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Maintaining Thick and Thin Skin

Editor’s note: This manuscript contains mentions of suicide and sexual assault.

Third-year rotations forced me to reckon with my emotional capacity as a human and future physician. With each patient encounter, I had to decide whether my skin was too thick or too thin. Should I lean in and emotionally engage? Should I remain objective and distant? With little understanding of my own emotional limits, I would, by default, pour myself into each patient encounter. Then came the worry of whether my emotions were clouding my judgment and whether such an emotional investment was sustainable. Striking the right balance felt impossible.

The clinical setting is emotionally charged, steeped in very human experiences like grief, shame, joy and pain. Ultimately, though, clinical care relies on rational decision-making. As medical students, we are thoroughly trained and vetted in the decision-making component of care through multiple choice questions with neatly presented patient information. The reality of the wards is that clinical decisions are based on patients’ complex backgrounds, circumstances and goals. Gathering this information and building trust with patients often requires an emotional investment, one we have little guidance on tempering.

The role of emotion in the clinical setting is complicated. While emotional intelligence is being studied as a valuable component of clinical decision-making, emotional reactions from clinicians have also been linked to medical errors and threats to patient safety. Over the past few years, we have seen health care workers struggle with the emotional toll of the devastating COVID-19 pandemic. Compassion fatigue has become an important concern for clinician advocacy groups across the world, and the medical community has started to take a deeper look into how our system trains and sustains its workforce.

I started my clinical training fresh from my first board exam with a brain full of medical minutia and a hunger to finally make valuable use of it. Yet, my first clerkship rotating in the county psychiatric hospital was a harsh introduction to my inability — and our medical system’s inability — to comprehensively help patients. I would carry home draining thoughts about patients and feel frustrated that, as a medical student, I likely had very little impact on their lives.

I quickly learned that even attending physicians had little influence over patients who were homeless, had severe mental illness and addictions and were readmitted to the facility hundreds of times. Their socioeconomic barriers, insurance issues and longstanding histories of trauma were insurmountable in the acute setting. These patients were usually lost to follow up for the same reasons.

I would ask residents and attendings how they managed to stay motivated in their work given the heaviness of dealing with illnesses such as treatment-resistant depression and suicidal ideation every day. They would reassure me that eventually I, too, would develop emotional resilience and the ability to compartmentalize patient-related stresses. This seemed more easily said than done, especially once I began rotating in the child psychiatric unit. Most of those patients’ issues were rooted in abuse, often at the hands of those closest to them. It took serious effort to remain composed while hearing their stories and to instill them with hope for their future.

A teenage patient, Carla, tested the limits of my emotional boundaries. She was admitted for a suicide attempt after overdosing on her mom’s antidepressants.

Carla was shy yet sassy. She gave me one-word answers from behind her overgrown bangs and thick-rimmed glasses. Initially reclusive and aloof, Carla became an open book once I brought up high school, her friends and her favorite band, BTS. We had lengthy discussions on what they meant to her and why she loved the group. “They sing about stuff other people don’t sing about, like depression,” she once said. “Why is depression an important topic to you?” I asked. In this way, I would springboard off our chats into the psychiatric interview to understand the deeper reasons behind her suicide attempt.

Our conversation about why she avoids hugging her boyfriend turned into confirmation that Carla had a lifelong history of sexual assault. When asked whether her offender was still in her life, she quietly nodded, avoiding eye contact. She refused to speak any further and this consumed me. I would leave the psychiatric center each day ruminating over my dead-ended conversations with Carla.

My attending and I would urge Carla to give us basic details about her assault to no avail. We needed to file a report with Child Protective Services (CPS) immediately so the authorities could begin a legal investigation and prevent further abuse. After three days of resistance, Carla finally agreed to share more information but stipulated she would only do so once, to one person alone. 

“You.” She pointed to me, and my attending pulled me aside. “Fatema, you don’t have to do this. If you’re uncomfortable, we can wait a little longer and she might talk to me.” I was already determined to hear Carla out. We simply could not wait any longer; she was improving clinically but could not be safely discharged until we filed the report.

Carla led me to an empty, tiny room in the unit meant for alone time and switched the lights off. We sat on the floor in darkness and silence for what felt like an eternity. I slid her my notepad and a pen. “Would it be easier to write about it?” I asked. In small, shaky writing, the note she passed back to me read “he touched me.” She was trembling and her eyes were empty.

Carla nodded or shook her head to mutedly answer my endless yes-or-no questions about the abuse, enough to identify her uncle as the predator, where and how he assaulted her and how many times he had done so. Once I had the necessary information for the CPS report, I thanked her for her cooperation and assured her this was the first step in her healing. I fought the urge to hug her. I felt unsure whether that was appropriate, whether I’d manage to maintain my composure. Carla bolted out of the room, clearly unable to stand another second of my probing.

I shared Carla’s case with my attending and the social worker. While part of me was relieved we could finally move forward with the CPS report, I returned to the work room with my attending and erupted into tears. I hated forcing Carla to relive her trauma. I hated the man who was supposed to care for her, who instead violated her. I hated that she felt too much shame to tell her parents and felt that taking her own life was less painful.

My attending gave me space, letting me cry for a minute (if you ever have a meltdown in front of an attending, make sure it’s with a child psychiatrist). He assured me, “What you’re feeling is totally valid and what you did was so important. Because of you, she is going to be safe.” I took a deep breath, coming to terms with the true impact of my exchange with Carla and the necessity of our conversations leading up to it.

My attending continued, “And let me tell you, learning about her trauma is hard but living it is even harder. The pain we feel for them is only a tiny fraction of the pain they feel.” I let this sink in and still remind myself of this every day. My role was not to feel angry for her. My role was to make sure she was safe, supported and on track to living a healthy, meaningful life.

I had to recalibrate to realize what patients deal with is exponentially more difficult than what we deal with on their periphery. Even then, what we deal with is hard. I wonder how I’ll manage to be present for my loved ones after having days like that one, sitting in that small dark room with Carla.

Eventually, I know I’ll settle into my role as future Dr. Shipchandler to my patients while protecting my role as Fatema at home. I am working on my ability to compartmentalize my emotional energy and learning to trust the process, especially as the medical field continues to evolve and increasingly prioritize physician wellbeing. I still worry this process will harden me to the point where I no longer feel deeply for patients the way I do now, not yet jaded by residency and years in the clinical setting. Hopefully, with time, I’ll strike the right balance between being human and being a physician.

Author’s note: The patient’s name and details have been changed to maintain confidentiality.

Image credit: Blank (CC BY-SA 2.0) by russellstreet

Fatema Shipchandler (1 Posts)

Contributing Writer

McGovern Medical School

Fatema is a fourth-year medical student at McGovern Medical School, part of the University of Texas Health Science Center in Houston. In 2019, she graduated from the University of Houston with a Bachelor of Science in nutrition and a minor in Medicine & Society. After graduating from medical school, Fatema plans to promote preventative care and health equity by pursuing a career in family medicine.