Just another day in medical school

I cried for an hour straight today, going through multiple tissues, soaking them completely with tears and the snot that always accompanies a good cry.  Why you ask?  Today's topic in class was dying, grief, and loss.  I even knew it was coming.  We had to read a big journal article on grief and watch a movie (203 Days) before coming to class to be prepared for the discussion. But I was not expecting the emotions that ensued.  

Every Thursday afternoon I have a 2 hour class that is called PCM (Patient Centered Medicine).  It's basically a course where we learn how to be a doctor, without all the science stuff getting in the way.  They teach us how to interview, take a history, and build that trusting relationship with your patients.  We play pretend doctor, interviewing standardized patients in front of the other 7 members of our group.  Then when it's done, we get critiqued by our teacher and classmates, usually on how we could have been more sympathetic.  "You could have leaned in more towards the patient.  She was obviously in distress and needed to see you actually cared," one classmate says.  "You should have explored her feelings about her dog's death more. Maybe that was why she was turning to alcohol", another chimes in. 

Inside I'm screaming, "NO, this "patient" is not in distress!  It's not a real patient!"  Instead, I just nod in acquiescence.  "You're right.  I was so worried about getting through the Review of Systems and Chief Complaint that I didn't give her time to truly express herself.  Completely my fault.  I'll try to ask more open-ended questions next time."  Not really, it had already been 25 minutes since I'd started the interview.  I'd heard everything from her kids' nicks and bruises to her mother's travels through Europe, all of which having nothing to do with her back pain.  It was time to wrap things up.  In a perfect world, a physician could spend 30-45 minutes on each patient, diving into the intricate details of their lives.  But that's not reality.  Hospitals can't afford that.  Physicians typically only get 15 minutes for each patient, usually only having time to hear the Chief Complaint, do a brief physical, then make the diagnosis and discuss treatment plans.  If the doc took the hour long appointments that our PCM class is essentially teaching us to do, then either the patients have to be charged an arm and a leg (the equivalent of 4 appointments) or hospitals would go out of business before you could say dentatorubrothalamic.  

Anyway, today's particular PCM class was not spent interviewing patients.  Instead we were being taught the stages of grief and how to cope with the death of a loved one.  Obviously death is a natural and inevitable stage of life, but it's one that most physicians have to deal with more frequently than the lay man.  Before class, I assumed the purpose of the lesson was to teach us how to help our future patients as they are dying and how to comfort the family during that difficult time, which is very useful for us to learn.  But it turned more into a sob fest where we just heard story after story of heartbreaking deaths.  First we had to go around the circle and tell a personal story of a time we were confronted with death, and how we handled it.  The girl sitting next me, and one of my better friends I've made here at UK, was forced into a situation that she was obviously not comfortable in.  Her brother died when she was 14 in a fatal car accident.  He was 20 years old.  It's not something she ever talks about, so she just briefly mentioned it and then put her head down in silence.  Another person talked about the last moments spent at his father's death bed, and how he had to choose whether or not to put him on oxygen or let him go.  He chose the latter.  It was painful to say the least.  At this moment I was starting to feel my heart race and my body was overcome with chills.  I could tell I was not emotionally stable and tears were going to start flowing if anything else remotely sad was said.  

Well it wasn't over.  We spent the next hour watching various documentaries on death and grief.  One was about a woman in her early 60's dying of ovarian cancer.  They videotaped her last Mother's Day at home with the whole family, her last appointment at the hospital where the doctor told her it was probably the last time she'd be there before her death, and her husband choking up as he tried to talk about what life will be like when she's gone.  We saw the tears stream down her face as she talked about her fears of dying in pain.  Another story was about a child with CF who was about to die at the tender age of 14.  She was drawing a picture of rainbows and angels and then laboriously whispered about how she knows she has a guardian angel with her, ready to fly her off to heaven.  She said she was not afraid of dying, just afraid of how her parents will cope with it after she's gone.  Meanwhile her father talked about his regrets of how he raised her, ignoring the fact that she was dying, and not talking about the important things in life with her.  And finally, we watched a mother talk about getting over the death of her 6 year old daughter - the rage she felt towards the physician who broke the news to her, the physical manifestations of her emotional distress, and the pleas to God about how unfair it was.

Needless to say, I bawled.  I couldn't even hide it.  I kept trying to distract myself by getting out my iPhone and reading USA Today, or checking my email and Facebook countless times, but no matter how hard I tried to shut it out, I kept hearing the stories and sobs in the background.  I attempted to hold it together and not let anyone see the tears forming in my eyes, but once I reached into my purse for the first kleenex, the class knew, and oddly I was ok with that.  Anyone who was still questioning whether or not I was blowing my nose because of a cold or because I was crying had their question answered when the lights were turned on.  I can't even pretend to hide it - my face screams that I've been crying with its puffy, red eyes (which stay like that for hours).

I left class today mystified.  Why had I been so affected by those movies?  Most of the other people in the class didn't react the way I did.  The only other person that cried was my friend who had lost her brother 8 years prior, and obviously her tears were merited.  My immediate thoughts were that I am weak and hypersensitive.  I then spent about 17 seconds questioning whether or not medicine was the right occupation for me to be entering if I can't handle death.  Finally I snapped back to reality and decided that I should probably just avoid going into oncology, geriatrics, or palliative medicine.  I'd be a complete wreck every day.  Life is precious.  I can't even fathom having to tell a patient that they only have a few more days left, or going into the waiting room to tell the family that they need to say their final goodbyes.  It takes a strong person to do that type of work, and that is most definitely not me.

I can't decide if it is a good thing or bad thing that I am such a cry baby.  The right side of my brain wants to hold onto that impressionability, since so much of medicine is not just treating a disease, but a patient's emotions and total well-being.  Plus, most of the public's dismay with the health care system is its lack of sensitivity.  They think physicians are just robots who don't care about the person they are treating.  But the left hemisphere then tells me that I need to toughen up and learn to deal with it better so that I will be able to give the best possible medical care, not clouded by my own emotional weakness.  As you've seen on Grey's Anatomy, it's not good to get emotionally involved with a patient...you may end up cutting an LVAD wire in attempts to perversely "help" the patient.  Dramatic example, but you get the point.  

It's a fine line for physicians to walk: finding a way to sincerely care for the patient and gain their trust, but not get too involved. I have yet to figure this one out.  I suppose I have plenty of time to learn.