Someone recently asked me how, as a physician, I could see death every day and not be depressed by the sadness of it all. This is something I have thought much about, but have never really taken the time to articulate. I explained that for me, there exists two different parts of myself that sometimes polarize when I’m at work. There is me, Genevieve – lover of the humanities, mother of a sweet daughter, and sappy movie watcher; then there is me, Genevieve – surgeon, physician, and crisis manager. These two people live side-by-side and exist at all times within myself, but I have learned to channel the person who needs to be present at any moment. I’m not saying that this is the best way to be or that there is not some other way of remaining fully integrated at all times, but I have not found it.

I remember distinctly that when I started medical school, I felt an earth-shifting movement away from some of the things that life had contained before. The infusion of unnecessary drama into situations, while never interesting before, became quite intolerable. As I lived and breathed the highs and lows of other peoples lives each day, I no longer understood why anyone would want to create drama when it was not otherwise there. I was just tired at the end of the day – emotionally and physically – and all the small elements of living were placed into proper perspective. Small fights over perceived slights were silly, long reflections over clothing or physical items seemed empty. I had a daily, visceral understanding of how short life was, and the minutiae became clearly that.

Yet, I sometimes do wonder if this parceling of our selves, our emotions, and our minds into these divided states can result in some negative fragmentation. Are we packaging and hiding moments that we never take back out and learn to deal with – these difficult pieces of our every day? I frequently apologized to non-medical friends when they were around my resident friends, as we quickly slipped into work talk every time we were out for dinner or drinks. We would recount some disastrous situation or another, sharing our moments of conflict and turmoil. Of course, we never couched it in those terms. Instead we would laugh about some story of unhappy endings, told with much head-shaking and dark humor. Yet in retrospect, I think this was our way of making sense of each day – our decompression and impromptu therapy sessions.

However, even with this decompression time, I don’t think many of us take time to consider the impact of what we experience in our jobs on our psyche. This is not an essay to complain about how medicine makes me sad. I love my job. I love my patients, and I am happy to serve in any capacity during the trajectory of their clinical course. But a casual question asked by a friend has brought back a lot of these thoughts that I had put aside in the business of life as a resident/fellow. Yet, somehow I knew this was all very important. Even as a resident, I remember making of list of moments where I felt myself dividing into two separate people in order to keep moving and get the job done. I have always loved writing and purportedly made these notes to eventually tell these stories some day, but I think I was also purging these experiences from my day. Unintentional catharsis.

I will never forget the cries of the parents of a young man who committed suicide as they cowered in the corner of the trauma bay while we unsuccesfully resuscitated him. Their gut-wrenching apologies, never heard by the patient himself, remain with me to this day. I still remember the patient who came into the EC with a leaking aortic aneurysm, obviously ill but still talking and chatting – a pleasant Italian man who proceeded to die abruptly on the OR table that night. To this day I am still affected by the child who came in unconscious with a depressed skull fracture, abused by her stepfather – a moment where the horrific nature of the situation made me physically ill. I think sometimes of the teenage terminal cancer patients I see routinely, who are dying in front of their parents eyes. They sit surrounded by their family whose lives have been taken over by this sickness, and as a parent myself I mourn for everyone in the room. I still remember the patient who I allowed to die in front of me, as I struggled to find anything or anyone who could help. And I see every day the many patients who die in the ICU, intubated, sedated, as they slowly drift away in a sea of infusions, ventilators, and invasive procedures.

I do not lament my choice of career – I love my job. It teaches me so much on a daily basis – it makes the minor inconveniences of life just that…. minor. And as I told my friend at the beginning of this essay, I take consolation in the fact that I’m helping people in their time of need. As a surgical oncologist, I generally see patients at a time where we may at best offer them a cure and at worst some meaningful time with their families. But the reason I ruminate on these issues now is that it is really fascinating that we, as physicians, live this life of high magnitude decisions and moments, and we are never trained nor counselled as to how to actually exist like this. I find it amazing and a credit to those in the profession that so many “normal” people can slowly exit the life they know of movies and cars and nice restaurants and go to work every day dealing with the critical moments of other people’s lives. And yet so many of us do this… and this life we chose as a physician becomes the norm.

On a personal note, I will confess that this splitting does not go away just because we are outside of the hospital. I remember when my father was dying of urothelial cancer. He was always a fit and slim person, and up until the rapid deterioration in which he died, we did not know he had diffusely metastatic disease. He might have suspected he was dying, but he shielded it from us and as his family members we never knew until the end. Looking back, I remember seeing him a month or two before he died and having a transient thought that didn’t even register until much later. A thought just popped into my head one day and then disappeared from consciousness. It occurred to me that if I were seeing him as one of my friends or colleagues, I would think that he looked cachectic and as if he was dying of cancer. As his daughter, I saw only my thin dad – his body habitus an exension of his long history of exercise and health maintenance. But obviously in some recessed part of myself, unrecognized, I knew that he was dying. It was not a part that registered in my forebrain, nor a part that even made sense until later. But that divided self was there even in my own time of tragedy – a part of me knew what was happening even though the human side of myself had absolutely no clue.

This also gives me insight into the difficulties of patients and families in comprehending the complex process of illness and dying. Despite what you may rationally know, neither you nor your family are experiencing this as your logical selves. Each person is seeing the moments from the perspective of a loving child, a spouse, or as the patient themselves. No one can retain perspective and clinical distance when you are in the thick of it because underneath it all we are all still human with the emotional and complex layers of perception and understanding, or misunderstanding, that comes along with it.

I used to be so incensed when I would be called in consultation on a patient who, despite being on a Phase I trial of an experimental drug, had no idea that they were dying of cancer. I thought these physician were clearly negligent in their duties and were obviously not educating patients appropriately about their disease. I thought, with a sense of moral superiority, that it was criminal that no one had spent the time to properly educate the patients about their situation or the fact that they were dying. This was reinforced by a recent article in the NEJM in which they demonstrate that the majority of patients undergoing palliative chemotherapy believe that their treatments are curative.

Patients' Expectations about Effects of Chemotherapy for Advanced Cancer β€” NEJM.

When I read this article in the NEJM, I believed that I again had found another example of how we as physicians had failed our patients. And this may sometimes be the case. However, I had the opportunity to discuss this article with the head of Palliative Care at MD Anderson, and he offered me some perspective which I did not have on my own. He pointed out that while it is true that we may often fail to appropriately communicate difficult information to patients, there may be other times where the patients or families have an inability to hear this information, even when clearly presented. This fact does not exonerate us from our responsibility to help these patients and continue to educate them throughout their clinical course. It does not remove our responsibility to clearly communicate without hiding behind unintelligible jargon. Yet for me, it does point out that while we do need to improve our communication skills during end of life discussions, we may also want to spend our time and energy on repeatedly communicating with patients over time, as the patients and their families slowly absorb the reality of the situation that they find themselves in. Having been a family member in denial, I am sympathetic to their plight.

Finally, as a physician I have to wonder if I can create a framework in my own life and career in which I integrate the polarized sides of myself so that I can be calm when everyone else in the room is not, but also remain connected to my patients and to others. I think many physicians are self-learners of this skill over time, a testament to themselves and the strength of their character. But I know many others who have separated their two selves so far that they no longer feel the pangs and heartache of their patients’ lives. I don’t believe that these physicians do not experience these feelings in some recess of their soul, but they have become compartmentalized and distant, which is apparent to everyone around them. I think to truly wade through the day to day of being a physician, we need to let these disparate selves come together now and again – in the quiet moments. Because we need to be whole people, not fragments, in order to truly heal ourselves and others.

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4 thoughts on “Our divided selves.

  1. Dear Genevieve,
    I truly appreciate your views on how to deal with the difficult emotional aspects of dealing with dying patients, the emotions of the families, and our responsibility as physicians to make the best possible decisions for our patients. I think over the years, that I try to bring my entire self along when I care for patients. I look at the doctor-patient relationship as a partnership and an open partnership. I look at my patients as partners and my role in the partnership is to try to improve health but also lessen the pain and suffering. A physician can be sensitive to the emotional and medical needs of our patients and try not to allow ourselves to become divided in the care of patients. One has to have be knowledgeable, caring, but straight forward in making decisions. I personally, do not experience discomfort in dealing openly with patients.
    I really was disappointed when I read the recent NEJM article. I think we should stop chemotherapy and avoid toxic experimental drugs when the hope for improving survival is minimal. I have stopped chemotherapy for at least 6 of my patients with metastatic colon cancer over the last several years because the treatment had significant side effects and the patient was losing the battle against metastatic cancer. There comes a point when we need to let our patients die with as much peace and dignity as possible.
    There are disconnected physicians, not really divided, so the personal reasons that you listed in your article would not apply to that group. Some docs just do not see service to others as the main reason for becoming a doctor.

    Geoff Braden

    1. Thanks for your insight. I don’t disagree with stopping therapy when there is a lack of benefit, and I agree that dignity in the end of life is often sorely missing in modern medicine. I think we often approach patients as if it is a failure (theirs and ours?) to transition to a supportive rather than treatment mindset. That’s why I’m glad that fields such as Palliative Care are catching on – I think they do our patients an immense service.

      And you’re right, perhaps there is a distinction between disconnected and divided.

      Take care, and please keep reading/writing!

      Genevieve

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