Abstract
“Lord, prepare me
To be a sanctuary
Pure and holy
Tried and true …”
The baritone voices drifted from the neighboring room out into the ICU hallway. The a cappella group came regularly, visiting only those patients who requested, or whose families requested, their musical presence and encouragement. Always a music lover, I welcomed their calming waves of sound in the midst of beeping machines and whirring ventilators.
This time, though, I hardly noticed their singing as I was focused on listening to Mrs. S, the daughter of my patient, and gathering the history for a new supportive and palliative care consultation. Suddenly, Mrs. S stopped the interview. “I'm sorry, I can't do this. I need some alone time.”
Bewildered, I said, “Sure, I understand,” but as I watched her turn and walk away, I thought to myself, disappointed, I don't understand! What did I do wrong? What just happened?
Just a few weeks prior, I had studied how to express empathy as I prepared for the Step 2 Clinical Skills Examination. I dutifully memorized the statements suggested in First Aid for the USMLE Step 2 CS study guide: “This must be difficult for you,” “I'm sorry you have so much pain,” etc. It didn't matter that the standardized patients heard the same statements 10 times a day and probably did not feel much emotion by the end of the day. It only mattered that we performed the ritual, that the patient checked it off the checklist, and that we earned the point, along with all the other items on the checklist, like washing our hands and addressing the patient by the correct name. It was just another hoop to jump through in the gauntlet of medical school.
Now I was back in the real world with real patients, real problems, and real consequences of communication. I was trying to help a real person like Mrs. S. Although I had a vague sense that seeing her mom in the ICU, on a ventilator and with a feeding tube must be difficult, I did not understand why she abruptly fled the interview. The ICU nurse kindly took me aside and explained that the a cappella group's song stirred up emotions for Mrs. S. Later, when the attending and I met with Mrs. S. and her husband, she revealed herself to be an emotional person, her eyes welling up with tears many times as we learned more about her mother's end-stage dementia.
As I observed Mrs. S weep, I started imagining what it would be like to lose my mom, to see her slipping away. I suddenly felt nauseated, swept away by a sense of devastation, and my own eyes started to sting. I fought it, driven by a sense of professional propriety, shaking a stern finger at myself, Your mother is not dying! Stop thinking about that! I breathed a sigh of relief, as if I had backed away from the edge of a cliff. Still, I had gotten a frightening view of the precipice. Mrs. S, I imagined, must feel as if her legs were dangling precariously over the edge.
The rest of the week I continued to say things like, “I understand how you can feel this way,” and other “empathic” statements, but I recognized that I actually could not fathom the enormity of the loss that many of these families were going through. I wasn't even sure, anymore, if I wanted to keep imagining that loss. I realized that although we are taught to say the empathic statements, we are not instructed to “Try to enter into the patient's suffering. Try to really step into their shoes.” It makes me wonder if the hidden curriculum in medical training is to encourage us to maintain composure while putting on a pretense of empathizing with the patient. If I thought about losing my mom with every patient would I collapse from emotional exhaustion by the end of the day? Would I be able to carry out my duties? Is it even humanly possible to re-imagine this loss multiple times a day?
My palliative care experience gave me an appreciation for how challenging this specialty is emotionally but also how rewarding the deeper connection to patients can be. It must be difficult for any health care provider taking care of seriously ill patients to find a good balance and continuously refill the reservoir of empathy. Empathy may be like a well of water that is at risk of drying up, at which point the heart hardens and the physician is at risk of burnout. Reflection is helping me learn as I go. How do I give the right amount of myself? How can I be a sanctuary for my patients, a place of healing? I find that this self-reflection is necessary to prevent myself from hardening my heart, and I hope to continue to make time for it.