Too Soon to Tell – A Reflection on Dr. Danielle Ofri’s Book, “What Doctors Feel”
I felt he found my letters and read each one out loud.
-Singer-songwriter Lori Lieberman, "Killing Me Softly"
I performed the wrong surgical operation on a man 25years ago. Since then, I have completed well over 6,000 procedures and have seen at least 35,000 patients in clinic, yet my patient’s face and the entire sequence of events before and after the operation are still fresh in my memory. The episode still haunts me. Writing about medical experiences that made me sit-up-and-pay-attention has always been important to me, but I have never tried to write about this man. Even now, I would not know where to begin.
My patient’s story resurfaced as I read Danielle Ofri's accessible and well-crafted book, What Doctors Feel: How Emotions Affect the Practice of Medicine (Beacon Press, Boston. 2013). Dr. Ofri demonstrates how the experiences all doctors share, even if unaware, can unleash startling moments of insight in the clinic and at the bedside. I was similarly moved by (and wrote about) the insights she shared in one of her earlier books, Singular Intimacies: Becoming a Doctor at Bellevue.
There are a myriad of influences that shape young doctors on their difficult path incrementally assuming life-and-death decision-making responsibilities. By any objective standard, the one-size-fits-all process through which they pass is absurd, but as I read What Doctors Feel, I kept thinking, "Yeah, I've been there. I’ve seen that. That happened to me."
Dr. Ofri lingers on the crushing of empathy. She explores how good and bad role models and the "hidden curriculum” exert pressure to change the young doctors. She explains the common experiences of fear and stress, the widespread yet rarely articulated reactions to death and sadness, and the feelings of shame and guilt that persist after medical errors and "near misses." She worries about the effect of being overwhelmed and burned out. She reports the suffocating feeling of being judged harshly.
She patiently, methodically and irrefutably makes clear that every physician has some – or many – of these harrowing moments. It happens to students, to residents, to practicing physicians. No one is immune. Interwoven within the recurring story of a woman with progressive heart failure for whom Dr. Ofri cares both medically and personally, she blends recent research data, accounts of colleagues’ difficult journeys and stories drawn from her own hospital ward and outpatient experiences. She explores several of the influences that thrust “normal” young adults through medical school and specialty training, delivering at the other end a cohort of practicing physicians.
More than many physician-writers, Dr. Ofri is strikingly honest about her own human lapses and failures, revealing her anxiety after missing a patient's pulmonary embolism and her shame watching a nursing assistant comfort a homeless woman whom she had avoided. She shares her apprehension after discharging a suicidal patient from the hospital and her chagrin of failing to see a patient as fully human until his family arrives to share his story. Even though I trained a few years before her and hundreds of miles west of her beloved New York City, each revelation led me to recall a similar experience from my own training.
In a moving sequence, she agonizes over a patient, Mercedes, who dies mysteriously a few weeks before Dr. Ofri completed her residency training. Although it took time to process her experience, Dr. Ofri remembers how she, as a young doctor, struggled to understand what had gone wrong. What did I miss? What simple thing done differently would have changed the outcome? “If all of the collective knowledge…could wither helplessly as a beautiful twenty-three-year-old woman died in front of my eyes, then what exactly was I doing as a doctor?”
These days, despite her hectic schedule as a physician, editor, and parent, Dr. Ofri has continued to write, explaining, "The deliberate pace of writing - in stark contrast to the breakneck speed of medicine - allowed me time to revisit these experiences. It gave me space for the deeper consideration I felt my patients deserved, something that was simply impossible in the real time of medicine." It took “years” before she was ready to revisit some of the more difficult encounters. Again, I said to myself, “Wow. I understand.” I do not have her writing chops, but I know that my own writing allows me to slow things down enough to search for some scrap of insight that would otherwise have shot past unheeded. This reflective technique is something I try to encourage in students and residents.
The dreadful mistake I made as a young physician still disturbs me. When the time comes, I will page through my notes, prop my patient's photograph on my desk, and write about the man who I harmed many years ago. I will reflect on the grace I experienced as he and his family forgave me. The images and discussions circling in my head for decades will eventually find their way to the page.
Like Dr. Ofri, though, it might be a while before I am ready to take that step.
||The following is feedback received for this blog:|
I just "discovered" you via the recent story on WUWM's radio website. And am so glad I did. I am a 3rd semester (out of a total of 4) nursing student at MATC and am extremely interested in the psychosocial aspects of healthcare in general and really, the systemic limitations inherent in design of practicing in modern times.
To be brief, I am currently finishing the last clinical week at St. Luke's and I believe I can speak for all of us nursing students when I too feel pushed through the academic and institutional systems to acquire knowledge and "think critically" without the proper time thinking critically actually takes to achieve. I struggle with this idea continually. For example, I recently had a sore throat and went in to the walk'in clinic to rule out strep. Surprisingly, my doctor and I got to talking about the recent Frontline about nightmare bacteria like MRSA and so on. he was interested and taught me a good deal that the article left out, much to my professional benefit. He talked to me like a human, without the stiff clinical distance preached in medical school. We spoke about what my career goals might be and his own troubles within the medical system.
- Dylan K.
Posted 2:20 PM
A Window Into the Inner Sanctum
You cannot connect the dots looking forward; you can only connect them looking backwards.
"Doesn't that window open any wider? Bring in another fan!" the surgeon demands.
Beads of sweat gather at the edge of his cloth cap and the circulating nurse steps up periodically to wipe them away. Heat and city noise roll through the open windows and into the operating room. The brief morning rain shower has left the shiny, green floor nearest the windows glistening and wet. A few levels below the OR, people are talking and laughing at the bus stop in front of the hospital. The diesel fumes from the bus and the cigarettes of the passersby blend and waft through the screens. A car honks on the boulevard. Pigeons land on the window sill and peer in. It is summer in Chicago in the early 1970s. Air conditioning won't be installed in the hospital for a few more years.
"Sorry, Doctor. We don't have any more fans."
He scowls. “Can you at least get me a sterile cup of ice water?”
I am home from college on break and working as a hospital orderly. Whenever I return for a few days, the hospital hires me back and offers me the opportunity to peek behind the curtain of Medicine. I am allowed to visit a place few people ever see except as a patient. It is a chance that, at the time, I take for granted.
For this particular stint, I am assigned to the OR – cleaning rooms, restocking supplies, transporting patients, setting up cases, folding linens, making coffee, running errands, finding X-rays, mopping hallways, scrubbing locker rooms…whatever is needed. Occasionally, when one of the OR staff is at lunch, I am pressed into duty as a surgical assistant. As a pre-med student, I am in heaven.
Today, I am assisting one of the orthopaedic surgeons. He looks at me from across the table. "Remind me your name again, son…Bruce?...Okay, here, Bruce," he says. “Hold her leg steady. I need to fix the hip fracture and it will go a lot more smoothly if all of the parts stay still.” He is a folksy, hardworking surgeon.
He grabs my hand and wrist and shows me exactly how he wants things to line up. He sets to work.
These are the days before CT scans and pre-fabricated femoral prostheses. The repair will be based on the physical exam and a couple of plain X-rays. The surgeon learned many of his trauma skills as a military doctor in Viet Nam. He will figure out how to best use the available metal plates, screws, wires, pins and plaster, drilling the holes with a power drill like the one my dad keeps on his workbench in the garage.
“Back when I was in school, these sorts of fractures were treated with casts, traction, and bed rest,” he tells me. “These days, we fix ‘em.”
It isn’t an easy fracture and he has to be creative. I want to help but I know little of surgery and am ignorant of the approach. I try to hold still as best I can. Eventually, we find a rhythm. Things move along and I get the hang of how he wants the leg stabilized. Soon, he is humming an aria as he lines up the fragments.
We move her to the recovery room and, soon, I am back in the OR holding a mop handle rather than the patient’s leg. I realize how much I enjoy being in surgery – at the table – helping.
A few days later, I am called to one of the floors to transport a patient. “Take the woman in Room 15 Bed 4 to X-ray,” the nurse tells me. “Be careful with transfers on-and-off the cart. She had hip surgery last week.” I walk into the room. Sure enough, it is the patient from the OR. She braces herself as she is moved from her bed to the cart. “Still really sore,” she tells me.
We talk as I take her down to Radiology. She doesn’t recognize me and I don’t tell her that I was the assistant for her surgery. She tells me about her family and her plans for going home.
She is recovering. Her hopefulness will stay with me for years.
Decades later, the memories of my first hospital job remain fresh. I can hear the hum of our original Bovie electrosurgical machines. I feel the conductive strips tucked inside my shoes to prevent sparks, although the use of explosive anesthetic agents like cyclopropane and ether had, by then, been abandoned. I sense the warmth of an open abdomen, retracting the liver as the surgeon removes a gall bladder through a large incision.
Even more than the technology and the procedures, though, I remember the people. There is one general surgeon who is comfortable performing essentially any operation and another surgeon everyone avoids whenever possible. There are specific patients and their families who stand out. And, even though almost all of the people with whom I worked in that OR years ago have retired or died, I hear the voices and see the mannerisms of the nurses, assistants and secretaries.
These are the people who will inspire me to pursue a career which will allow me to spend much of my professional life in the operating room.
Of course, surgical technology and practices have evolved dramatically. The rooms themselves are now twice the size they were in the 1970s to accommodate all of the computers, endoscopic equipment, monitors, microscopes, and robots. The only windows we have now are Microsoft Windows®. Almost everything about surgery has changed although surgeons still scowl, on occasion.
The people, though, and the sense of the operating room as a place set apart for a purpose – those things have not changed. I still love my work and feel as though I am coming home every time I enter an operating room. When I started, crossing that threshold always felt like stepping into an inner sanctum. Even after forty years, it still feels that way.
A version of this essay will appear in the November-December issue of Surgical Products Magazine. I would like to thank my roundtable at Red Bird – Red Oak Writing.
Posted 8:16 AM
Wearing Her Heart on Her Sleeve
Medicine offers you a front-row seat on life. Meaning is all around you. When you can see it, it gives you a sense of gratitude for the opportunity to do this work.
-Rachel Naomi Remen
The first-year medical student cried openly during the session. Not hard, but enough to be embarrassed.
“I’m really sorry,” she said, “but this is one of the things that scares me most about going into medicine. I cry all the time. When I get the least bit upset, the tears flow. I can’t help it. How can I be a doctor if I am crying all the time?”
She reached for a tissue and looked at me.
“What do you think?” I asked her. “Are you worried that you are too compassionate?”
“No, I don’t think so,” she decided, “but how can I take care of sick people like this?”
As a profession, we physicians are rarely accused of being overly empathetic despite the oaths we swear as we enter our careers (“May I see in all who suffer only the fellow human being…”).
Even when we strive to be consistently caring, our execution often falls short, yielding to the pressures of our own lives and the need to get long lists of tasks accomplished. There is no shortage of real or imagined pressures that physicians blame for the loss of compassion just as there is no shortage of criticisms that patients fire back at physicians and at those of us who are helping to educate the next generation of doctors.
At its most fundamental level, is there a way to improve the doctor-patient relationship? An essay in the New York Times
by chronicler of social innovation, David Bornstein, explores one approach that medical schools, including our own, utilize to help students fight the natural urge to become more-and-more emotionally detached from patients as they become physicians.
The Healer’s Art Course
is an five-session elective offered during the first year of medical school that helps the students explore their own motivations, their fear of loss, and their experiences with grief. The course helps them understand that, beyond science, the practice of medicine still requires openness to mystery. The course also reminds them of their obligation to society and the world beyond.
The developer of the Healer’s Art Course, Dr. Rachel Naomi Remen
, was an intern when a 3-year-old was brought into the emergency room after a car accident. The child died and young Dr. Remen accompanied one of the older doctors to tell the parents. Dr. Remen started to cry when the parents did. Later, the older doctor took her aside and berated her for being “highly unprofessional.” She didn’t cry again in the presence of patients or families for many years. Only later did she realize the damage that had been done when she was disciplined by the older doctor.
The Healer’s Art Course emphasizes “generous listening” among the participants. Hopefully, they take the skills they develop to the clinic and the hospital.
As one of the facilitators of MCW’s Healer’s Art Course, I was careful to let my weepy student tell her story and said that it was perfectly fine to be emotional in front of patients. “It is one way we can share our stories together,” I said. At the same time, I wondered if she might naturally gravitate toward a specialty where she would be spared emotional ups-and-downs.
I do not know if the Healer’s Art Course session impacted her, but she remained a good listener throughout medical school and is currently training to be an obstetrician/gynecologist. I can’t think of many other specialties where there is such potential for rapid fluctuations between heartbreak and delight.
I hope she continues to find meaning in her work during those moments of great happiness and those moments where the tears might start flowing once again.
Posted 2:01 PM
Difficult, Unspoken Questions
Do not now look for the answers…At present you need to live the question. Perhaps you will gradually, without even noticing it, find yourself experiencing the answer.
-Rainer Maria Rilke
Two men, Ted and Ron, were long-term professional colleagues. I do not believe that they were particularly close, but they had been acquainted during their working lives. Each had retired.
In what was a remarkable coincidence, both men were diagnosed with nearly identical cancers. The tumors were of the same type, location and stage. They each came to see me, Ted first and then, several months later, Ron.
Ted was the first to undergo cancer treatment. It was rugged but he recovered well. By the time Ron was diagnosed, Ted had recovered completely.
The two men must have re-connected before Ron came for his first appointment, because he was well prepared. Ted had already filled him in on what to expect.
"Ted has been a great help,” Ron said. His wife agreed. “How soon can we get started?"
Ron's treatment was also rugged, but he recovered completely, as well. At subsequent follow-up visits, they each occasionally mentioned the other. Things went very well for a couple of years.
Unfortunately, Ted developed severe treatment complications and then a massive recurrence of his cancer. Despite several attempts to control the raging cancer, we ran out of treatment options.
I tried to figure out what had happened. Why the difference? There were no obvious answers. The two men presented with essentially identical tumors. They received identical treatment and had very similar underlying health histories. There was no clear reason why Ted’s cancer had returned.
Not long after Ted died, Ron came in for a routine visit. He continued to be cancer-free. As the visit was wrapping up, Ron became quiet. “What a shame about Ted,” he said. “He was a great person.”
“Indeed, he was," I said. "It was an honor to be involved in his care.” It was quiet in the room. What must Ron have been thinking? Ron had watched Ted go through so much. I could only imagine his questions.
I reassured Ron that everything looked great, realizing, at the same time, that I had offered the same reassurance to Ted during his the initial cancer-free interval. Ron could have legitimately asked me, “Could what happened to Ted still happen to me?”
These are moments of uncertainty.
One of my favorite mentors, a plain-spoken surgeon, sometimes would respond to similar questions with a lighthearted but sincere, “I don’t have a crystal ball. I wish I could tell you but I cannot.” I do not know if that is the best answer (and for some people, it clearly is not), but I understand the sentiment.
As surgeons – and as people – we want answers. Sometimes we do not tolerate ambiguity very well.
So, I reassured Ron that he was doing very well. “Things look great. Nothing concerns me at all. We are always available and if you notice any new problems, call us and come in. Otherwise, we will get together again in a few months."
In the meantime, I suspect we will both think about Ted and what his life meant to each of us.
Posted 5:33 PM