Growing up, I was discouraged from becoming a doctor; I was too emotional. My mother, a geriatrician, worried about my attachment to patients and the volatility of inpatient medicine. To some degree, I understood her concerns; I’m tearful during goodbyes and inconsolable at funerals. Yet my interest in medicine persisted, and I began medical school. In my third-year, I experienced the innumerable emotions associated with witnessing patients’ deaths. I was amazed not only with the diversity of their experiences of illness, but also the variability of my own reactions. Three patients I met most captured my range of responses.
Mrs. X. One day she was there; the next day someone else lay in her bed. She died unexpectedly of a heart attack overnight. In the morning, we received sign-out from the covering team. She died after midnight. It was now our duty to manage the repercussions. Or rather, it was the intern’s job as she wasn’t my patient. But I knew her story, could list her problems and answer consults regarding her various complications. I’d met her sons on rounds. I thought I knew the ins-and-outs of her case. But when I’d heard of her death, it felt matter of fact. I watched the intern sign her death certificate, yet I thought of my upcoming lecture.
Where were my tears? Disconcertingly, I hadn’t responded to death how I’d expected. Had my soft emotional exterior already hardened? Attendings teach that we’ll build a thick skin. But we’re also warned against callousness. Wasn’t it too soon to be callous?
Mrs. Y. Her death was slow — metastatic cancer. She and her family rejected hospice until the end, hoping for a miracle cure. The team never rounded on her together because it was “a difficult situation.” The resident and attending always went in alone. They’d sigh before entering. I knew she was dying. The attending and resident discussed it in the team room and on rounds. But I was sheltered. I didn’t observe her respirations slow everyday, or her confusion worsen. Yet, I watched my resident cry in the team room. I heard the choir music playing on her stereo. I saw family members and church-goers streaming from her door. But that room was a no-go zone. Out of sight and out of mind — a vague story told by those who treated her. Her death meant one less patient to discuss, one space on the list, and one new patient added in her place.
After removing her from the list, I didn’t grieve. The autonomic response that I was so accustomed to previously failed to activate. I was disappointed with myself. I feared that I’d lost that sensitivity that was so proudly integral to my identity.
Mr. Z. Admitted for metastatic cancer with a life expectancy of a several months, he was still receiving chemotherapy. He required only several days of IV antibiotics. We all rounded on him. We conferred about medication dosages outside the room before entering. His wife and daughter were always there. They were the kind of family in which the parents call each other Mom and Dad. Every day, we observed him. We witnessed his worsening confusion and pain. His life expectancy diminished from months to days in 72 hours. He stopped cracking jokes about Greek yogurt. Rounds began to consist of hospice care recommendations.
We discussed his impending death with his family. He clenched his jaws in pain so that every tooth was visible. They wanted it to be over, for his sake. Silently, the team exited the room. The residents passed glances across the hall. I sighed. And then we rounded on the next patient.
I felt the weight of these decisions and their consequences on his life and future death. I was burdened by the team’s silence, the failure to share our thoughts beyond medical decision making.
For the first time, I grieved and permitted myself to do so. I found relief and comfort in mourning. Finally, I felt concordance between my feelings and the situation, found connection with that “emotional” version of myself.
In the hospital, the diseases and families differed, yet my role remained unchanged: medical student, straddling the divide between lay-person and physician. I had some of the knowledge of the physician, but not the responsibility. Throughout clerkships, students are exposed to the painful processes of healing and suffering. At times, we’re shielded from these moments. Our supervisors recommend that we “sit this one out,” remain outside the room. We see only what happens out of the room, thereby creating a partial impression of the patient. And yet, we continue to experience the suffering and loss of our teams’ patients and our teammates’ grief around us. We internalize this mourning, and ultimately, the shielding doesn’t protect us at all.
I acknowledge the dilemma inherent in medical education’s intersection with death and dying. Being new to the hospital environment, students are influenced by the suffering, decision-making, care and death routinely encountered in the hospital. Releasing students onto the wards without consideration of their inexperience would be careless; however, I wonder how students could be brought into these rooms and discussions in a safe, nurturing manner such that they leave with the concept of a dignified death rather than a punctuated perspective experienced outside the room.
Even with this distance, we glimpse pain and suffering without knowing the patient, eventually asking, “Am I even allowed to grieve without knowing and caring for this patient?” By questioning the acceptability of my emotions, I’ve alienated myself from my self-identity as a caring, empathetic medical student and person. This discord is unsettling. But in seeing only a medical diagnosis rather than a person, I’ve noticed a disconnect between their disease and their humanity, and in turn, a detachment from my own. I fear this dissociation between disease and person, the loss of my emotions, but also the heaviness and emotional weight of knowing a patient. Looking ahead to many more years of training, I wonder, how can I reconcile these fears?
Taliya Lantsman is a medical student.
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