Giving bad news never gets easier. And the older I get the more difficult it becomes. I suppose it's because I now have more life experience and when I was a younger doctor I could easily separate patients' lives from my own. Recently, I had to tell a woman that she has metastatic cancer. I had suspected as much but, like her, I was holding out unrealistic hope.
The past week or so I've been having paroxysms of sharp pain in my right temple and in my back, over my ribs on the right. The pain doesn't last long, seconds, but the rib pain, especially, catches my breath.
Normally, I'm prone to ruminating over whatever ache or pain I may be experiencing. Let me clarify, I don't ruminate frequently, but when I do have a pain, my mind immediately conjures the worst case scenario with me dead within weeks to months.
The mind and body have such a powerful connection. I'm not particularly new-agey but things in your subconscious can manifest themselves in many different ways, both bizarre and simple. Over time, doctors develop coping mechanisms to deal with unpleasant and uncomfortable feelings. Humor and repression are two popular and convenient ways to handle them. My husband is on a committee that deals with professionalism and medical students. Many of the committee members are not clinicians, meaning they have no patient contact. To them, some of the things that are spoken during rounds or in clinic would be incredulous. What they don't understand is that clinicians, on the whole, aren't cold and insensitive; we're simply trying to stay sane. In his brilliance, my husband has developed something called "the box of unprofessionalism". It's kind of like a confessional booth in that while you are standing in the box of unprofessionalism (which is far away from patient care areas and behind closed doors) you can say whatever you like without reprimand. It's not that he embraces insensitivity or crassness, rather he understands the importance of decompressing during incredibly stressful situations. (Maybe this is why he wins so many teaching awards).
For several days I've been repressing my grief over my patient's diagnosis. I had to tell someone, speak aloud, the words no one wants to hear. Every year Lee and I, along with one of our colleague's, give a lecture to the medical students about being a doctor and having an illness. We all discuss how your life changes the day you (or a loved one) receive the unwelcome news. All of the sudden you have to alter the landscape of your life. As a doctor, I don't think I can discount or underestimate the significance of giving another person equally life-altering news. What's the correct way to process? There is no course in medical school or residency that tells you how you are supposed to act, feel, behave. And for how long afterwards should you feel like shit? What's that patient thinking right now? Is she scared? Resolved? Indignant? Angry? I'll tell you how I feel, overwhelmingly sad and if I'm really honest with myself, guilty. Why her and not me? Why do I have the burden and responsibility of reminding someone of their own mortality and why is her number up and not mine?
I think that if I could get alone for a bit I'd probably have a good cry and I think I need a good cry. Not just for myself, but for that lady. Maybe the lump in my throat would go away and the pain in my head and the ache in my back.
One last thing, especially since I'm typing this on my phone while my family is on a road trip and my kids are about to mutiny because they want lunch (and maybe that's why I can finally think about this. I'm not helping someone with homework, or finishing a yearbook, or paying a bill. I'm on vacation); it's a story from medical school. When I was a second year student on my general surgery rotation, my friend and I were given the task of sewing closed a young man's chest cavity after he had died. I can't remember the mechanism of his accident, either a gun shot wound or a car accident, but he had been brought into the emergency room as a shock, meaning he was being artificially resuscitated. Well, chest compressions alone weren't reviving him, so the surgeons cracked his chest and performed cardiac massage. After what seemed like an eternity, they called the code realizing nothing was going bring the guy back to life. What had moments before been a shock room full of frenzied activity was now silent, with me, my friend and the dead man. The nurses and surgeons had gone to talk to the family and left us to "close him up" so he would be presentable to his family and so we could "practice our suturing skills." So Carie and I stood there, silently, each carefully sewing up one side of his thorax. Sometimes we still talk about that night an how ill-equipped we were to be given such a responsibility and how, afterwards, no one but us thought it was a big deal. When the surgeon came back in he said, "Good job, but make sure to take the tube out of his mouth because it's upsetting to the family." And that was it.
In the 22 years since I started medical school, they have advanced a lot in terms of sensitivity training and all of that 21st century PC stuff (no such beast as a professionalism committee in the early 90s), but personally, it never gets any easier and I hope it never does.
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