Monday, February 29, 2016

There are these moments

There are these moments between when a doctor knows something and when a patient does not.

Potential spaces.

And, while for patients, such space may be filled with hope or dread or some combination of the two, the same space means something different for the doctor. After all, it's not my pregnancy or my heart; it's not my father's chest x-ray or my son's leg bone. But it is my patient. And my patients' experiences inevitably become a part of my story. My story fills in every day with all of these unique moments-- the discovery of an unintended pregnancy, the surprising death of a father, the unanticipated complication, the missed lab finding, the remarkable recovery. The good and the bad.

What I say, the look on my face, or the gesture I make may be remembered forever. Especially if I do it wrong. Or even if I don't get it quite right.

Sometimes these potential spaces are wonderful--  the few seconds between when I put an ultrasound probe on an anxious pregnant woman and see the blessed heartbeat and when the words come out "all is well". The pathology report coming across my inbox announcing the mole was not cancerous. The marked improvement in a heart's ejection fraction.

Then there are times I wish I didn't know. Or at least I didn't have to be the one to tell. The times I must walk into a room, sit upon a stool, take a deep breath and deliver the bad news. The life-changers.

Three times this week, five times this month: the cancer in the colon of the woman who'd been losing weight, the non-viable pregnancy in a woman who tried for six years, the brain tumor in the young dad who'd been having headaches, the syndromic features in the baby born just yesterday.

Who am I to do the telling?

I am just a regular human being whose fridge has moldy leftovers and whose car is in desperate need of an oil change. I have children who I get impatient with, toenails that need trimming, and a tendency to be a bit of a know-it-all. But I also went to school for a very long time and have spent many years of my life trying to understand how to distinguish between health and sickness, learning how to communicate the difference effectively, and practicing how to be present with patients through all of it. Some days, I feel unequivocally qualified. Other days, I literally look around and think, "Me? You're trusting me?"

Am I sure?

So often, I am not. And yet patients want me to be. They want me to be sure when I reassure them: "No, don't worry. Yes, you will recover. No, it's not serious." They also want me to be sure when I give bad news. And so do I. I want to be 100%-absolutely-without-a-doubt sure. I want to know as much as I possibly can about this diagnosis or your lab result or this condition I am going to name for you.

Years ago, I told a young man I was confident he did not have cancer; several months later, we discovered, in fact, he did. He died shortly thereafter. I will never forgive myself for my naive certainty. I will never again be as sure as I want to be. But I do my best, my very best, to gather as much information as possible, to be informed, and to be thoughtful. I trust that there is tremendous science behind much of  medicine,and I try to be clear with my patients where the science gets soft and where my knowledge runs out.

All that said, to be perfectly honest, no, I'm never sure.

How much do I say? 

We were taught in medical school that when you deliver bad news, people hear the first few sentences and then shut down. I've seen it, it's true. Their eyes blur, their ears get fuzzy, they literally float away.

And there I sit. On the stool. With more to say.

In each of those moments, as I watch my patient hover overhead, I find myself confused, insecure, and surprisingly unprepared. Do I stop after the first few sentences? Do I leave them to their fuzzy blur? Do I smile? Do I frown? Do I give them the reference? Do I hand them a piece of paper? Do I hand them a tissue? Do I warn them to stay off the Internet? Do I . . ?

There is no one correct answer to any of these questions. For each of us is unique and needs something  different in each of these unique moments. And this is why relationship is so very important-- how, by knowing you, I can provide you with the right amount of answers in the right amount of time.  Too bad relationship is so undervalued. Too bad, too often you have no idea who I am. I just met you seven minutes ago. Too bad you don't know that I, too, struggled with infertility, that I lost a dear cousin to alcoholism, that I want nothing more than to be with you, right now, in this moment (despite my body language stating the opposite). It was for these very moments I became a physician, after all. Yes it was.

A few weeks ago, I supervised a physician in training giving bad news. I had literally never met the patient, and I stood there in the corner, watching the learner do what she will do hundreds of time, perhaps for the very first time. I wondered. Who is this woman? What does she need from us right now? How can we best serve her? Will I ever see her again? One thing I do know, from my experience as a patient and as a physician, she will flash back on this moment forever-- the buzz in the hospital room, the lighting, the words tumbling toward her. She may not remember the faces or the names, but she will surely remember the feeling, the emotion, the tone.

And it's not just her that remembers. It's me too. My big errors are not necessarily the procedural ones (though I have written in the past about some of those). My biggest errors are the human ones. The times I didn't say enough. Or the times I said too much. The time I put my hand on the doorknob before you were done, the times I was human.

What if I want to cry?

Sometimes I do cry. But usually I don't. And I'm not sure if it's professionalism or paternalism or some other -ism that prevents me from doing so. Probably mostly it's just that I am a private crier. 

But also, this moment, this little space in time, really isn't about me-- it's about you. I am merely a blessed witness, a privileged counsel, a space holder. Some higher force put me in this room, in this moment, in this space to be with you and to offer you-- I hope-- exactly what you need. If I cannot, if I did not, I am sorry.

What I can promise is this: when I leave the room, I stuff this moment into my bulging bag of moments, into my disorganized file cabinet of doctoring, and carry it around with me forever. It changes me and challenges me and teaches me and hopefully makes me better the next time I have to do it again.

So, thank you.

For these moments.


  1. That was awesome. I should write something like that about teaching, you have inspired me.

  2. That was awesome. I should write something like that about teaching, you have inspired me.

  3. Powerful!
    Thank you for being who are, and for sharing that with all of us.

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