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Mindful Practice

Stacking stones

Stonerook, Ethan MS, MPAS, PA-C

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Journal of the American Academy of Physician Assistants: January 2020 - Volume 33 - Issue 1 - p 1-2
doi: 10.1097/01.JAA.0000615516.38420.65
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The hospital has been quiet all night, and room 710 of the cancer center seems to be the source of its silence. At 3 a.m., the nurse calls me to the bedside. Two grown men are standing at the foot of the bed, holding each other. The shoulders of the younger, wrapped in the arms of the older, shake with a deep, inaudible crying that reminds me of one of my own, much younger children. These are the son and husband of the woman I am here to see, to diagnose her death. She has been on comfort care for 6 short hours, and we have never met. The room is dark except for a small desk lamp and the streetlights along the roadway outside, below the window. Both sources of light cast a warm yellow across my patient. Her hospital gown is halfway down her thin chest, rippled with ribs like beach sand after the tide has gone out. Her still precordium is painted in freckles earned over the past 72 summers. Covered like an August sky rife with witness stars. I listen for her silent heart. I open and shut the lids of her green eyes. I rub her resting sternum with the same gentleness I use to wake my youngest daughter. I stand, and briefly but surely, I put my hand on the shoulder of her husband, now untethered to his story by the loss of his longest companion, and I leave the room.

My own story started on a small island surrounded by glassy saltwater, in the shadow of the launch pads at Kennedy Space Center. I spent happy-go-lucky afternoons skipping rocks and waiting for redfish and snook to swim by my gold spoon. I assumed my life would always revolve around that native marine landscape, but at the age of 37 I now spend my days (and some nights) in the tertiary care world of leukemia and stem cell transplant, in a medical center far from saltwater or space shuttles. Happy-go-lucky feels like a lifetime ago.

This work is wonderful. Its continuity fosters depth, intimacy, trust, and vulnerability with patients. But these benefits also are its biggest challenge. You and I are a people whose primary vocation, before diagnosis or treatment, is to bear witness to the illness and suffering of our patients. Whatever we expected going into medicine, if we are committed healers, our patients' stories slowly become part of our own.

I imagine these burdens of witness as stones that involuntarily rest in the space previously occupied by the thymus; somewhere between the heart, throat, and stomach. For the first 6 years of my career, I took an ad hoc approach to dealing with them. My working life seemed to sit in contrast to my “real” life—or worse, seemed to bring into sharp relief the fragility that secretly underwrites that real life. I have diffused this vicarious trauma, putting its burden on the people I love, on myself, and on my body. I have experienced periods of numbness, anxiety, apathy, and inflexibility.

Some stones are harder to externalize than others. I once cared for a German man born to a Nazi tank mechanic in 1945. He was gentle and soft-spoken, and he carried his fear directly on his brow and in his tremulous questions. He came to clinic one day for routine follow-up after transplant and had a sudden drop in his platelets, prompting a bone marrow biopsy. As he lay prone on the procedure table, he turned his head to the side and in his slow German accent, said, “I have never had someone to pray for me. I have never heard someone pray.” I asked him if he would like me to do so. He hesitated, reluctant to betray a lifetime of strict, material rationality, and asked me to do so silently. His bone marrow biopsy confirmed relapse, and the day I discharged him to hospice, in an apologetic plea, he asked if I would call his wife and check on her the following month. Years later, his blue eyes inhabit the crow-footed faces of so many of my patients.

What do I do with these stories? They are more than a moral cost of doing business. They are the business itself, but they do carry a weight that requires something of me. If I store these stones inwardly and privately, they remain one-dimensional and distressing. If I can get them outside that space in my chest, I will see them more clearly. I can even allow others to reflect upon them with truth, grace, and generosity. In the words of Nellie Hermann, creative director of the program in narrative medicine at Columbia University, “... by moving what is internal to the external, particularly in the case of experiences that trouble us, that diminish the space inside us, we create more room where experiences can live.... We create literal objects, text on a page, that can be examined at different angles.... By externalizing we allow others to share in our experiences, not just in the events as they happened but as they felt, to us as individuals, through our particular and specific lenses.”1

So I write them on clean white pages that I can hold outside of myself. I stack them like a cairn that I can visit and reflect on. Sometimes I picture them round and smooth in my hand, and skip them across glassy saltwater pages.

Box 1
Box 1


1. Hermann N. Creativity: what, why, and where? In: Charon R, DasGupta S, Hermann N, et al., eds. The Principles and Practice of Narrative Medicine. New York, NY: Oxford University Press; 2017:215.
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