Watching patients suffer and die is not an easy thing to do. Left unchecked, I don’t think most front-line doctors would last too long immersed in that kind of setting. First, the emotional toll would be too high to maintain over a long period of time. Second, working at the extremes of emotion doesn’t allow a physician to competently and objectively apply medical knowledge to heal disease and alleviate suffering. Not convinced? Imagine you get terrible news about something or someone, or are as angry as you could possibly be. Now, while still feeling that way, go take a high-stakes exam or give a presentation to a large audience. It would be tough, if not impossible, to do, right? If you could get through it, I’m certain it wouldn’t be your best work. Well, this emotional effect can hinder doctors too if we’re not careful.
In late medical school and residency training, for the sake of emotional self-preservation, doctors are forced to learn through firsthand experience, and by watching their mentors, how to emotionally detach just enough to remain effective. In fact, this lesson in medicine is so important that it has been written about. In an incredibly popular book called House of God, the author takes a satirical and comedic look at intern year of medical training and outlines hospital rule #4: “The patient is the one with the disease.” Now, the author’s intent wasn’t to be insensitive toward patients at all, but instead to convey a serious message to aspiring doctors. To survive working amid suffering and dying, the doctor must make a conscious effort not to fully enter the suffering of every patient. Please understand, however, there is certainly a balance to this approach. The goal is for the physician to remain compassionate and caring, not a cold, robotic healer in a white coat.
Having said all that, I’m going to tell you this approach doesn’t always work. Since physicians are constantly working close to the fire, it’s only natural we occasionally get burned. I started medical training in 2001, and I admit I’m now mostly accustomed to taking care of horrible diseases and sad cases, but sometimes it is just too difficult not to enter the full suffering of the patient. These are typically the cases that remind me of a loved one or are so unspeakably tragic that no coping mechanism is going to work.
I have cared for many of these cases over the years, some of which I still carry with me to this day. I can recall details of each case like it was just yesterday, and probably always will. They help remind me that doctors ultimately treat people, not diseases. We don’t work in an emotional vacuum. In fact, the most recent case that was just plain terrible was a couple of weeks ago. A female in her early 20s had been having back pain for the last six months. It started off rather innocently, and she didn’t think too much about it. After all, she was pregnant and just assumed it was related somehow. Unfortunately, the pain worsened, even after she gave birth to a healthy son. She finally came in when she was no longer able to walk. Her son is two months old now.
A CT scan revealed an enormous mass originating from her left hip and pushing on the nerves coming from her spinal cord. A biopsy confirmed our fears — it was a form of bone cancer. She started on chemotherapy and was released to home on pain medication, but her life will never be the same. Her cancer won’t be curable, and she very likely won’t survive to see her new son start kindergarten. To be honest, maybe not even his first birthday. How tragic! Perhaps it’s because I have young children too, but there was no detaching from this case. I felt the weight of her diagnosis as much as someone looking in from the outside possibly could. I’ve been thinking about her often since she left the hospital. I wonder how she is doing now?
Cases like this are not infrequent for many physicians. They serve as a potent reminder to make sure those you love know exactly how you feel, and not to take your time for granted. You shouldn’t live in fear, of course, but none of us are guaranteed anything.
It’s nearly impossible for a genuinely compassionate doctor not to leave small pieces of themselves behind along the way. But, to be honest, I wouldn’t have it any other way. That’s the way medicine is supposed to work.
Kevin Tolliver is an internal medicine physician who blogs at My Medical Musings.
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