Sunday, November 27, 2011

Curiosity versus compassion

I never thought I would call cancer “cool.”

It was the last day of anatomy lab. Finally, we had dissected through everything: starting with the back, moving through arms and legs, hands and feet, chest cavity with lungs and heart, abdominal cavity with gastrointestinal organs, pelvis, and ending with head and neck.

Looking at our cadaver was disorienting. There were insides where outsides should be. Organs completely removed. The head literally sawed in half. Some of it was hardly recognizable as belonging to a body.

Before my labmates and I bade farewell to the body that had taught us so much, our professor handed us an envelope containing two pieces of information that had been kept from us throughout the journey: our donor’s date of birth, and cause of death. We tore it open eagerly.

“Cool!” I exclaimed, as one of my labmates simultaneously said, “We got it! That’s awesome!”

Our first response to the news of prostate cancer was gratification.

Stepping into pathologists’ shoes, we had made our guess several weeks earlier. During the pelvis dissection, we sliced through skin and fat and located the prostate gland. It is supposed to be the size of a walnut. The one we found was the size of a tennis ball. We reassembled skin and noticed tiny blue dots tattooed on our donor’s abdomen, indicating he had undergone radiation therapy. This must have been it; this was what got him, we had decided.

“I mean… um, cancer isn’t awesome,” my labmate clarified, embarrassed.

I knew exactly how he felt. As future doctors, we have to be especially careful as to what emotions we let on. Trust is eroding in the doctor-patient relationship. There exists a stereotype of a cold, distant doctor, who objectifies rather than empathizes, seeing patients as problems to be puzzled through instead of thinking, feeling human beings. It isn’t the fairest characterization. Yet its persistence means that we who are entering the profession must take extra efforts to combat it.

No one wants a doctor who thinks cancer is cool.

In medical school, I sometimes feel inundated with conflicting messages. On one hand, we are encouraged to think like scientists. To be curious. To ask questions. To form innovative hypotheses, and to test them. To find the beauty in discovery. Many times over the course of anatomy, our professor came over to a cleanly dissected region on our cadaver and called it “beautiful.”

And it was beautiful. As the weeks went by, I found myself increasingly awed by the elegance of the human body. I held a human brain, weighing a mere three or so pounds, and thought about all the things it can comprehend and create. There is so much happening beneath our conscious awareness, you’d think the human machinery would malfunction more often – or that we’d at least notice some of its efforts. The smooth inner workings of the body provide us the luxury to engage in everything else that makes us human.

And that’s the other message medical school sends. Be a humanist. Cultivate and display empathy. Care about people as people, not just as hosts of disease.

When to display each quality is a trickier matter. I wonder what the appropriate reaction would have been during that last day of anatomy lab. Should we have opened the envelope with solemnity? Summoned fitting empathetic remarks? Taken a moment of silence?

Our professor called our cadaver our “first patient,” implying we occupied a caregiver position. But was he really a patient? Should we have treated the news of his illness with the same compassion we would have expressed if learning a patient’s diagnosis? Is it ever appropriate to feel a sense of wonderment over illness?

We traverse the boundary between investigator and carer so frequently, it is hard to remember where we are supposed to be at any given moment.

I once interviewed a patient with advanced cancer. Tears came to his eyes as he told me about how he had to leave his job, couldn’t run around with his grandchildren, couldn’t do the things he loved, not like he used to, nope, not anymore. A single diagnosis had inflicted such profound devastation.

In an emotionally detached cadaver, cancer was cool. In a person, it was anything but.

As my training continues, I imagine that I will uncover more beauty in medicine. I imagine I will feel gratification when I diagnose something correctly, and that I will encounter phenomena that will make me think, “Wow. That’s so cool.”

I want to stay fascinated. I want to care.
                                                                   
It’s a clash of emotions I wonder if I can ever fully reconcile.

9 comments:

  1. Interesting piece, thank you. Hope you manage to keep up your blog throughout your career. So many drop off; but yours has promise as it covers, so far, both the pragmitics and the humanism.

    I don't work in medicine at all, but I've been a patient, and I've witnessed the experiences of other patients.

    Other important issues are:

    Keep the patient informed...

    Often doctors fail to do this sufficiently well. It's easy to assume the patient is with you, when really they are just nodding their heads because they are out of their depth but don't want to feel dumb. My 80+ mother as a deferential respect for doctors and never questions them. A relative with abdominal problems had details of his condition explained to him; but he was under the influence of morphine and retained none of the information.

    And, some patients may be as entusiastic as you are for the medical details.

    Be professional on the wards...

    The relative with abdominal surgery has good hearing. On admission he was supposedly out of earshot when his surgeon and anesthetist were debating, at 10pm, when to operate. He was a sufficient emergency warrant an operation within a few ours, but not immediate. Should they wait and risk other emergencies bumping him to later into the next day, or should they get right down to it now. The patient heard the anesthetist say something to the effect of, "I don't want to do it at 7:30am" Now this might have been quite innocent - he may have just come on duty and wanted to be fresh (there were complications associated with the patient having a chest infection, and the abdominal condition couldn't be delayed while that was cleared up). But the patient heard it as the anesthetist simply wanting the surgery to fit his personal preference. I think the lesson is, if you're going to discuss the patient, do it openly in front of him (and say it to him, not just about him), or well out of range. Being just around the corner, or worse, through bedside curtains, isn't appropriate, no matter how much you think you are whispering.

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  2. I think you still need what the medievals and James Joyce referred to as an "agenbite of inwit." To become a compassionate practioner, you must imagine yourself sitting in that interview chair and, later, lying on that dissection table. You, too, are human, subject to all the maladies and foibles that humans suffer, and you must never, EVER forget it.

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  3. My grandfather was a general practitioner who died of prostate cancer. I think that if his had been the cadaver you were dissecting, he would have smiled at your and your labmate's initial reaction. :)

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  4. This is a really wonderful reflection of the anatomy experience!
    The seemingly conflicting concepts of curiosity vs. compassion might not be mutually exclusive after all. In fact, I personally believe that curiosity – the fascination and determination to solve puzzles and find the Truth - is central for compassion in medicine. The moments that we lose our curiosity (due to frustration or getting “burned out” by the pressure of modern medical environment) are also moments when we lose compassion as well. There are many patients who are suffering from severe chronic pain or sudden weakness for which we have no clear explanation – they continue to suffer while being subjected to suspicion or abandonment, all under the quick & easy label of “malingering.” There are also others whose life stories are subjected to wildly unfair speculation after their death - their loved ones continue to live in guilt or fear as long as the causes of death remain unexplained. The story of AIDS, the “gay-men disease” of the 1980s, is a very tragic example of how the lack of knowledge and insights, as well as the lack of willing to attain such knowledge, has led to ignorance, discrimination, and cruelty.
    There is certainly no excuse for focusing only on the disease and forgetting the human beings who suffer. I also doubt that using “dark humor” to deal with emotional stress is a right thing to do. But I’m sure what you did in the lab was not simply saying “cancer is cool,” but, as you pointed out, an expression of gratification. I think it meant a lot. By correctly putting together the diagnosis for your first patient, you are able to make the connection and thus understand the profound devastation that cancer has brought to his life. Your patient unfortunately suffered and passed away, and there’s no way you could have helped him. But I believe you have come to understand him and his suffering so much better - certainly better than if all you did was dissecting blindly to fill the checklist. I think you should be very proud. I of course can’t speak for your patient. But if I were him and had donated my body for the stated purpose, I would be very happy and proud of your achievements too.
    Congratulations for being done!

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  5. @Ron Murphy: Thank you for your kind words and thoughtful comments. I think you make a lot of very good points. As just a first-year in medical school, I have stood in the patient's shoes more frequently than the doctor's, so I can identify with your concerns. I would call some of my doctors my "best" doctors exactly because they kept me consistently informed and did not speak down to me. I'm hoping I can learn from them.

    @Nosehair: Agreed that it's always helpful to put yourself in the patient's perspective. Doing that consistently seems to be the challenge.

    @Rodentia: Interesting story! Thank you for your comments.

    @Bao Truong: Thank you for the congratulations and your reflections. I imagine you can relate, as you've been through all this not too long ago. Using "dark humor" is an interesting point. We have begun to do it. I have mixed feelings.

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  6. Interesting persepctive. i think there's a clear difference between medical research (in which cancer can legitimately be called "cool" and treatment and care of patients (in which cancer may never be considered cool.)

    Trying to instill both at once might well be squashing interest in both. Keep up the blog and let us know what you think!

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  7. We had an oncology lecture in school a few weeks ago (vet school) and at the end of it, the oncologist couldn't help but exclaim, "I love cancer!" She was so earnest about it and it was exactly what you describe that she was expressing - her interest and fascination as a scientist. The thing is, she is also an amazing doctor and (we were once told by another hospital veterinarian) that her department probably gets more 'thank yous' and gifts from owners than any other in the hospital. So I think you can do both. In fact, the one (curiosity and fascination as a scientist) may actually help with the other (the compassion needed to be a gifted doctor).

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  8. I tried to use your "email me" option but was unable to. Would you contact me at capradr@yahoo.com want to ask about you writing a post for a medical blog I co-moderate. Thanks.
    Doug Capra

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  9. Ilana,

    What a wonderful post. My first thought at reading was "She's just like me". Only my perspective was from the patient side with a diagnosis of MS. My (curious) mind was thinking "Cool!" when I was told what was causing my symptoms. I told few people that I thought it was cool because I knew they'd think I was crazy, but since I was a kid I had been fascinated with the brain. So I "get" where you're coming from. As another commenter has stated, that curiosity may help with the compassion.

    Shauna

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