco Joint Medical Program. She is currently a first-year resident in family medicine, Contra Costa Regional Medical Center, Martinez, California; e-mail: chenneberg@ccfamilymed.com.

Author’s Note: The name in this essay has been changed to protect the identity of the patient and her family.

First of all, Mrs. Muramoto, you had me fooled before I even walked into the room. I was picturing a petite, salt-and-pepper-haired lady with a Japanese accent. Instead, you are Caucasian, fair-haired, big-boned, legs dangling over the side of the exam table. In the chair by your side sits Mr. Muramoto, smiling broadly, the missing piece of the puzzle: Japanese people are named Muramoto. White people get melanoma.

I sit facing you, on the surgeon’s stool.

MELANOMA. LEFT KNEE. That’s all I’ve been told, besides your name. And this brief description, like your name, is misleading—the mole is in fact an inch or two below your left knee, on the wide part of the leg that’s not quite shin, not quite calf. How will I describe this in my note?

I focus my physical exam entirely on the lesion:

Size: 2 cm.

Color: Black/brown.

Location: (???Left knee/shin area???)

Border: Irregular.

Shape: Circular.

What else? What else to say about this MELANOMA?

Because I can think of nothing else, I ask you about the book in your lap, a history of ancient Greece. You are a student, too, it turns out. And in a moment of unsolicited intimacy, you confess that you are terrified of surgery. Two tears roll down your cheeks, one from the corner of each eye. Mr. Muramoto gazes at us, silent.

I vacate the stool when the surgeon arrives, but he has no use for it. He does not sit to examine your LEFT KNEE. Instead he stands right in front of you, scanning your body, starting with your head. He wraps his enormous, gentle hands under your chin and the back of your skull, palpating occipital and cervical lymph nodes. He presses the pads of his fingers into your armpits and probes deep into the groove along the length of your clavicle. He listens to your lungs. He flashes a light and asks you to follow his finger with your eyes. Press your tongue against the inside of your cheek. Raise your eyebrows. Show us your teeth. Good, Mrs. Muramoto.

It seems, after all my careful scrutiny, that the exact size, shape, and location of the MELANOMA on your LEFT KNEE are quite irrelevant. Do you realize, Mrs. Muramoto, what I’m realizing at this moment? I have the feeling that you don’t yet grasp the significance of these diagnostic maneuvers—the penlight in your eyes, the stethoscope on your back. Does it occur to you that what we are really looking for is the melanoma in your lymph nodes, your lungs, your brain?

It sinks in now, a deep, terrible truth: This is what they meant when they said, “As a medical student, you will identify with the patient and with the doctor at the same time.” Now that I’m finally putting it together—what’s happening in this room, what’s happening to you—I find myself holding a dark secret. And I walked in here as naïvely as you did, Mrs. Muramoto! I was expecting salt-and-pepper hair and a Japanese accent, stones skipping on water. I imagined a tiny mole whose exact dimensions mattered—to you, to me, and, more importantly, to the surgeon. But none of those details matter anymore, do they?

Oh, Mrs. Muramoto. You and I can both learn this lesson today: nothing is what it appears, here in this windowless room—your name, your mole, my dark secret.

I am filled with dread. Oh, Mrs. Muramoto.

© 2013 by the Association of American Medical Colleges

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