Mr. L is an 82-year-old scheduled for total mesorectal excision of stage IV colorectal cancer.” As a third-year medical student presenting a patient to my new surgical team, my mind races in anticipation of the surgeon's questions. Fragments of knowledge flash into focus regarding this patient's case—Wnt signaling pathways, adenomatous polyps, deactivating mutations of TGF-β. While presenting the case, my mind recalls Mr. L's responses to questions, and I cannot help but try to place his dignified, unpretentious accent. The distance in his eyes occurs to me only after I have left room 482. I was with Mr. L for several minutes this morning and could answer any question my attending might ask regarding his last 24 hours. I was embarrassed to admit to myself, however, that I had learned nothing about him. With a consciousness littered by medical jargon, my parents' words of wisdom infiltrate and sting with awakening—“have compassion, fight indifference.”
“How is the preoperative CEA concentration predictive of relative risk of death in patients with colorectal carcinoma?” The surgeon's question interrupts my sympathetic diversion, tempting me to once again equate Mr. L to statistical evidence and lab values.
“The CEA concentration is predictive of….” My mouth regurgitates a protracted, effectual answer while I secretly marvel at my ability to reduce this patient to a recitation of evidence-based medicine. As a medical student, I am engineered to obtain a history, create a differential diagnosis, and apply scientific logic to sculpt a reasonable plan. There is no letter in our SOAP note template for compassion. It is easy to allow a barrier to arise, to allow cold indifference to separate the cerebral physician from the compassionate healer he or she once strove to be.
“Fantastic answer. You just earned yourself primary assistant in Mr. L's resection.” Just as the surgeon commends my knowledge, I am busy swearing to myself that tomorrow I will make an effort to know Mr. L. Each memory he shares and each facet of his personality I observe will be currency to redeem my self-diagnosed disinterest in him. Little did I know that what I would soon learn from Mr. L would change me forever.
At 6:00 the next morning, I entered room 482 and found a somnolent Mr. L. The room's oversized window framed the pink light of dawn spreading behind a dark bank of clouds, the rays fighting to touch the fresh January snow. “Good morning Mr. L, I am with the surgery team. Are you having any pain?” My greeting sounded too standard, so I mindfully selected words with more inviting undertones. “This must be so difficult for you. I am here because I want to help you in any way that…”
“Bricks!” Mr. L interrupted my greeting. “Bricks!”
“I'm sorry, I don't underst…”
“I made bricks for them! I have no pain because I have known real pain.” His abstracted accent placed me in another time. Never have I seen such urgency, such intellect, as I saw in Mr. L's despairing eyes. “I was 14 years old when they came to my Warszawa. When they marked us and took us.” Mr. L pulled up the sleeve of his hospital gown, revealing a handwritten brand—73618. Now fully alert and escaping his hypnopompic confusion, Mr. L assumed a more refined character. He then seemed to position himself in a formal posture more suitable for a visitor. “I apologize,” he said, “I suffer with a dark past.”
“If you would be so kind to share with me….”
Immediately Mr. L began recounting his childhood in Poland, his time in Auschwitz, and losing his entire family to unspeakable deaths. He spoke of his last 65 years attempting to reconcile the abyss of his memories with his desire to weigh the goodness in each human life. Effortlessly producing a wise smile, Mr. L took my hand and said, “If I learned anything making bricks in those camps, it was that hope is the most vital thing of all. There we were, prisoners making bricks. Strangers turned into each other's necessity. We ignited each other's fight for survival. Disease is no different. Become a doctor who understands struggle.”
Tears speckled the clipboard of papers in my lap. I was left without words. My usual template of questioning, the carefully formulated differential diagnosis, the treatment algorithms—I could say nothing. Each of these crutches I had leaned on for so long had vanished, beaten away by bricks. Mr. L saw my white coat as a symbol of safety to reveal his delicate past. Stunned with reverence, I considered the implications of Mr. L's bricks. Out of such a detestable scene, he turned the very product of his revulsion into a mechanism of hope. Bricks line the walls of room 482, a place where white coats create an atmosphere of honest transaction. Without care our white coats, the talisman for our compassion, can become another kind of brick wall. They can be a divisive barrier that turns a well-intentioned medical student into an indifferent medical encyclopedia.
“Keep this old man's words in your heart.”
Of all the things I wanted to say, I simply replied, “I will never forget you.”
Mr. L's unique lessons serve as formative and enduring contributions to my education. From him I learned that every patient has a story to tell and a lesson to teach. Through his story I came to grasp the depth and breadth of my parents' wise words. Medicine provides the daily opportunity to offer compassion, and I must transform my medical knowledge into devotion and sensitivity. The simplest form of compassion is also its most significant substantiation—listening to patients in a way that fosters their speaking, and speaking to patients in a way that fosters their listening.
The Arnold P. Gold Foundation Humanism in Medicine Essay Contest
The Arnold P. Gold Foundation is a not-for-profit organization founded in 1988 to nurture and sustain the time-honored tradition of the compassionate physician. Today, students, residents, and faculty participate in at least one Gold Foundation program at over 93% of our nation's medical schools and at schools abroad. Its programs and projects are derived from the beliefs that compassion and respect are essential to the practice of medicine and enhance the healing process; the habits of humanistic care can and should be taught; and medical role-model and mentor practitioners who embody humanistic values deserve support and recognition.
In 1999, the Gold Foundation instituted the annual Humanism in Medicine Essay Contest as a way to encourage medical students to reflect on their experiences in writing. Since the contest's beginning, the foundation has received close to 2,000 essays from students at more than 125 schools of allopathic and osteopathic medicine.
Contestants for the 2010 Humanism in Medicine Essay Contest were asked to address the following prompt: “Describe a barrier a physician might face to practicing humanistic patient care. How might this be overcome and what can be learned in the process?” Winning essays and honorable mentions were selected by a distinguished panel of judges. For the ninth year in a row, Academic Medicine is pleased to publish the winning essays from the contest.
Winning essays are also published on the Gold Foundation's Web site (www.humanism-in-medicine.org) and in the foundation's DOC newsletter. For further information, please call The Arnold P. Gold Foundation at (201) 567-7999 or e-mail: [email protected].