I entered my Manhattan apartment around midnight, roughly an hour after observing a transplant team recover kidneys and a liver from a young patient newly pronounced dead. Still wearing scrubs, I sat down on my bed, and, like a ghostly twin or guardian angel, watched myself spill tears.
The scene I witnessed in the operating room that evening as a second-year medical student was at once grotesque and hallowed, shocking and valiant in its intensity. Surgeons fought time for organs capable of saving a life while a life bled free before them. A body turned cold to my touch. In its rawness and severity, this experience served, among other things, as an initiation: an initiation into the inner, emotional world of medical providers.
Over the next several years, my familiarity with this world grew. I explored its depths and shallows in the capacity of student-doctor. Quickly, I recognized how significantly this world shapes physicians’ day-to-day existence, and, by extension, patient care. Though diversely lived, certain internal struggles seemed ubiquitous among trainees and clinicians. A set of emotional experiences appeared to bind providers in a mutual—but muted—understanding.
Indeed, it was rare for me to hear physicians openly discuss the emotional experience of medical practice. The weekly “debrief” sessions required on my internal medicine clerkship, however, were designed for precisely such conversation. I was grateful to hear choruses of “same here!” and “me, too!” following peers’ anecdotes and reflections. My classmates’ stories unveiled a range of emotional conflicts and frustrations encountered in the clinical setting—from unrelenting pressures of limited time to feelings of helplessness in the face of bureaucratic-legal obstacles. Their experiences were consistently recognizable and relatable. I felt heard, safe, and unlonely. But I wondered: were we alone in this unloneliness? Did other trainees and clinicians have sufficient opportunities to unpack whatever internal “tensions” rattled their day, week, year? Could they name those tensions aloud, tease them apart with trusted others? How might such tensions, especially if unacknowledged or pent, negatively affect physicians’ mental health?
Collaboration: Navigating alliance and autonomy
How do clinicians engage/balance patient autonomy, partnership, and mentorship in their practice? What is the emotional experience of navigating various approaches to collaboration across diverse clinical and interpersonal scenarios?
The mental health crisis among medical providers in the United States is a topic frequently discussed and written about. Numerous studies reveal that physicians are at elevated risk for mental health challenges, with “higher rates of burnout, depressive symptoms, and suicide risk than the general population.” Striking statistics—between three and four hundred physician suicides per year, one in every four residents poised to experience a major depressive episode while training—illuminate the severity of this crisis. Like most “big issues,” this one is extraordinarily multifaceted, with innumerable known and unknown inputs. Quantifiable factors, such as administrative workload and system inefficiencies, are often cited as causal. But the unquantifiable tolls of clinicians’ inner lives—and of silence around them—are an absolutely critical component of the equation.
So, in my final year of medical school, tasked with completing a “Scholarly Concentration” that “delve[s] deeply into a field of medicine that matches [my] professional interests,” I chose to explore the contents of physicians’ inner lives—and the lives of those lives. I sought to probe not only the nature of emotional challenges physicians face in our medical system, but also the internal, lived experience of those challenges. I set out to capture the expressive heart of various ethical-humanistic tensions clinicians may encounter, with the ultimate goal of stimulating discussion in the medical community around the many nuanced factors influencing provider mental health.
Dislike: Reaction, response, and continuing to care
There are countless reasons why a physician may “dislike” a patient. In light of personal and professional expectations of physicians as tolerant, welcoming healers, what is the internal experience of recognizing and grappling with such “dislike?”
In collaboration with several New York-based artists, I created a collection of ten photographs. Each photograph is paired with a narrative contextualizing the image within medical literature and philosophical discourse. Every photograph-narrative duet, in turn, addresses a specific tension.
These tensions can be conceived of as knots that tighten or loosen with time and circumstance. Deep-seated and enduring, these tensions harbor capacity to complicate and indelibly mark the inner lives of clinicians, rippling to upset provider wellbeing and patient care alike.
I hope you find inspiration, comfort, a little discomfort, and a higher level of self- and communal awareness as you look, read and contemplate.
The full project can be viewed here (tentensionsproject.com). Below is the photograph-narrative duet for just one of the ten tensions—Uncertainty: Limits of Knowing.
Uncertainty: Limits of Knowing
For medical providers, what is the internal experience of facing, or even simply recognizing, personal limitations in knowledge and knowing? How do societal expectations of physician wisdom, capability, reliability, and liability contribute to this experience?
Uncertainty is everywhere in clinical practice. Most obviously, uncertainty may surround scientific facts and/or medical knowledge. A provider may a) not know certain information because that information is out of the scope of their daily practice; b) not routinely keep up with advances in specialty areas; c) have forgotten details due to rare utilization; or d) have never learned certain information because science has not yet progressed to offer such knowledge in the first place. Moreover, as physician-scientist Steven Wartman reminds us, collective “scientific and technologic progress will [only] continue to reduce the ability of physicians to solve patient problems singlehandedly,” increasing relative uncertainty and limitation at the individual doctor level.
But uncertainty in medical settings may also relate to what philosopher Gilbert Ryle deems “knowing how” (as opposed to “knowing that”—i.e., knowing facts or information). “Knowing how” refers to knowledge obtained from first-person lived experience. It is unattainable by reading, listening or watching from “the outside.” A physician may, for example, find identification with a patient’s experience challenging due to the fundamental uniqueness of human bodies and ways they embody physical sensation (e.g., pain). Or a physician may lack exposure to diverse “ways of knowing,” such that certain approaches to knowledge and interpretation of experience (e.g., spiritual, cultural, intuitive) remain foreign and thus inaccessible in a given moment. Uncertainty around “knowing how” relates to what I call “hermeneutical insufficiency,” defined as an absence of the hermeneutical resources required to understand or empathize with non-universal lived experience. In many ways, hermeneutical insufficiency parallels the “fallibility” of all science; “no matter how sophisticated our measurements become,” a recent article in BMC Medical Ethics argues, “we remain limited in our ability to access the truth because of our fallibility as observers and…the intrinsic technical limitations of the instruments we use.” Critically, hermeneutical insufficiency is a precursor to hermeneutical injustice. Such injustice occurs when one’s experience is “obscured from collective understanding owing to a structural identity prejudice in…collective hermeneutical resource[s],” leading “even the most sympathetic social peers” to respond inadequately.
Acceptance of uncertainty, personal limitation, and capacity for ignorance is thus required for patient-centered, bias-conscious care. Yet acknowledging uncertainty of any sort in medicine remains challenging for many reasons: years of training throughout which getting “the most right answers is rewarded;” fear of upsetting or disheartening patients or colleagues; losing hard-won trust; pressure on self by self.
Nina Shevzov-Zebrun is a medical student and creator, Ten Tensions: a Photographic Exploration of the Physician’s Inner Life.
Originated and directed by: Nina Shevzov-Zebrun
Writing and research: Nina Shevzov-Zebrun
Academic mentorship: Katie Grogan and Arthur Caplan, PhD
Photography: Mateo Salcedo, Nikko Tonolete and Haley Ricciardi
Movement: Danielle Russo
Cast: Antuan Byers, Roya Fereshtehnejad Carreras, Ingrid Kapteyn, Danielle Russo and Nina Shevzov-Zebrun
All photographs are set in the New York Simulation Center for the Health Sciences (NYSIM).