Being on my first month of clerkships means that details most hospital staff take for granted often strike me as odd. Like how the keys to the morgue dangle next to the elevator keys at Presby’s trauma bay—an ironic metaphor for what polite neighbors we medical providers can become to death. Or how hospital beds on which patients took their last breaths are sanitized and reused for a new patient soon after. I wonder if these beds should be held with more reverence. But heart attacks and infections don’t tarry, IVs must be placed, labs drawn, meds administered. Patients must be bedded.
As a fresh-faced clerkship student, I am deeply confounded by death and suffering. I wonder at what point I will be able to say that “So-and-so patient expired at X time,” as a medical fact and move on. I wonder if I will be able to see someone suffer without a spate of emotions hounding me. Will death ever become routine to me, and is it okay if it does? I constantly ask myself, how can I witness the pain of others each day without being overwhelmed or numbed to the reality of suffering?
It didn’t take long for me to directly confront these questions in the wards. My very first patient was admitted for new onset confusion and a strange constellation of neurological symptoms. I had practiced my neurological exam with Likhitha, a good friend and classmate on my team, and rehearsed the choreography again in my mind before entering my patient’s room. My patient looked elderly and fragile under his three layers of blankets. He barely stirred when I greeted him.
Moving through the motor exam, I asked my patient to bend his arms so his fists rested by his armpits (“Like a chicken!” I said) to check his deltoids. Though my patient did not know the date or where he was, he became solemn with concentration when I explained that I was testing his strength. I was about to push down against his elbows when he began to earnestly flap his arms. I burst out laughing. To my surprise, he began to laugh with me. I couldn’t help grinning under my mask at his effort.
I knew nothing of his personality or life experiences besides what I gleaned from his chart and a phone call with his wife. Yet I felt for him the unique fondness one has for one’s first patient. He was the first person I had an ounce of clinical responsibility for, and he responded to my unpracticed neurological exam with the eagerness of a star pupil.
Interacting with him also made me feel a keen sense of loneliness. In the sickest hours of his life, my patient did not have his wife’s reassuring hand to squeeze or any familiar faces anchoring him in his waves of confusion. Instead, his only visitors were masked strangers in identical hospital garb. Only a week ago he had been joking with his dentist, but he was now experiencing a bewildering delirium, an affliction likely made more painful by the sheer loneliness of it. This realization weighed heavily on me. Because his family could not be with him, I realized I was one of the few people who could accompany him through this illness.
My patient descended into a severe seizure and was found to have a serious and rare CNS infection. Several days later at lunch, my senior resident took a phone call and swiveled around in his chair to update me that my patient was being moved to hospice. Since his seizure, my patient had been intubated and sedated. Given the rapid progression of his disease, my resident gave him a day or two longer to live.
It was disconcerting to me that I knew more about my patient’s imminent death than he did, that I could characterize the functioning of his body by the vitals and blood work I had been tracking while he lay fevered and unaware of his shortly ending life. I asked to see my patient before he was transferred. Likhitha, recognizing my distress, offered to come with me. As soon as the elevator doors closed behind us, I felt a rush of tears in the presence of my friend.
Empathy powerfully provides emotional depth in caring for patients and families, and grief is an appropriate response to death—after all, what good is there in dying? But as I grappled with losing my first patient, I realized that experiencing the full extent of these emotions with every one of my patients would quickly drain, if not crush, me.
My psychology professor from college, Dr. Paul Bloom, wrote a book provocatively titled “Against Empathy: The Case for Rational Compassion.” In it, he argues that acting on principles of compassion is far more important (and sustainable) than empathy alone. I was initially hesitant about his ideas, but now I think I agree. It was Likhitha’s decision to accompany me that most comforted me. I don’t know if she shared exactly how I felt, but her validation of my sadness through her words and actions were what made me feel cared for. What makes pain more painful is experiencing it alone. Accompanying someone through an otherwise solitary experience of suffering, regardless of how one personally feels, is the heart of compassion.
When Likhitha and I entered the room to say goodbye to my patient, an EEG technician was removing electrodes from his scalp. The electrodes, which tracked my patient’s seizure activity, had left his skin irritated and his hair a gluey mess. Likhitha and I chatted briefly with the technician as she combed his hair. She said she always did this for her patients. Though he lay heavily sedated with only his most primitive reflexes intact, there was something dignifying in restoring a semblance of what my patient looked like before his hospitalization. These moments quietly speaking to my patient and watching the technician comb his hair were my last in accompanying him through his illness. A day later, he passed away.
My time with my first patient has helped me think more deeply about what it means to have compassion—to “suffer with.” Though the questions I ask myself will likely take an entire career or even a lifetime to answer, it is clear to me that much of becoming a good physician is learning to become a companion to sufferers.
Audrey Luo is an MS2 at the Perelman School of Medicine.
Image by Catherine Yang, an MS2 at the Perelman School of Medicine.
