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.