Several days ago, I had the opportunity to listen to a lecture by a visiting physician who practices narrative medicine, a medical humanist. She is well-known for bringing a voice to the interactions between doctor and patient, the healing relationship, the bond formed between these two individuals that is unparalleled. In her talk, she spoke of the “turmoil” that ensues when caring for a patient – caused by the interaction of deep concern for the patient’s well-being, years of medical knowledge and experience, humility in the face of illness, the trust of a patient, fear of choosing the wrong path, and shared amazement at the ability of skin and soul to heal.
I had never heard it described that way before. “Turmoil.” But how apt and my response was immediate. I almost relaxed into myself, knowing that there is a smart, capable, experienced physician out there who feels both privileged and sometimes overwhelmed at the responsibility required to care for others.
The advice that is generally given, by those in medical school, courses on doctoring, senior colleagues, your peers, is to be sympathetic and removed. Complete dissociation from the red-eyed, pale individual pouring her story into your lap, however, is impossible. The encounters change you, sculpt your responses, awaken you from sleep. A night spent telling a roomful of family members that their sister will not survive til morning, explaining to a woman that her husband, healthy and playing football with his sons just 6 months ago, is now bedridden, are not carried out by an emotionless machine. It is the faces, the pressure of cold hands holding mine, and the hoarse “thank you”s that I remember most. The stern eyes of family who can’t help but blame the dissolution of their loved one’s flesh on you. The raspy breathing of a man lying with eyes closed between 4 steel enclosures in a white hospital bed – it is their faces and the stories of their failing bodies that stay with me. The courage of individuals to say “this is enough, please call my family, I need to say goodbye.”
We travel in directed paths around the hospital, young and inexperienced as interns and residents, with clear immediate purpose but hazy long-term understanding. Oncology floor to radiology to ER to morning report to medical floor to perform the paracentesis to rounds. The nature of hospital work, built of sharply defined short-term goals, intense patient interactions and scuffed Dansko clogs, is both comforting and soul-churning. It is heartening to see a patient breathe again after the fluid filling his lungs is removed, but the feeling of futility can be consuming when a chronic disease, long uncontrolled, visibly erodes a life in a matter of hours or days.
Turmoil results, throwing patient and physician one way or the other. Cases with the hope for recovery, the potential for healing, often seen in the deep and lasting relationships between patient and doctor in outpatient care, may actually cause the greatest inner tumult. This tornado of thought and emotion may be seen as the mark of a good doctor – caring so much that patients are always on your mind, running late since you take time to fully listen to each person on your overflowing schedule, giving and caring for your patients as if they were members of your family. To shape these qualities to act as boons rather than paralyzing burdens, however, requires a different kind of relationship – that seen between peers in the world of patient care.
It is a balance that develops through experience and sharing of inner reflections with peers and respected advisers. Physicians do not practice medicine in silos, but with animated scientific discussions of challenging cases yielding new collaborations and better science. Dealing with the inevitable emotional turmoil, to minimize its potential destructiveness and bring forward the positive, healing nature of so much trust, care and good will, also requires advice and instruction. We are not, after all, interacting with pneumonia or the torn shoulder or the inflamed heart. We are working with a patient with difficulty breathing that is making him miss work, shoulder pain preventing another to play her beloved softball, or a grandfather’s frailty after a heart attack.
It is this personalization that is the stuff of most medical school admissions essays. After the self-preservation skills learned and often required in the early years of this career, we need to help ourselves to find our own confidants and mentors and friends. Our lifelong education can be expanded to include lessons in the humility and humanity required of us to best respect ourselves and our patients. It is this infrastructure of support that separates those who use this inner turmoil for benefit rather than burnout.