Love, Medicine and Miracles

Quill

The Privileged Listener

The idea of the exceptional patient is not taught in medical school. I came to it only after a long period of unhappiness and soul searching in my profession. I didn't have a class on healing and love, how to talk with patients, or the reasons for becoming a doctor. I was not healed during my training, and yet I was expected to heal others.

In the early 1970s, after more than a decade as a practicing surgeon, I was finding my job very painful. It wasn't a typical case of burnout; I could cope with the unending problems, the intensity of the work, and the constant life-or-death decisions. But I'd been trained to think my whole job was doing things to people in a mechanical way to make them better, to save their lives. This is how a doctor's success is defined. Since people often don't get better and since everyone eventually dies, I felt like a failure over and over again. Intuitively I felt there must be some way I could help the "hopeless" cases by going beyond my role as a mechanic, but it took years of difficult growth before I understood how to do so.

When I'd started out, I'd looked forward to facing new problems each day. It was an exciting challenge; it kept practice from becoming dull. After several years, however, the challenges themselves became monotonous. I would have loved an easy day when everything went according to schedule and I had only routine cases. But there were no "normal" days. It was only later that I became able to look upon the emergencies, and even the breakdowns in hospital procedure, as extra opportunities for helping people.

Surgeons aren't perfect. We always do our best, but complications still occur. Although disheartening, they keep us grounded and prevent us from starting to think of ourselves as gods. The one case that most shook my faith in myself was an injury to a facial nerve in a young girl I operated on early in my career. Seeing her wake up with half her face paralyzed made me want to hide forever. To become a surgeon in order to help people and then to end up disfiguring someone was a shattering experience. Unfortunately, I hadn't yet learned that my typical physician's response -- to hide my pain when something went wrong -- helped no one.

The pressure never let up. When a patient was taken to the operating room with severe bleeding, the staff was tense and panicky -- until the surgeon walked in. Now the knot was in my stomach, and everyone else relaxed. There was no one to whom I could transfer it. I could only look inside myself for reassurance. As every operation began, the sweat poured off, and then, even though the lights were just as hot as before, I cooled off as things came under control. I used to feel desperately alone, expecting perfection of myself. The stress followed me home. Days before a difficult operation, I'd live it over and over in my mind, praying that the successful result I visualized would come to pass. Afterward, even if all went well, I'd suddenly wake up in the middle of the night questioning my decisions. Now, after years of being educated by my patients, I'm able to make each decision, live by it, and put it behind me, knowing I'm doing my best. Just like a minister who feels alone because he never learns to talk to God, a doctor feels alone if he or she never learns to talk with patients.

One of the worst hardships is having so little time to spend with one's family. The athlete can shower and go home after the game, but for doctors the working day often has no end. I had to adjust to the idea that being home on a weekend was a bonus, not something I could count on. Moreover, I was suffering from two-way guilt: snatching a few hours off felt like stealing time from my patients, while the sixteen-hour days felt like stealing time from my wife and children. I didn't know how to respond to the guilt or how to unify my life. Many nights I was too tired to enjoy my family after I did get home.

Once I was so exhausted that, when taking the babysitter home, I automatically drove to the hospital instead. She probably thought I was kidnapping her.

Even the time I managed to spend at home always seemed to get interrupted. The kids were constantly asking, "Are you on call tonight?" Everyone was nervous when I was on call, sure that the family evening wouldn't last. For most people the ringing of the telephone is a friendly sound. For us it meant anxiety and separation.

One of a physician's most unnerving trials is due to the fact that death comes in the middle of the night more often than at any other time, something I now understand. One can't help but feet a twinge of anger when a patient who has been in a coma for days passes away at 2 A.M., and the doctor and family must be awakened with the news. We think, "Why can't the dying have a little respect for the living?" Few of us ever mention this hostility. We just feel guilty about it. Then there's the added burden of having to be cheery and alert in the operating room at 7 A.M., despite family problems and two or three calls in the middle of the night.

On New Year's Day in 1974, I started keeping a journal. At first it was largely an outlet for my despair. "At times it seems the world is dying of cancer," I wrote one night. "Every abdomen you open is filled with it." And another night: "Your stomach hits the floor, and the horror sweeps over you as you see the future. How many faces must you look into and say, 'I'm sorry, it's an inoperable tumor'!"

I well remember Flora, one of my patients from that period. Her husband had recently died, and now she herself lay dying of uterine cancer, which two operations had failed to halt. She agonized over how much each day in the hospital cut into her life savings, which she had willed to her granddaughters. Wanting to prolong life, at the same time she wanted it to end so that no more of their education would be squandered on her frail body. "How," I wondered, "can I find strength to support all these people in their struggles?"

Thanks to the introspection of my diary I eventually realized I had to change my attitude toward medical practice...