Dr. Mikkael Sekeres, the director of the leukemia program at the Cleveland Clinic describes the rituals he uses in his personal life and medical practice….

Every night when I put my six-year-old son to sleep, we go through the same routine. At his request, I carry him upstairs, slung over my shoulder like a “sack of potatoes.” Then, I sit on his bed while he changes into his pajamas; help him brush his teeth; read exactly three stories; arrange his stuffed bunny to the right of his head and his stuffed black bear to his left; kiss him on the cheek; and finally tell him that I love him and say goodnight. But he will not return my parting words until we have the following exchange.

“Are the monsters going to come? he asks. “There’s no such thing as monsters,” I answer. “When did you check?” he persists. “Before I came upstairs,” I respond. “O.K., good night Dad, love you.”

Every night, the same routine. I imagine it gives him comfort to know that he can close his eyes safely, without fear of evil, and to know that he is loved. The ritual, the sameness of it, must assure him that he will wake again the next morning, just as he did the previous one, unharmed.

When daylight does come, I walk him to his bus stop and then drive to work, where I will engage in my own rituals as I see my patients.

After spraying some sanitizer foam onto my hands and pausing outside the exam room, thinking about the person I am about to see, I knock on the door and walk in, still rubbing my hands together before shaking my patient’s hand. I will wash my hands twice more, once before examining my patient and once after, and then “foam out” when I leave the room, a cleansing rivaling that of Lady Macbeth.

Years later, many of my patients tell me how much they remember the smell of the soap on my hands. They both appreciate the attention to hygiene and revile it, associating the smell with the cancer treatment they receive. But I go through this sequence for each patient, every day, promising myself that if I do, my patients will be safe from the germs that could overwhelm their fragile immune systems.

After we chat for a few minutes, I escort my patients to the exam table, holding their arm, regardless of age, as they get settled, acting as a sort of human training wheels. I do the same as they get off the table. Many of my patients have anemia, or infections, or are taking medications that can affect blood pressure, so the threat of instability is real. In the 12 years since I completed my training, no patient has fallen during this process – though a couple have come close – and I was able to catch them because I was near.

Performing a physical exam is its own orchestration, a carefully arranged composition that starts at the head and works its way down to the toes. While books have been written about performing the exam, there is an intimacy to it that isn’t captured by the written word or pictures.

Much of the practice of medicine is an apprenticeship, and the physical exam is always taught directly by masters of the technique to their medical students. The exam I perform, the one passed down to me by a variety of masters, is identical on all of my patients, head to toe, with minor variations guided by their symptoms. I do this despite knowing that there is little we really learn from the exam, if we listen closely enough to what our patients tell us about how they feel. But I conduct the same exam anyway, comforted in knowing I have left no stone unturned, no crevice unexplored.

At the end of the visit I say goodbye to my patients, some with a handshake and some with a hug, and we all breathe a sigh of relief when they are healthy, and hope for the same at out next encounter.

I move on to my next patient, trusting that the rituals have kept the monsters at bay for one more night.


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