I was recently granted one of those rare, quiet Sunday afternoons we experience in medical school, and decided to spend it reading short stories. The story I picked up was “I Want to Live!” by Thom Jones. The story focuses on a cancer-ridden woman, Mrs. Wilson, reaching a meaningful place in her life amidst the throes of death. As I read the journey of Mrs. Wilson, my eyes flooded as my emotions finally caught up with me.
The story hit close to home and my thoughts flew back to the hospital where I started my medicine rotation a year ago. In the spring of 2013, I was a second-year medical student just stepping into the terrifying and new arena of clinical rotations. My first stop was the oncology service at Hospital A. At the time we did not have any new admissions, so my attending referred me to another oncologist, Dr. T, so that I could start to follow up with one of Dr. T’s new patient.
Dr. T began with a brief synopsis of my new patient: “You can see my new ICU patient who was admitted with metastatic lung cancer and congestive heart failure. His tumor is compressing the laryngeal nerve so he may not be able to talk much, but he is a very nice guy.” Dr. T proceeded to write down the patient’s MRN and room number. “I hope he can teach you something,” Dr. T said.
Nervous and inexperienced, I knocked and entered Mr. P’s room, my very first patient on the medicine wards. Surrounded by numerous family members lay Mr. P, bed-ridden with multiple IV lines radiating from each arm. He looked much older than I originally thought: his brown, wrinkled skin looked like a well-used brown paper bag and his gentle eyes, dull and cloudy from years of witnessing too much suffering.
“Good morning, Mr. P. My name is Emily. I’m a medical student with Dr. T. Is it okay for me to ask you some questions about why you came to the hospital this time?”
Mr. P nodded and, with great difficulty, was barely able to respond in a deep harsh voice. “I can…write…” he said as he reached for the pen and paper with his fragile, wrinkly hand, ready to answer all my questions. He listened attentively throughout the interview, and tried his best to explain to me about his chronic illness via brief phrases on the paper.
Inspired by my first medicine patient, that weekend I spent hours looking up cancer guidelines and writing a detailed problem-based assessment and plan for Mr. P. Feeling thoroughly prepared, I was excited to see Mr. P again the next week and follow up with his care. Unfortunately when I returned to work on Monday, I was not able to find him in his room or even locate his electronic record. I eventually found out from the nurses that Mr. P was discharged home over the weekend. Although I was a little surprised that he could be discharged so quickly, I did not question this information too much.
A week later, I ran into Dr. T on the wards. Right after I greeted her, a pulmonologist came over. “Hey Dr. T! So what happened to that patient, Mr. P? Did he die?” “Yes, unfortunately he did,” Dr. T replied. Quickly realizing her mistake, Dr. T turned towards me and said, “I’m so sorry, did I not tell you? This was the patient you saw last week. He insisted on going home to spend Easter with his family, even if the whole treatment team thought he was not stable enough to leave. He passed away over that weekend.”
Suddenly I could not process Dr. T’s words, as if my brain was short circuited. How could this happen? Someone I just talked to no longer exists on this earth anymore! It felt like I just saw him yesterday, but now he’s dead, completely removed from this world! Although I was aware of death, I was never warned it could be so close to me.
Even a year later my heart is still filled with guilt and sorrow whenever I think about Mr. P. Mr. P’s story made me start to ponder the inadequacy of the current medical education system. Emphasizing the theory of patient-centered medical care, the current medical school curriculum attempts to incorporate subjects such as art and literature, in hopes of making medical students more sensitive to the social and psychological needs of their patients. However, this focus appears largely to be on the patients, not the young doctors themselves. In addition to the acquisition of clinical knowledge and skills, the current medical curriculum fails to promote young doctors’ self-reflection and appreciation of the patient-physician relationship.
Although medical schools have recently added more liberal arts courses in pre-clinical education designed to address the humanistic aspects of medicine, these courses are either credited as electives or taught by non-physician professionals, perhaps unwittingly implying that these aspects of professionalization lie outside of medicine’s realm.
Meanwhile, the clinical training during medical school encourages young doctors to deny or suppress their emotions. Young doctors are supposed to maintain fixed boundaries with their patients and achieve a detached objectivity about human behavior. Faculty tend to minimize the importance of emotions, or suggest that the attention to that side of medicine hampers the focus of medical encounters in the clinical setting. Consequently, any affect expressed towards the patients could be potentially considered by the faculty as “unprofessional” or “low maturity.”
Therefore, young doctors have to defend against personal emotions by focusing on operational skills, and retreat into medical knowledge for its own sake. Under such medical education curricula, it is not surprising that the study done by Eron and the colleagues has showed the freshmen medical students initially entered medical school as compassionate, caring, humanistic individuals, but graduate as cold, cynical, dehumanized physicians.
I hope the future of medical curriculum can promote the awareness and validation of the emotionality of young doctors. Specific instructions targeted toward the medical humanity should be implemented throughout the medical school training and clinical environment. Faculty should be trained to properly address the emotionality of young doctors in challenging medical situations, and discuss the coping strategies when facing psychological stress. After all, we do not want to see the tragedy of future physicians all turning into impersonal and self-serving robots.
As I read through the ending of Mrs. Wilson in “I Want to Live!,” I was comforted that she was resting in peace after her prolonged battle with cancer. Before fading into oblivion, Mrs. Wilson discovered: “if you were happy, if you had something to live for, if you loved life, you lived.” I hope this is also true for my patient.
Rest in peace, Mr. P.