Wednesday, June 22, 2011

the great wall

You would think that for doctors, who work with life and death issues every day, the issues of our own frailties or the tenuous line between health and sickness for our own families would be, if not accentuated, then at least more immediate than to those who, say, do investment banking for a living. But the strange thing is that despite our easy familiarity with human mortality, it is not the case at all that we are able to readily apply these scenarios to ourselves. We see patients who are sick or even dying on a daily basis--sometimes patients who very much remind us of ourselves, our spouses, our parents, our kids. But it's just a constant stream of other people. And seeing so frequently that it happens to other people, more than anything, starts to make you feel unconsciously like it's always other people, that it could never happen to you, or to those we love most.

Two years ago, when Joe was hospitalized after an acute bout of viral myocarditis (from which he has since totally recovered), the experience was not so much of concern or apprehension--though, of course, there was plenty of that too--but more than anything a feeling of disorientation. We were in an ICU. It was morning. Morning work rounds were underway, and even through the closed door, I could hear the scrum moving from one bed to another, emitting a low hum of recited numbers and medications and therapies that, even just partially overheard, sounded wholly familiar. But I was inside the patient room now instead of outside like I usually would be, and Joe was lying in the bed beside my chair. The environment was familiar, but the context was completely strange. What was I doing here? Why wasn't I outside at the nursing station, checking labs, writing orders? Why was Joe wearing a nasal cannula? Why was he the patient? How could this be happening?

Some of the experience of being a doctor involves being close one instant and yet distant the next. It sounds strange, and sometimes patients interpret the emotional boundary as coldness, but in many ways, maintaining a distance is necessary in order for to be able to do the job well. I am warm with patients, as familiar as I need to be, but in my mind, I set up barriers. Sometimes there are things that I don't want to know. Sometimes there are things that I don't want to see. Taking care of patients is wonderful, an honor, and yet sometimes, the things we know threaten to tear you up from the inside, in small, insidious ways when you least expect it--like tiny shards of ground glass you didn't even know you'd swallowed.

Because sometimes things happen and you can't set up barriers, because they're too close, or happen too quickly. And that's when it's hard. And those are the nights you come home to your family after work and you hug them a little bit tighter, a little bit longer. And your kids think you're crazy and start running around, shouting about whose turn it is to throw the Frisbee, that they're ready for their evening snack, and asking if they can watch "Kung Fu Panda" for the umpteenth time because they haven't watched any TV at all today, not even a single second.

Then they ask you about your day. And that's when the barrier comes up again, as you force a smile and sneak in another hug before telling them that your day was fine, just fine, thanks for asking.


  1. I think we see someone and too quickly jump to the conclusion that their prognosis is poor, why are they full code, we should just go to comfort care etc. But when it's one of your own family, all our common sense goes out the window, and we're left clinging onto every daily gain or setback, unable and unwilling to acknowledge the bigger picture. Then when we see our patients' family go through the same angst, we can be more patient and understanding.

  2. Anonymous9:17 PM

    Great post, Michelle. Anything in particular prompt this entry? Hope everything is okay!

  3. Anonymous9:28 PM

    after all these years, i've definitely become more emotionally labile as a result of that cultivated detached warmth. a calm, easygoing demeanor at work with a touch of dry humor get me through the work day. but at home, the littlest thing can set off explosions of emotion. lots of love, warmth and hugs from friends and family is the best remedy. great post, michelle. thank you.

  4. I am sorry for whatever happened. Have been there.

  5. Anonymous9:53 PM

    Yup. Definitely know this. In a weird way I am also a little relieved to know that my humanity hasn't been completely beaten out of me.

  6. I understand this completely. Thanks for such a great post.

  7. i feel this way so many days. how do i tell someone their cancer is unresectable and they are going to die from their disease and then come home and cook a nice dinner and comfort my husband who is sick with a cold. it is such a hard balance.

    i find this is one of the things i write about most often on my own blog, mostly because it is such a hard thing to process internally, and getting it out, even if only in the typed words helps me emotionally come to terms.

  8. I know exactly what you mean. I think as doctors, we create an emotional barrier around our hearts to protect ourselves from being overwhelmed by what we see & sometimes, do.

    I did a rotation in the NICU before I had my kids. I believe that if I had done that rotation after becoming a mother, I would have been an emotional wreck & would not have been able to function as effectively (not that I was unfeeling about what the parents of the sick babies were going through, but there's nothing like having a child to bring out the maternal empathy & instincts when faced with a sick child).

  9. Anonymous5:09 AM

    great post, Michelle, that's the greatest fear of all human beings, and as doctors we are not immununed

  10. What a timely post. My son is currently in the PICU, after having had a surgical repair of an aortic coarct at 12 days old. While my husband and I have both been worried sick the whole time, only I felt my own heart in my throat as I saw his whited-out left lung field on a chest xray yesterday, only I knew that something was WRONG wrong when we took him to the ER (a 10 day old with no infectious symptoms and severe tachypnea makes me think SOMETHING IS WRONG WITH HIS HEART, while my husband thought he had a cold), only I can "read between the lines" and read the facial expressions of his medical team so that when they say "he's doing pretty well," I know they are also thinking, "except for this one thing that I'm not going to bring up just now..."

    On the other hand, we've had incredibly good and compassionate care and I do think being "in the club" has contributed to that a little bit. The team has welcomed us to join their circle during rounds and offered us the opportunity to ask questions and contribute without making us feel like a nuisance. And we've had the nicest rooms in both the NICU and the PICU. So, I guess my medical background is both a blessing and a curse just now.

  11. Anonymous11:33 AM

    Whatever it is that sparked this insightful post on a rarely spoken about but common issue, I hope you are ok.

  12. Anonymous6:39 PM

    There but for the grace of God go I....

    This saying swims through my mind from time to time when I encounter patients who remind me of family or friends. sometimes it is a thin line that separates us all and I count my blessings every day.

  13. People always ask me how I deal with what I see in the hospital on a daily basis (burns are kinda nasty...), but I just tell them that it's not my family/friends, so it's easier. When I start picturing my parents in the shoes of some of these people, that's when I lose it. Or when my patient can talk instead of being intubated. A few weeks ago, I came home from a particularly rough shift (pt was very sick and it was an emotional night for all involved!) and laid in my bed and cried...if I did that for all of my patients, I'd never be able to make it through the work day!

    I can't imagine what it would actually be like to have a family member or close friend in an ICU, hooked up to all those monitors that I know the beeps of all too well.

  14. michelle, thank you so much for writing this. i'm so sorry for the child who prompted it. i totally know how you feel... i have two patients on hospice now, one of whom i think will die within the month, and i just don't feel like i'm helping her or her family enough. i'm dating a non-doctor right now, which is a little hard because i think even if we all deal differently with death, we understand how it is to have to deal with it. tonight he just kept wanting to talk about it and about my day, and i know he was trying to be sympathetic, but i just wanted to NOT THINK ABOUT IT and move on to something else, or make a joke to make it ok, and i think it must come off as heartless to people... or that's what i'm afraid of. but anyway, thanks for saying so much better than i could what we're all thinking.

  15. I know what you mean. When a month or so ago we learned that our four-month-old daughter's murmur was not benign, that she needed a heart cath... while intellectually I knew her problem really isn't that big a deal in the scope of medicine... hearing the cardiologist say "her valve will never be normal" just made me dizzy.

    And a few weeks ago, when we informed a parent about her son's genetic mutation that will cause him to continue getting recurrent pancreatitis, and she started to cry... I understood, at least somewhat. It's one thing to know your kid is sick, but it's another thing to know they will NEVER be all the way better.

    Anyway, it reminded me of what one of my attendings said when I was pregnant, that "being a parent makes you a better pediatrician, much more than being a pediatrician makes you a better parent."