Abstract
A
I developed complete medical records on all of my stuffed animals. The grinning, pink, three foot tall inflatable rabbit named Easbit was notorious in our home as he was regularly rushed to surgery for deflation episodes. I would wake at 4 am (in keeping with surgeon hours), prepare him with IVs, and then submerge him into the bathtub to determine the source of his leaks. He would then be carefully patched with duct tape and sent to the recovery room in our surgical suite (also known as the basement playroom). Poor Easbit was forever enduring one of these procedures or wrapped in a bandage, yet that cheerful grin of his never dimmed.
Unfortunately, when I was six years old, the grandfather who engendered this behavior was diagnosed with stomach cancer and when I was seven he died. It was difficult to sort out what was said and what went unsaid during this emotional year, but I'm quite certain I never said goodbye. This was the 1970s, I'm not sure the medical profession was putting a lot of thought into how to talk to families and kids about these things. He was beloved by the family and, at only 58 years of age, his illness and death were very difficult for the family.
Despite his physical absence, Grandpa Warren continued to serve as an inspiration. Every college essay, medical school application, and document requesting an accounting of my reasons for choosing medicine as my field of study would tell of his role in my unwavering devotion to the field. Once it was clear that internal medicine was the place I fit most naturally into doctoring, I added to the story an apology about drifting from his dream that I'd become a brain surgeon. Although I didn't regret my choice of specialty, I did feel he had other plans for me—he wanted me to be a brain surgeon. I rationalized that perhaps he really didn't know what went into being a brain surgeon—did he? Deep down there was no rationalizing, he was a smart man, he knew—the disappointment persisted.
I went on to subspecialize in geriatrics. Surely he would have thought this subspecialty was noble, the only underserved subspecialty designed to care for such important members of society. Then, when the subspecialty of hospice and palliative medicine emerged, that seemed to make a lot of sense because there was unfinished business with him. I'd never said a proper thank you, I love you, or goodbye, so I'd help others in their journey. I'd try to gently open doors and allow the precious days in the final weeks of life feel less isolating. I also got a PhD along the way, which surely would have resonated with him. He was a scholar—I still remember being so impressed with the detailed notes he took as he taught himself to speak French. The apology found its way into the story in spite of all these seemingly scholarly pursuits. Yes, I became a doctor but not a brain surgeon.
Early this morning (those 4 am episodes with Easbit started a habit of early mornings) I went running. It was a glorious peaceful, sunny Sunday morning in Colorado and I decided to listen to a TED talk sent by the psychologist on our palliative care team. She has a knack for finding touching stories, so I'd tucked it away for a quiet moment like this one. The TED talk speaker was a pediatric oncologist who told the story of his patient who was rushed to the emergency room with disabling dyspnea due to advanced cancer. He was understandably concerned about her suffering and immediately provided morphine to relieve her dyspnea. Once she was more comfortable, to his surprise, her focus quickly turned to the details of transferring to another medical center for a Phase I toxicity trial. His assessment was that she was actively dying and her focus on a Phase I trial was a distraction. This focus would only serve to further isolate her from the conversation that needed to happen—how could she find meaning in the days that remained. With great precision, he quickly identified the tasks before him. First, he needed to give her control of the conversation because otherwise he'd lose any chance of having her listen to his concerns. Second, he needed to find a way to create space in their conversation to talk about how she wanted to spend her remaining days.
As her father started to perceive the calculations this clinician was making, he dialed her mother and included her in the conversation through speaker phone. The oncologist then asked the young woman about her journey that evening to the emergency room. She described it as long, lasting 45 minutes, miserable, and scary. He then asked about the trip she would need to take to enroll in the Phase I trial. She acknowledged that it would take several hours. The physician expressed his worry that this could be very hard on her. She paused and asked what would happen if she didn't go. Suddenly, space was open. Her mother perceived this over the speaker and interjected with the question they'd been too fearful to ask until that moment—how much time did their daughter have left? The oncologist respectfully asked whether the young girl wanted that information and, after she agreed, he responded that he thought her time would be measured in a week. It was at this point that her father found space too and let his daughter know he was concerned that they could not do this alone. He asked the doctor what help was available. They then discussed how hospice could provide support, and by the time they left the emergency room that evening with several doses of morphine to keep her comfortable overnight, hospice services were arranged to begin the following day.
Dr. Barfield, the pediatric oncologist in this TED talk, likens the precision of this conversation to that of brain surgery. Brain surgeons arrive at the operative field not as they wish the brain appeared but as it does appear and carefully work around the vessels and tissue encased in foreign matter with hopes that when they leave the patient, they are more whole; however, with one slip, the consequences can be devastating. Dr. Barfield arrived at this emergency room to find a young woman and her family encased by fear and discomfort. He carefully facilitated a reconstruction that provided transformation and left them more whole. A slip and he would have lost this opportunity risking harm not only to his patient but also to her parents who were able to be present with their daughter because of the space he so skillfully opened amidst a web of tangled emotions.
I found the talk compelling and was pleased I'd taken the time to listen to it that morning. After it ended, I continued running and thought to myself, “We should really have our learners watch this video.” I then returned to the brain surgery analogy and thought, “Such an interesting way to describe the skills we seek to refine every day as clinicians in palliative medicine.” Then, the brain surgery part crept in and with it that reflexive apology accompanied by the familiar feeling of disappointment. And then I reflected on the point of his talk and thought—“Oh my, perhaps I was not a disappointment after all.” Tears started streaming down my face as I considered the possibility. Perhaps what Grandpa Warren wished for me was that I'd end up in a field where I'd strive to be precise and where, like a brain surgeon, I would have the opportunity to open space with the intention of making patients and their families more whole. As a subspecialist in palliative medicine, perhaps I'd achieved his vision after all.
Reading this now it's hard to believe that I couldn't make meaning of my own journey until I found the clarity this Sunday morning offered. I anticipate many of us are encased in our own beliefs about success and failure in the medical profession. The forces that drove all of us here were clearly powerful or we would not have endured the rigors of training. If you too find an apology entering conversations about your career, consider that the regret can be reframed. Although Dr. Barfield relieved me of a very specific and unnecessary burden, his story also reminds us that for many, relief of burden often happens in the final weeks or hours of life. As a profession, we are acutely aware of the preciousness of life and have an opportunity to care well for ourselves and others today. The truth is that most mornings I'd typically be distracted by continuing medical education broadcasts or review of a hopelessly long to-do list but there were no fresh broadcasts available that morning and I'd grown weary of the to-do list that fortunately turned my attention to something more generative.
I will never know what Grandpa Warren saw in that four-year old but I've seen nothing but a physician in myself because of him and now with more clarity than ever. Dr. Barfield's analogy focuses on the precision required in our professional lives but perhaps we'd do well to demand less precision in our personal lives and open some space for making ourselves more whole.