Mr. Swendiman is a fourth-year medical student, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, and is currently working toward a master of public policy degree at the Harvard Kennedy School of Government, Cambridge, Massachusetts; e-mail: email@example.com.
Dr. Latessa is associate professor of family medicine and campus director, Longitudinal Program, University of North Carolina School of Medicine Asheville, Asheville, North Carolina.
It is a challenge to capture a medical experience in 55 words or less. As a third-year student at the University of North Carolina at Chapel Hill School of Medicine, I had such an opportunity during our monthly “Art of Medicine” discussions, where seasoned attending physicians met with budding student–doctors to deliberate on life as a physician. Instead of focusing on the pathophysiology of diseases or individual clinical cases, we considered work–life balance and humanism in everyday practice. Each month we peppered veteran physicians with our questions on a wide range of topics. We reflected, and we wrote.
I wanted to present a case that spoke to the helplessness I often experience on the wards—a feeling of inadequacy that goes beyond the simple lack of knowledge every third-year student faces. Medical students typically enter the profession expecting to ameliorate suffering and improve the health of their fellow human beings. However, we often idealize this notion, imagining our power to be much greater than it actually is. As I spend more time in clinical medicine, I struggle with the limits of my knowledge and abilities. I cannot ensure that my patients take their medications or quit smoking. I cannot guarantee that they will have food on the table and a roof over their heads. And, I cannot always safeguard a child from the trauma of physical abuse.
This case unfolded during a day I spent with a pediatric orthopedic surgeon in Asheville, North Carolina. The radiological studies showed a clear pathologic process which the doctor narrowed down to one of two very unfortunate diagnoses: advanced bone cancer or child abuse. The mood in the operating room was grim. This was the first case in which I assisted where there was no “good” outcome for the child. I retracted quietly, not looking forward to the inevitable conversation with the parents. A cloud of silence rested heavily over the room as we waited for the call from the lab, heads bowed, as if in prayer.
In the end, a child abuse specialist was brought in, and the case was turned over to the authorities. I did not see the patient in follow-up, nor was I able to track the progress of the investigation. Left powerless, I did the only thing I could do: I wrote.
Students are themselves caught between a rock and a hard place in navigating their approach to difficult patient situations. If they try to harden their spirit and detach to survive emotionally, this will lead to loss of empathy and poor connections with patients. If they take each tough scenario too much to heart, they will not be able to practice medicine day-to-day.
These situations will continue throughout Robert’s medical career, and they are the ones that will likely challenge him the most. We all develop ways of coping after years of experience, introspection, and humility. Each person’s response will be unique. One possible strategy is to do just what Robert has done: reflect on difficult experiences and write about them. Reflecting about reactions to difficult medical situations with a peer or faculty mentor can help allay some of the uncertainty and feelings of powerlessness. This can create a healthy balance between “letting go” and confronting the issue in a productive way. When I have a particularly tough experience, I discuss the case further with colleagues, share my vulnerability, feel gratitude for my own blessings, and reach out more to connect with others in my daily professional and personal life.
Vulnerability is perhaps at the core of many of these difficult patient care situations we face. Robert has been able to discover this at a very early stage of his professional development. Through a particularly challenging patient encounter, he has found that he, as a physician and person, is as vulnerable as his patient. Brené Brown1 reminds us that feeling vulnerable is not a weakness but, instead, is evidence of courage and is the “birthplace of innovation, creativity, and change.”
Welcome, Robert, to our professional and human condition. Do not pull away from it. Embrace it and allow it to lead you. It will make you a better physician and person.