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A Tale of Two Passings

Smith, Sarah

doi: 10.1097/ACM.0000000000002965
Teaching and Learning Moments
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S. Smith is a fourth-year medical student, University of Michigan Medical School, Ann Arbor, Michigan; email: sarahsmt@umich.edu.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

Author’s Note: The names and identifying information in this essay have been changed to protect the identity of the individuals described.

We begin medical school thinking like patients: Medical jargon is confusing, the physical exam feels uncomfortably intimate, illness is overwhelming, death is terrifying. Somewhere along the long, arduous route of our training, we learn to think like providers: Jargon becomes a second language, a breast or prostate exam feels no different than a lung exam, illness and death become a part of our routine. The medical student clerkship year represents a transitional period, a liminal time when we are insiders with the mentality of outsiders, providers with the mentality of patients fresh in our minds.

It is through this lens of my clerkship year that I tell the story of my first experience with death in the hospital. Mr. Brown was an incredibly kind, 53-year-old, previously healthy man, admitted to my internal medicine team for a new diagnosis of metastatic cancer. The oncologists predicted he had days to live. Mr. Brown decided he would like to spend his final days with home hospice care. On the morning of intended discharge, a fellow medical student, Anna, presented to the senior resident and attending on rounds: “Mr. Brown’s white cell counts continue to trend up. I think he’s developing an infection.”

What followed was an awkward exchange between Anna and the senior resident in which the senior resident pushed back on Anna’s desire to search for the cause of, and treat, a possible infection. The senior resident, annoyed that the length of the discussion was slowing down rounds, finally responded, “Even if you’re right, he’s going to die any time now, so I don’t know what you want to do about it.” In retrospect, I know this was the correct medical logic: With days to live, why subject Mr. Brown to an extensive and potentially painful medical workup? But we were caught off guard by the directness of the senior resident’s comment and the blunt manner in which a patient’s imminent death was discussed. The conversation was over, and our fast-paced rounds continued, leaving Anna behind in tears.

Anna and I decided to buy Mr. Brown flowers after we left the hospital that night. Maybe it was his kindness, the senior resident’s crass choice of words, or the fact that it was an early experience with death in the hospital for both Anna and myself, but Mr. Brown’s suffering felt personal to us. I sobbed the entire drive to the flower shop. This was my first experience as an insider confronting a patient’s death with an aching heart and an endless flow of tears.

Contrast Anna’s experience with the experience of another one of my classmates, Asha, who was midway through her clerkship year when she saw a 19-year-old girl suffer a complication from a renal biopsy and be rushed to the ICU, where she died. Immediately following the code, Asha’s attending asked her to walk with him to the neonatal ICU, where he explained that “these situations are the darkest side of our profession,” that the team had done everything it possibly could to help the patient, and that today, it was important for Asha to see new life and feel hope. Her attending took 10 minutes out of a busy day to pause and remember how a code feels to an outsider and to help a trainee who needed support and guidance.

Like the medical jargon and the physical exam, learning how to witness death is both a rite of passage and a skill to be learned. Teaching medical trainees how to cope with death requires slowing down. When attendings or residents pause to remember what a first code feels like and debrief the experience or offer guidance on how to cope, it is impactful to trainees. That pause allows trainees, navigating the space between insider and outsider, not only to feel supported in learning to cope with one of the most challenging parts of our profession but also to make the transition into the kind of insider who remembers, even celebrates, a patient’s humanity in the face of death.

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Acknowledgments:

The author would like to thank Dr. Joel Howell, who supported her in finding her narrative voice and inspired her to share a message she feels is important.

Copyright © 2019 by the Association of American Medical Colleges