It’s not all great. But sometimes changing expectations … and lowering them … is the right thing to do.
I’ve been thinking lately about how these writings emphasize the Positive. The people we help, the cool parts of our job, and other things that I hope decrease the overall slog of the current physician practice. However, focusing on the good does not mean forgetting the bad. I thought it dishonest to pretend that it’s all lifesaving and happy feelings.
A long time ago in a HIPAA-compliant hospital far away (as always, names/sex/surgery/dates/specific clinical situations changed so the meaning is the same, but the situations are not identifiable) , I had a day where I had seven deaths between 5:00 AM and 10:00 AM. More than one per hour. One was a code, two were unexpected severe worsening of already intensely sick people, and the other four were fairly “planned” withdrawals of care. By planned, I mean that the family was arriving and had set a time for them to all be present and with their loved one before escalating our focus on comfort and decreasing life-saving drips like adrenaline and so on.
It was a horrible day. By the third or fourth, I recognized something that had in the months prior had insidiously arisen in me: Compassion Fatigue. Compassion Fatigue is a sad emotion for intensive care physicians (all physicians, really, but certain groups experience it more frequently, like Palliative Care physicians, Oncologists / Oncology Surgeons or, ICU doctors like me). It is sad because Compassion Fatigue makes you feel less of a major thing that makes you human: sadness for another’s loss. Further, the drive to be there for families during their most sad, intense moments or to otherwise guide people through the shadows is a driving force for critical care doctors. I brought it up on every single personal statement (even pre-fellowship) I’ve written. Something about experiencing that feeling with someone, or guiding them through it, is crucial to who ICU doctors are. It isn’t just something we like about the job… it is something important to our sense of self.
I doubt any of the families that day knew. I could still put the face on, speak softly and with intentional pauses, and offer condolences the same way I’d done so many times before. But the absence of internal emotion was so conflicting. By the end, I remember walking out of the room and thinking, “Whew, that’s hopefully the last one today, I’m hungry I wonder what’s in the cafeteria?” Such discordance to the compassionate physician I was, and who I wanted to be.
Families frequently say things like “You must get so used to this stuff,” and “You must detach a lot,” and even “I couldn’t do what you do, I would feel sad too much.” Yes – I am used to death, dying and sadness in my job. I am also used to helping people and occasionally fixing catastrophes, which feels pretty cool. But I am always put aback by the statements. I’m sure the people saying them mean well and many are probably even being complimentary – they’re glad I’m there and they can’t understand how someone does it.
But, the idea that I must withdrawal or be numb to do this is not true. I feel it when I lose my patients. I am sad, I am sad for the loss, for the family, for the idea that someday it may be my Mom or Dad, my sister, or heaven forbid one of my girls (those – where parents lose children – are the hardest to be present for). And yes, I still have to go back to work after each of those losses and each of those intense and sad conversations. I still have to teach medical students and residents, give lectures, chart, whatever. And I have to teach people not only science and medicine in general, but that what we do has value and meaning, and that we can do it in a positive way and be happy at work. That’s hard to do after losing someone and yet, we have to do it.
But I am not numb. I decided long ago to allow myself to feel things as much as I can when I’m with families. I don’t know the patients well; typically they are long-gone by the time I’m responsible for them. But I know the families, even briefly, and I know they put their trust in me, and I know that sometimes I am letting them down by not offering them hope or by not having fixed their loved one. And I feel it. Nowhere near the feeling of intense loss of a friend or family member, and I would never, ever pretend it is that severe, but I always – always – let myself feel it. To be sad and be human. To be honest, I tear up or blatantly cry at least once a week most weeks I’m staffing our medical ICU. It is who I am to be human, to feel and to guide, and to hope that I can help someone. I am sad when I can’t.
I have also learned to adjust my expectations. The goal of a “Code Blue” is sometimes to save someone who will go on to get out of the hospital and be there for their family again. But, just as often (honestly, more often), I adjust my goal. It is to get them back so that they can pass away comfortably, surrounded by their partner, family and friends – not having chest compressions and surrounded by people they don’t know. Sometimes in the ICU my goal isn’t to help “save” someone, but instead to review with the family how the last year has been horrible for them and on them, and maybe we should be reviewing what exactly we are doing to “help” them. Maybe helping isn’t antibiotics, breathing tubes and other aggressive cares in an ICU where their brains struggle and they get delirium. Maybe helping is re-establishing goals to get them home and comfortable and not coming back to the hospital again.
So, it isn’t all home runs and cheer-squad. What we do is horribly sad sometimes. I lose people I hoped I could help. I have families that sometimes get upset that I can’t fix something, or that are just upset, period. And some weeks are really, really hard on me personally and emotionally. But thankfully I’ve learned to allow myself to Feel, to be sad, and to be human with my patients. And I’ve also been able to balance my ICU life better, so that I can recover after tough weeks and months, so I experience compassion fatigue far, far less frequently. But no, I am not numb, and I am not really “used to it” in the sense that it is meaningless to me. I just know that when I lose someone, that bed will be open for someone else that deserves my full, undivided attention. And maybe that time, I’ll be able to help.