Care about people as people, not just as hosts of disease

I never thought I would call cancer “cool.”

It was the last day of anatomy lab. Finally, we had dissected through everything: starting with the back, moving through arms and legs, hands and feet, chest cavity with lungs and heart, abdominal cavity with gastrointestinal organs, pelvis, and ending with head and neck.

Looking at our cadaver was disorienting. There were insides where outsides should be. Organs completely removed. The head literally sawed in half. Some of it was hardly recognizable as belonging to a body.

Before my labmates and I bade farewell to the body that had taught us so much, our professor handed us an envelope containing two pieces of information that had been kept from us throughout the journey: our donor’s date of birth, and cause of death. We tore it open eagerly.

“Cool!” I exclaimed, as one of my labmates simultaneously said, “We got it! That’s awesome!”

Our first response to the news of prostate cancer was gratification.

Stepping into pathologists’ shoes, we had made our guess several weeks earlier. During the pelvis dissection, we sliced through skin and fat and located the prostate gland. It is supposed to be the size of a walnut. The one we found was the size of a tennis ball. We reassembled skin and noticed tiny blue dots tattooed on our donor’s abdomen, indicating he had undergone radiation therapy. This must have been it; this was what got him, we had decided.

“I mean … um, cancer isn’t awesome,” my labmate clarified, embarrassed.

I knew exactly how he felt. As future doctors, we have to be especially careful as to what emotions we let on. Trust is eroding in the doctor-patient relationship. There exists a stereotype of a cold, distant doctor, who objectifies rather than empathizes, seeing patients as problems to be puzzled through instead of thinking, feeling human beings. It isn’t the fairest characterization. Yet its persistence means that we who are entering the profession must take extra efforts to combat it.

No one wants a doctor who thinks cancer is cool.

In medical school, I sometimes feel inundated with conflicting messages. On one hand, we are encouraged to think like scientists. To be curious. To ask questions. To form innovative hypotheses, and to test them. To find the beauty in discovery. Many times over the course of anatomy, our professor came over to a cleanly dissected region on our cadaver and called it “beautiful.”

And it was beautiful. As the weeks went by, I found myself increasingly awed by the elegance of the human body. I held a human brain, weighing a mere three or so pounds, and thought about all the things it can comprehend and create. There is so much happening beneath our conscious awareness, you’d think the human machinery would malfunction more often – or that we’d at least notice some of its efforts. The smooth inner workings of the body provide us the luxury to engage in everything else that makes us human.

And that’s the other message medical school sends. Be a humanist. Cultivate and display empathy. Care about people as people, not just as hosts of disease.

When to display each quality is a trickier matter. I wonder what the appropriate reaction would have been during that last day of anatomy lab. Should we have opened the envelope with solemnity? Summoned fitting empathetic remarks? Taken a moment of silence?

Our professor called our cadaver our “first patient,” implying we occupied a caregiver position. But was he really a patient? Should we have treated the news of his illness with the same compassion we would have expressed if learning a patient’s diagnosis? Is it ever appropriate to feel a sense of wonderment over illness?

We traverse the boundary between investigator and carer so frequently, it is hard to remember where we are supposed to be at any given moment.

I once interviewed a patient with advanced cancer. Tears came to his eyes as he told me about how he had to leave his job, couldn’t run around with his grandchildren, couldn’t do the things he loved, not like he used to, nope, not anymore. A single diagnosis had inflicted such profound devastation.

In an emotionally detached cadaver, cancer was cool. In a person, it was anything but.

As my training continues, I imagine that I will uncover more beauty in medicine. I imagine I will feel gratification when I diagnose something correctly, and that I will encounter phenomena that will make me think, “Wow. That’s so cool.”

I want to stay fascinated. I want to care.

It’s a clash of emotions I wonder if I can ever fully reconcile.

Ilana Yurkiewicz is a medical student who blogs at Unofficial Prognosis.

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  • http://makethislookawesome.blogspot.com/ PamC

    Speaking as a patient, I’d like you to be okay with cancer being cool. Please enjoy that moment knowing that you got it right. I want you to have the incentive of feeling that moment, because it’s a reward for getting the diagnosis, and the diagnosis is what I need for proper treatment. Pat yourself on the back… I mean that. Once you’ve savored that, /then/ switch to my shoes. 

    Know too that it’s the *disease* that ruined my life, not the diagnosis. I was already suffering. Putting a name to it was a relief. It gave boundaries to the mystery. It let me know what to expect. It let me know what I would need to manage, and danger signs I would need to look for. It took a lot of the scary away, even as it added to it. It wasn’t guesswork anymore. That was a comfort. 

    So my suggestion is: don’t avoid the joy. I want you to have happiness with your success. That’s a good thing. I want you to be eager about my case. There’s enough heart-hurt to go around already.

    • http://twitter.com/ddwebster Dana Webster

      I agree with Pam. 

      3 years ago, I went through 5 months of chemo, enjoyed a 2.5 year remission, and I just learned my stem cell transplant appears successful.

      I want my HCPs to be ridiculously nerdy and excited about cancer.  Hodgkins is one of the easier cancers to treat initially, but for those of us who experience recurrence, it takes on new qualities and is harder to treat.  We consulted with Jane Winter, MD at Northwestern in July.  She almost got giddy at the prospect of treating me because it is such a challenge for them, and they get to test themselves as physicians to give us the best possible outcomes.

      Ultimately, I chose a treatment I didn’t want to endure.  I was talked into it by enthusiastic interns, fellows, and lymphoma specialists who wanted me to live another 50 years with as few side effects as possible.

      Bring on the enthusiasm.  Show me, as the patient, you are stoked about taking on my beast.  But, be honest with me when necessary to keep hope in perspective.

      • Ilana Yurkiewicz

        Thank you for commenting; it’s really wonderful to hear patients’ perspectives. I
        think part of my internal conflict about showing enthusiasm stems from the fact
        that I imagine each patient reacting differently. Basically, I am terrified of
        making a blunder that would offend someone who is already in a state of vulnerability.
        I’m trying to get a better intuition for the demeanor of each patient I meet.

  • Michal Haran

    Your post echoed something I have been writing over the last few days. My son just started anatomy class, and it made me rethink about it, and the way in which death is introduced to medical students. (which I am not sure is the right way). I have copied what I wrote below. 

    And yes, you are right, there is always this conflict-we have to be interested in the diseases, in diagnosing them, in finding the optimal management approach to combat them, be as objective as possible in our analysis and decisions, and at the same time remember that we are taking care of a person. We have to be emotionally involved and yet not let our emotions overwhelm us. For instance: We have to be academically fascinated by the blasts we see in our patient’s bone marrow, so that we can learn to recognize them, characterize them to the finest details. But, we then have to go back to the patient, discuss his concerns hopes and fears and gradually become his partner in doing every-thing possible to make those blasts disappear forever. 

    Anatomy class: 

    Death is something every physician has to learn to encounter. Death is
    the normal continuation of life. But death doesn’t have to be grotesque or
    painful. It can be a peaceful departure from those you love. It is a way a
    person ends his life in this world, but stays with us, those who have known
    him. He remains with his deeds and words.

    Over the years I have been with many patients and their families during
    their last hours. I remember each and every one of them. I remember my 92 year
    old patient who would write me poems (I still have them with me). I remember my
    60 year old patient with myeloma who wanted me to fight with him until the very
    end. I remember our discussions. I remember them as people. I know and  so do
    their families, that we did everything we could to make their life as good and
    long as possible. Every now and then I talk with their loved ones and we
    remember them together. We mourn their death together and remember the people
    they were. I remember all of them as people, except for those I saw during the
    first year of my training. Those who were a piece of flesh not connected to any
    human meaning.

    I and my class mates, were expected to conquer our (normal) fear and dread from this grotesque way in which
    death was presented to us. A way which is very different from what death really
    is.

    There was no sadness or mourning. It was more like a surrealistic
    picture: Groups of young to-be physicians standing around corpses and tearing
    them apart. Like a very cheap horror movie.

    We were expected to detach ourselves from any emotion that would
    normally arise when seeing a dead person. We were supposed to concentrate on
    the organs that were revealed to us as we used our scalpels to cut through
    their skin and fat. We were not supposed to feel. We were supposed to experience academic interest and fascination with what was revealed to us. 

    Is this the way a physician should first encounter the human body? Is it
    reasonable to present the human body in such a manner, instead of seeing the person
    as a whole? Is this experience truly required, or does it create physicians who
    see their patients in a dual way? Who see them as organs which are detached
    from what is human?Shouldn’t the first encounter with death be in a very different surrounding? 

    • Ilana Yurkiewicz

      Hi Michal — I really appreciate your taking the time to write that out.

      I especially agree with this characterization of anatomy:

      “We were expected to detach ourselves from any emotion that would normally arise when seeing a dead person. We were supposed to concentrate on the organs that were revealed to us as we used our scalpels to cut through their skin and fat. We were not supposed to feel.”
       
      While we were encouraged to discuss our feelings outside of class if we needed, inside the classroom – I did get that exact vibe. We were supposed to be professional and competent. That meant concentrating completely on body parts.

      When we got to the head and neck dissection, my lab manual read:

      “Uncovering the face of the donor can sometimes be a difficult experience. After you have removed the cloth, take a moment to be sure that all members of your dissection team are ready to proceed.”

      It struck me how short and simple it was. What we were to do if someone on our team wasn’t ready to proceed? Immediately, the next statement was about the nuts and bolts of anatomy. I often felt we didn’t have much time to react in the actual setting.

      • Michal Haran

        Dear Ilana, 

        I think that all through medical school and in fact our entire training we are expected to detach ourselves from our emotions. Most people are capable of doing so, but I think that without realizing it, this involves some degree of emotional crippling. We are given the message that in order to be competent and objective physicians we can’t let our emotions get in the way. Almost like soldiers in the battlefield.  

        You can learn not to be sad when one of your patients die; you can learn to become indifferent to human suffering and pain, and develop a very detached and academic interest in your patients and their diseases; You can learn to see your patient as a puzzle, result of test or name of disease, but is that what we really want our physicians to be? And don’t we as physicians miss so much when we become like that?

        I believe that no amount of ” humanistic studies” , or interviews that are meant to pick up ” emphatic physicians”  can counteract this kind of inbreeding. 

        I am constantly surprised to see how many physician are not ready or willing to deal with the (normal) emotional responses of their patients, either referring them to psychologists/psychiatrists or offering medications. And this is not only because of time constraints. How many physicians impatiently cut their patient’s story short and ask them questions that fit their “working diagnosis”  without realizing that they may have just missed an important and pertinent clue. How many physicians are incapable or unwilling to understand normal human concerns. 

        If you are taught to suppress your emotions and see them as something that interferes and is in the way, something that prevents you from being objective and competent, doesn’t it eventually lead you to think that this is true for emotions in general, including those of your patients? Doesn’t it become an obstacle in seeing them and yourself at the same eye level? I believe that to some extent it surely does.

        I think that being aware of it and refusing to comply doesn’t make you a less competent and objective physician, but the exact opposite. Emotions are the driving force in what ever we do, and in any human relationship. Learning to recognize and accept the entire spectrum and complexity of your own emotions (which include feeling some degree of discomfort with your cadaver, and at the same time thinking that cancer is cool, and also feeling guilty for feeling that cancer is cool etc.)  will help you recognize and respond to those of your patients. It will also enrich your experience as a physician .

        At some point reaching the correct diagnosis will not be as exciting any more, but mostly become a daily routine. Further more, there will be times in which you will never have this satisfaction and never really know what is the source of your patient’s obscure symptoms. Other times, even if you do reach a brilliant diagnosis, your patient’s disease may unfortunately not respond to your not less brilliant and no doubt very effective, “state of the art” treatment . Getting to know the people who come to you for help, and gradually creating a very unique human relationship based on mutual trust and respect, while finding what will best control their specific illness, alleviate their symptoms and concerns, improve as well as prolong their life, never becomes a routine and never ceases to be rewarding.  

  • http://profiles.google.com/leejcaroll Carol Levy

    It is importabnt as you say to keep both in mind, the excitement of the ‘find’ and the ampathy.
    Little anecdote.  I worked in a teaching hospital and had a crush on one of the interns.  Years later I was in the hospital for trigeminal neuralgia, a severe and often debilitating facial pain disorder. There was a chance of brain surgery.
    The door to my room opened and in walked my old crush, now a neurosurg resident.  Figuring sooner or later he would remember I reminded him who I was. No problem.  A while later I was standing with a bunch of interns and residents just schmooaing.  The issue of the surgery came up; whether I might have it but not a serious talk.  “You know”, piped up my old crush, “you could go into coma, be paralyzed, have a stroke.”
    All of us looked at him a little strangely, it was so outside of the discussion.  Later he told me, “I was just trying to be social.”
    Chances are your med student, resident, fellow, will not be an old crush but there needs to be the understanding of not only how to care and understand the disorder and what you may have to pffer us in terms of treatment, but how to talk to us.

    • Ilana Yurkiewicz

      Carol, I’m sorry that had to happen to you. At my school, at least, they are training us to do both: treat AND talk. We practice patient interviews. In the beginning, I think a lot of us make silly or insensitive comments (unintentionally), but simple practice is tremendously helpful.

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    I have been on a reading streak lately – many books about life in health care – all found at my local library. Currently one called “Happy Accidents” about all the amazing medicines that have been found thru serendipity. If it were not for these many people over the years having that curious facination with life and discovery, we would never have many of the simple antibiotics on the market today. They just don’t give up b/c they wanted to help those soldiers during the war or the kids dying from tonsilitis.

    I think the point is you are at a stage where you MUST learn – that is your job. And if you’re not excited about what you’re doing, well then, do you really want to be doing it? Really, for any of us to keep current in our professions we have to keep up but life is about learning and knowing and being amazed by both the simple and the complex. And those who can continue learn will continue to create – and whether they are 85 and learn how to email their great-grandkid or 25 and find a new genetic sequence, it’s a discovery all the same.

    At the same time, you make a great point. Is a great doctor one who is brilliant and can cure the world but has the bedside manner of Oscar the Grouch.? Well there is that famous guy named House….. Or would folks rather have someone who is pleasant to talk to and makes us feel special at that very moment of most critical need, yet is willing to admit that something needs to be looked up or maybe a second opinion is needed. Honestly, I guess we want smart and nice, but I’d pick number 2. Always caring, but ALWAYS ready to learn more.  

    • Ilana Yurkiewicz

      Hi Diane — your point is well taken! We are often told that medicine involves committing ourselves to “lifelong learning.” There’s a part of me that hopes the enthusiasm and the “that’s so cool” reaction never lessens.

  • http://twitter.com/LHPatientAdvo Loving Heart Pat Adv

    Dear Ilana,  Thank you for an insightful article. As  a doctoral student in Medical Humanities (Drew University, Madison, NJ), I am always researching about teaching doctors (particularly, future doctors) ways to be more empathetic. You point out the excitement of discovering the cadaver’s malady and that it was “cool”.  I think it is cool. But what is also cool is that medical students recognize that this cadaver was an actual person with an actual family who, perhaps loved him.   
        
    I believe this experience will prepare you to be a doctor who is a great prognostician and empathizer. People often refer to House, who is very much a part of our pop culture.  However, the doctor who recognizes the patient/s story and personal narrative may be able to discover a greater understanding of the affects of the disease.  Patients really are people and not just hosts for disease.  I applaud you for having a sense of “uncomfortability” with just being “cool”.  My colleagues and I are studying how to bring Medical Humanities into the medical school curriculum.    It is refreshing to here this someone like you, so early in  your career. Would love to hear more of your thoughts.  My email address is cjones1@drew.edu
    .
    Again, thank you for a wonderful article.