The Stoic Doctor
I still remember the first patient who passed away under my care.
I was a fresh intern then, two weeks into the job. He was a terminally ill, elderly man who had been lying in hospital bed for two months. He couldn’t speak or eat or ambulate. He wore a diaper which had to be changed by his nurses twice a day. A nasogastric feeding tube dangled from his left nostril.
For confidentiality’s sake, let’s call him ‘John’.
John’s daughter had signed a “Not-for-Resuscitation” form for him after we, the medical team, advised her that any resuscitation efforts at this stage of his illness will only prolong his suffering. If it’s time for him to go, let him leave smoothly and with dignity.
Each morning, I’d do a brief checkup on him. A quick scan through his file: vital signs, fluid charts, water intake and urine output, medication doses and timings, et cetera. Then I’d perform a short examination. I’d pry his limp arm away from his chest and listen to his heart. His patient gown would be soaked with perspiration from lying immobile in one position for long hours. An acrid stench hung in the air.
He wouldn’t move a muscle or utter a sound during the examination. He couldn’t. But his eyes would follow me. They twinkle. And somewhere behind them, I could tell he was aware of me, of who I am and the gulf between us, that he was an old man lying on his deathbed and I was a nervous young sapling in his second week of work.
This ritual continued for a week and half each morning until one day I turned up at his bed to find his breathing shallow and his eyes glazed. He wouldn’t look at me, even after I called out his name or gripped his shoulders. His vital signs were off, heart rate and oxygen saturation declining. The senior consultant was promptly called. The command was given to notify the family of his imminent death. Morphine IV to ease the pain, oxygen mask so he breaths easy during his last hours. Everything was swift and methodical.
A few hours later, however, I received a call from the nurse telling me that John has a full bladder. In other words, my dying patient now had a bladder obstruction. I was faced with one of the first medical dilemmas of my infantile career.
We all know what it feels like to have a full bladder – the discomfort, the urgency and the pain. Now imagine being unable to pass urine while having a full bladder and at the same time, you can’t move, can’t even speak and voice your complains. And on top of that, you’re dying. Not a pleasant way to go, I assure you.
At this point, nobody knew precisely how long John had left to live. His heart could give up within five minutes, or he could live on for hours. I had two choices: insert an urinary draining catheter now, which would cause pain during the procedure but thereafter relief the severe discomfort associated with an obstructed bladder, or leave it alone and avoid causing extra and possibly unnecessary pain with the catheter, hoping cynically that he’d pass away quickly and the obstructed bladder wouldn’t be his problem for long.
I picked the former, took the equipments from the store and with a nurse by my side, proceeded to insert the catheter. It went in smoothly, but for some reason, the urine wouldn’t drain. I fiddled with it, adjusted its position again, and that was when the nurse tapped me on my shoulder. She pointed at the breathing mask over John’s face. No mist.
I clasped my fingers over his neck to feel for a pulse. There was none. It dawned on me that John had died while I was inserting the catheter.
It’s strange how the human mind works when under duress. My first thought then was I had killed my patient, that the pain he felt when I was inserting the catheter finally pushed his frail body over the edge. That I was the worse doctor in the history of doctors and instead of saving a life, I’ve only hastened a death. But that thought lasted for a mere second before the rational part of my brain took over. Reconciling with myself, I realised my decision was made in John’s best interests. He may have died at an inopportune time, but he could have just as easily lived five hours longer, in which case he’d be thankful to have his bladder obstruction relieved. Sometimes, things don’t always go as one hopes.
Following protocol, I called my seniors as well as the family members, reminding them to bring the patient’s identification documents. I signed my first death certificate that evening. I took a last glance at John, captured a last mental image before his body was moved to the morgue.
I didn’t lose sleep that night. I didn’t shed a tear. That doesn’t however mean I was unscathed.
Sometimes people build a caricature of our jobs in their heads. They think our first patient death would inevitably be traumatising for us young impressionable doctors. We’d break down in tears, sob for a couple of hours before rising up stronger the next day like hardened combatants.
That didn’t happen to me nor any of my peers who I talk with. Our first patient death is a rite of passage, not a hazing session. We all go through it with little to no drama. We move on. We don’t feel particularly tough or hardened after it either. Yet many of us do remember how our first patient died even years after. It left its mark on us, perhaps not overtly, like a histrionic scar, but inside of us, like a dormant cancer cell.
I don’t remember being taught this – this stoicism. No one in medical school told me specifically I had to be this Andy Dufresne character in the face of tragedy. But the very nature of our job demand us to be so.
The perfect example is in how we disclose a patient’s death to his/her family members. We have to be sharp and concise:
First, we fire a warning shot by saying, ‘We have bad news for you.’
A moment of silence to let the statement sink in.
Then straight to the point: ‘I’m sorry to tell you that Mr X had died.’
A junior, inexperienced doctor may be tempted to soften the blow, use language which are more obscure and less blunt. Beat about the bush. But that’d serve nothing except confuse a group of already very distraught people who were waiting anxiously for the doctor’s verdict. Clarity of information is the priority here. Not everyone is in the right state of mind to interpret an well-intended but nevertheless ambiguous statement precisely the way you want them to. Not everyone understands English well, for that matter. Even the phrase ‘passed away’ is discouraged by some of our consultants. Disclose the information in a succinct manner with the simplest words, we were taught.
And that is often right after a rollercoaster of resuscitation efforts where we failed to revive the patient. We’re still mentally reeling, heads pounding, sweat still clinging onto our shirts from the chest compressions we’ve done. We’re furious with ourselves for not saving the patient. But we put up our stoic faces and professional fronts, and disclose the bad news to the patient’s family members in a clear and concise manner. In a way, we’re reading our failures to ourselves in a clear and concise manner.
I’d been through several of these horrible days. It’s during these high-octave, mind-numbing days, when the stress builds to an apogee and your self-esteem is at an all-time low, when you start questioning your career choice and if you’re fit to be a doctor, that all those unpleasant memories which you once brushed aside start rushing back, such as that one time your patient died while you’re inserting a urinary catheter. And this time it gnaws at you. It bites. It confirms your suspicion that you suck horrendously at being a doctor. Amidst your emotional turmoil, it becomes just an additional bit of insecurity for you. Like I said, it’s a dormant cancer cell. And if you have enough of those, they’d tip you over the edge into mental illness in the presence of a trigger.
It’s no secret that health professionals have some of the worst mental health of all professions. Stress, burnout, anxiety, depression, suicidal ideations, suicide attempts, completed suicides – doctors experience the whole gamut at a much higher rate than the general population.
People have talked about the numerous factors contributing to this. Bullying in the medical field is one of them. The inhumane working hours and a lack of work-life balance is another. These are all valid concerns.
But I’d argue that the single biggest factor is the job itself. A job where the majority of the time you’re listening and talking to sad people. People who are sick and at their worst moments of their lives. People who are dying and families who are grieving. People who never wanted anything to do with you but are here only because they have to. And all this while, you’re supposed to play the poised figure, the counsel giver and guidance provider, the Andy Dufresne, the stoic doctor.
This doesn’t make us stronger. For many of us, this simply took its toll.
A week after John passed away, I had my first M&M meeting with the team where we discussed our entire patient cohort for the month. There were lots of numbers, percentages, stats. No names were mentioned; all patients were de-identified and discussed in a cold objective manner. You pretend you didn’t know them personally, don’t remember how their sweat-soaked gown stank or the way their sad eyes twinkled at you. They were now a statistic on paper. A couple of stand-out (de-identified) cases were discussed briefly. At the end of the meeting, the team came up with a few patient-management goals for next month based on the stats. It’s easier to manage numbers than real people I suppose.
As we left the meeting room, the mental image of John’s dead body lying on his sweaty hospital mattress reeled into my head. When I was young, my mother told me dying is like falling into a deep sleep in the lap of an angel, who’d then take flight and carry you away. I noted how he didn’t look like he was sleeping at all. He just looked dead. Un-alive. Like a jumble of skin and flesh and bone and precisely nothing else.
I felt somewhat wistful having been disabused of this notion of a ‘dignified death’. But that feeling didn’t last long as it was interrupted by a ring from the nurse requesting my attention on another patient.
The Stoic Doctor
Research & References of The Stoic Doctor|A&C Accounting And Tax Services
Source