More than halfway into my third year of medical school, I still found it difficult to shake the feelings that came with the inevitable daily identity crisis resulting from the expectation that we are to constantly adapt to the unique preferences of each resident and attending. This is just one of many layers of pressure put on us; we also have the expectations we set for ourselves to be top performers, to always go above and beyond for our teams, all while trying to learn and deliver quality patient care. Rotating through clerkships with constantly changing expectations keeps us on our toes and out of our comfort zones to make sure that we are always prepared. But for all of us, there are moments that make us feel unprepared, those moments that grab hold of us and remind us what being a physician is at its most bare and stripped-down core: being a human who cares for others.
For me, one of these moments occurred during my neurology clerkship, a week into working in the neuro intensive care unit (NICU). I took part in a meeting with my team to update a family on the status of their loved one. It was my first time in this type of meeting, especially for a patient that I was directly involved in caring for. To our team of medical professionals, he is our 51-year-old male patient with a 45-pack-year smoking history, but to his family, he’s a son, a husband and a father. All they understood about his condition up to this point was that Mr. R had a heart attack that led to some swelling in his brain.
We were tasked with conveying that Mr. R suffered from an episode of cardiac arrest that lasted long enough for his heart to fail at pumping blood to his brain, causing an anoxic brain injury with poor prognosis. What we needed to explain to his loved ones was that the state of his brain injury from a temporary lack of oxygen and nutrients was so severe that Mr. R would remain comatose and most likely never wake up. Choosing to keep him alive would mean keeping him in a special care facility on a ventilator that breathes for him, with a full-time staff that feeds him through a feeding tube and manages his other basic needs to sustain his life indefinitely.
For neurocritical care physicians in the NICU, this is a common outcome for patients with severe anoxic brain injuries. These physicians are unfortunately well versed in meetings like these, breaking bad news to families, whose family members they often have known for less than a day, in the most respectful and empathetic way possible. Though it usually takes just 30 minutes to 1 hour of their time, for a patient’s family, hearing this news is one of the most devastating and traumatic moments of their lives and can feel as though it lasted a lifetime.
To Mr. R’s three kids, it means they will never get to talk to their father again. It means they will never have their dad at another birthday party or have him walk them down the aisle at their wedding. To Mr. R’s wife, it means she lost her best friend, her lover, her partner in crime and the father of her children. To his parents, it means they had to live to see their child pass away before his time; every parent’s worst nightmare.
As our team walked to the conference room with the family, I found myself experiencing an overwhelming mix of emotions. I was anxious, nervous and distraught all at once. My heart was pounding, my body stiff and my palms were clammy. As we trickled into the cold and dimly lit conference room, I could see a similar mix of emotions on different family members’ faces. Some tried to make eye contact and read into our expressions to get a hint of what was to come.
As I entered the room, I remember wondering how to conduct myself. What kind of facial expressions would be compassionate, respectful and comforting all at once? What was the right balance between acting professional and acting human? Though we learned strategies for delivering bad news in medical school and practiced role-playing scenarios during small group sessions, nothing truly prepared me for what it would be like in real life. Emotions are predominantly beyond the scope of our control. There is no recipe for how to process and manage their physical and mental manifestations when they hit you.
After a few minutes of trying to micromanage my own expectations and uncomfortable feelings of vulnerability, I allowed myself to be present — not just as a medical student, but as a human being watching a family fall apart. I let go of my self-imposed insistence to appear prepared and opened myself up to act and process the experience in whatever way came naturally. I listened, I cried, I gave head nods, I passed around tissues and I touched his father’s shoulder on our way out. At first, I felt bad because I wasn’t perfectly prepared and my emotions showed through. But I later came to realize that I would never be prepared for this the way I thought I should be and that is perfectly okay. That is perfectly human.
While practicing medicine involves both algorithms and altruism where in an ideal world both calculated decisions and compassion are balanced and operate in sync, the truth is that life is messy, and the practice of medicine is no exception. As a medical student integrated into the clinical environment, it quickly became apparent that the reality of being a doctor was far more difficult and complicated than the “butterflies and rainbows” many of us thought it would be like while growing up. Even as students, it is easy to get overwhelmed managing our clinical duties to the point that we get so caught up in following treatment protocols that we lose sight of the fact that being present and empathetic is just as, if not more, important for patient healing. With so much at stake and so little time to process, we tell ourselves that if we do the right things and act in accordance with the guidelines, our patients will be fine.
But it is these moments that help us to realize that there is no such thing as perfection in the practice of medicine. It is these moments that serve to remind us that quality patient care isn’t based on sticking to the SPIKES protocol script for delivering bad news. It is these moments that remind us that fundamentally, we are human caretakers. I understood why we are always kept on our toes, trying to anticipate the unexpected — but sometimes being prepared is not possible or even beneficial. Sometimes altruism should take precedent over the algorithm. Being a doctor means being human first and foremost; perfectly imperfect.