coronavirus chronicles #6

Reflections on becoming a doctor & professional obligations: Before our gastroenterology session on the esophagus, Dr. Richard Rothstein updated us on COVID-19. He asked us to remember that we are in the lull before the storm. We have had the benefit of time, unlike the West Coast or New York, to prepare. Doctors are training each other how to be hospitalists, critical care doctors, to prepare for the surge. He asked us to imagine a future, an acceleration of telemedicine, telephonic medicine, and at-home diagnostic medicine. He asked to believe that we will come through this fine, and acknowledge that there will be a lot of challenges, but that life will go on.

‘You become a physician in time through incremental experiences. When the patient is in front of you, consider why they are there, when they are there. Being a physician is to study human behavior.’ (Dr. Richard Rothstein).

‘It’s not what kind of doctor you want to be. It’s what kind of person you want to be as a doctor. Society depends on you to get it right.’ (Dr. Manish Mishra)

What it’s like to be a medical student during this historical example of heroism in the medical profession? I am inspired and motivated. I’m also thinking a lot about professional obligations and a duty to treat. I wrote briefly on obligations of medical students in pandemics, and I think it’s fair to say that while medical professionals should help, however, within reason, with conditions. I am disheartened and upset about how healthcare workers are not being protected by their governments or their society. It’s unacceptable for doctors to enter in high-risk situation without protection, especially amid so much uncertainty and lack of leadership. It’s unacceptable to expect healthcare workers to take care the sick, if society isn’t willing to mitigate risk. Dr. Sandeep Jauhar eloquently addressed these conditions to the duty to treat in the NYTimes today a compelling Op-Ed:

“It would be a mistake for people to assume that our professional obligations are unconditional. An unconditional obligation would absolve society of its own responsibilities…Social order relies on reciprocity. Imposing outsize burdens on one group without sacrifice from others is unfair. Doctors and nurses and other health care workers may be heroes in this pandemic, but we will not be martyrs.”

Questions still on my mind: What risks do physicians inherently accept? Do doctors have an obligation to take on risks to which they would not be reasonably or usually exposed? Can doctors opt-out of duties to treat if the conditions are unacceptably adverse?

We should acknowledge the great sacrifice and heroism of medical professionals, but also remember doctors are not necessarily exceptional in the sacrifices they’re taking on in this pandemic. There are a lot of beautiful, meaningful ways to live life. And I think every profession plays a vital role in society, and the particular importance of those roles ought not to be so seriously compared. Within this pandemic, heroes are firefighters, teachers, supply chain logisticians, custodians, and other essential workers. They shouldn’t go unsung. Countless brave souls are helping our society survive; there will be many more who help rebuild our nation.

Helplessness & Mortality: This morning, we talked about death and mortality and mourning in our morning session of “Psychology of Illness.” Jessica Horak Stout, who lost her middle child, Ryland, to terminal illness, wrote a book, Feel Me Brave, about her family’s experience. We weren’t able to hear from her in person, but through writing, she impressed on us the importance of the power of human connection. She offered that the quality of genuine, unhurried care and caring (especially tone and body language of the physician) is incredibly impactful on patients and their families. In our readings of medicine and mortality, a few other ideas stood out. Dr. Raymond Barfield asked doctors ‘to become guests in the patient’s story.’ Dr. Paul Kalanithi offered: a “physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”

I’m not sure how to cultivate the quality of caring and care Stout described. Still, I’d like to be attentive, compassionate, authentic, calm, and caring when I have the privilege of being a physician to a patient. 

I’d like to be my whole self and carry some of my memories into the room. When I think about loss and the people who have left my life, I’d love one more day, one more conversation, one more hello. What would I say? Ira Byock, a palliative care doctor who worked at Dartmouth, offered in The Four Things That Matter Most: “Forgive me, I forgive you, I love you, Thank You.” I’m not sure what I would want to say, but I don’t think I want to prepare a speech ahead of time. I would just want to say whatever I needed to say at that moment.

A prompt from Dr. Martha McDaniel: You’ve been socially isolated and living in uncertain times for a while now. What insight do you think this might give you into the experience of the family members of a person with advanced cancer?

As Stout suggested, this is a timely discourse in a pandemic reality marked by helplessness, anxiety, and uncertainty: foreboding feelings that dominate cancer and severe illness and are characterized by a lack of control. I think the burden of social isolation exacerbates these feelings for me, as our society sickens and its prognosis dims, as I wonder what role I can play, as I think of how I can protect my loved ones and neighbors. Loneliness feels like speaking in a room, but I can’t hear or feel sound: a divorcing of myself from senses through which I can’t relate to others or be understood. Not being able to do activities or live life usually makes me feel stranger to myself, as I renegotiate what is at the forefront of my identity. I can’t imagine what pain and distress feel like knowing death is imminent for those families, as even amid this pandemic, I still have a lot of hope and statistical belief that all will end well. As someone who has not experienced severe cancer or illness, I don’t know. Still, I lean towards thinking of what does give me comfort in the context of those foreboding feelings: Calm and soothing conversations, gentle honesty about the reality of the situation, and authentic caring. 

The latter, authentic caring, while easily observed, is harder to describe, as Hannah Wild writes, there’s no algorithm for empathy.”

“There is no equation for how to understand an individual patient’s experience of their condition and no script for how to respond in a genuine manner that takes this into account. But by elucidating these as the goals in the face of patient distress, we will achieve something much closer to meaningful presence in their pain. Suffering looks me in the eyes and demands, “Give me something real.” I look straight back.”

Her piece has made me think about medical education and how we learn how to do the physical exam or patient interview—conducting patient interviews and exams still feels uncomfortable to me, but less so over time (more on that perhaps later). But what Wild said about “something real” also strikes me differently. In this solitude, what matters most to me is what feels real and valuable in my life: having conversations with loved ones in which I can be myself, pursuing activities/hobbies that bring me joy, and doing whatever meaningful thing the day asks of me.

Considering what it felt like to lose loved ones to terminal illness, read other’s experiences, and have our morning conversations: I think this unusual experience of social isolation and uncertainty gives me a particular insight into illness experiences. I have a better understanding of what may provide comfort and what remains important when life is lived so intentionally and intensely. But more so, I think it’s as simple as asking what the person in front of me needs or wants, listening to what they have to say, and creating space for them to fulfill those needs and desires. 

Thanks for reading!

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