Reflections on a Palliative Care Fellowship

It is difficult, perhaps undesirable, to compartmentalize one's passions in life. I can only remember how many times my experiences in competitive athletics became metaphors for my career in medicine and how my passion for literature and literary theory has enriched both. The parallels between going uphill into the wind, a long, seemingly endless night on call, and an incomprehensible text are unmistakable, but not surprising. After all, life is really not that complex. Whoever we are, whatever we do, wherever we go, the same challenges present themselves in different disguises. The process of learning to recognize these disguises, appreciate and savor the underlying challenges, and feel reassured and even amused by the metaphors is perhaps what we call “experience.”

I just completed my second fellowship, having started it one month after I received my Medicare card. I had a very successful and rewarding career in a procedure-oriented specialty when I decided that the real pleasure in my practice was from connecting with my patients and that the technical aspects, and definitely the call, had become expendable. I went back to my academic cradle and started a program in Hospice and Palliative Medicine along with four colleagues who were a generation younger. These were exceptional people who were filled with energy, exuberance, and enthusiasm, whereas I felt serious interest, more measured excitement, and a healthy curiosity. They masterfully manipulated multiple information systems, finding intuitive what seemed to me entirely nonrational. They prioritized and proficiently learned within a month a vast amount of didactic information. For me, echoes of my literary interest played in the background, “And indeed there will be time…time yet for a hundred indecisions, and for a hundred visions and revisions.” ¹ Perhaps the incredible urgency that I saw in my young colleagues and young faculty had been part of my past as well, but I no longer felt such pressure, and at the same time I also knew that I was not yet an archaeological relic.

I felt a particularly keen interest in the new communication skills I was learning. Sensitive and effective ways to approach difficult conversations, and even the nonverbal aspects of communication, were my new passions. I loved the challenge of meeting people and their loved ones at a difficult time in their lives, hoping to find the right words that would make a positive difference. But I took longer to see the expected number of cases per day, perhaps because they were no longer “cases” to me. In short, I was different. Clearly it was time for reflection and perhaps the search for a parallel that would help me understand my situation. My work in literary theory immediately came to mind.

One of the concepts in literary theory that I find most fascinating is the interaction between the author, the text, and the reader. Since the early 20th century, “meaning” is no longer a defined object but an experience. A text contains a repertoire of historic and cultural norms and each reader also brings his/her own set of norms and experience to the reading process. The reader's social, cultural, and intellectual norms form his/her “horizon of expectation.” If reading the text provokes a change in the reader, that is, the reader experiences an evolution in the norms that he/she originally possessed, then his/her subsequent horizon of expectations becomes different. In other words, the reader gains experience and evolves.

In my new life in Palliative Care, this idea of author/text/reader corresponded well in my mind to the patient/the patient's situation/palliative care doctor. The patient came from a particular social and cultural setting and had a unique personal and medical history. As a palliative care doctor I brought my own knowledge, history of previous conversations, and culture into the room, my “horizon of expectations.” If I just filled in the blanks of the template, asked the questions I was told to ask, and then spent time crafting a “note” of thesis length that was largely plagiarized and repetitious (one of the miracles of the electronic medical record), I had just efficiently seen “a case” and could move on to the next. However, my interest was in the horizon of change, the opportunity that each patient offered to influence and perhaps change my horizon. This took a little more time, but considerably more energy. It was my way of building an ever evolving, larger self that met each new patient and had an increasing likelihood of making the positive difference I wanted to make. Allowing myself to take this opportunity for personal and professional growth was a gratifying and life-transforming experience.

On a more practical level, I also felt that I could expand this concept of “horizon of expectations” to the program and to the constraints of the modern healthcare system. I realized that my horizon of expectations was not really different than that of the program, but was just following a different timeline. I did, in fact, learn the facts that fill the palliative care tool box: drugs, doses, conversions, and alternative treatments. Having first spent time learning to communicate and to discover what really bothered my patients made the factual learning more efficient, practical, and nuanced. This academic learning was both useful and undeniably an important part of the training. I learned more about the “nonrational” information systems (although far from mastered them), which was also an effective survival technique. In the end, I could see as many patients as expected in the allotted time, apparently not pose a clear and present danger to the ones in my care, and document everything in a comprehensive manner. I even started to receive compliments from some of the original skeptics. This horizon of change was gratifying in a more intellectual way and was clearly a necessary and fundamental part of my palliative care development. I am grateful for having been part of a program that was rich in information and provided a generous buffet of opportunity. To introduce another metaphor, the didactic information was akin to a drawing and basic colors. The interpersonal interactions supplied the shading, the intensity, and the contours that transformed this drawing into a work of art.

From my vantage point of an older adult (aka “senior citizen”), I found the evolution of my interaction with my inspiring young colleagues of exceptional interest and importance. We were scattered all over the city for our daily assignments and only came together one morning per week when we had a didactic session and a very special hour called “Care for the Caregiver.” This hour was facilitated by one of the fellows in the chaplaincy program and ran a gamut of topics from interactive “getting to know each other” games to a discussion of poetry and some philosophical ideas that palliative care engenders, such as “fear,” “loneliness,” or “joy.” As the year progressed, I felt less and less like an outsider looking in; the generational separation was becoming less important; we were able to coalesce around a commonality that this year of training had produced. We became friends and colleagues with a special bond. The formal, required training period is now over. However, the impact of the program, but especially the impact of our patients, and of each other will form a special and important part of our horizon of expectations that we will carry into the future.