One of the best aspects of my medical school’s preclinical curriculum is the use of Standardized Patients for our clinical skills course. This aspect of training provides students with a relatively stress-free learning environment (instead of training them on real patients first), and it gives students a chance to get direct feedback from the patient-actors and faculty. (Fortunately for us, we also have a lot of clinical extracurriculars such as patient care at free clinics and in emergency rooms where we get to provide care to patients under supervision of the attending physicians and residents.) While some might still think that it’s better to just jump right into the deep end and start with real patients, there are some situations that the vast majority of medical students wouldn’t be prepared for.
Today, I was presented with one of those: telling your patient that he or she is going to die. During this problem-based learning session for Gross Anatomy, I served the role as the “moderator” and as the physician caring for the patient (whose role was played by a Standardized Patient, an actor that is trained to simulate an actual patient based on a real patient’s history, diagnosis, and treatment). In this case, I had the opportunity to take the history, make a differential diagnosis, and perform an abdominal exam (with the help of my other eight group members). We quite smoothly came to the right diagnosis, but the news was bad, and it was my job to deliver it. I don’t think my group members envied my position, and as soon as I figured out what the correct diagnosis was, I felt depressed with the prospect of explaining the prognosis (the likely course of the disease) to the patient.
Our faculty facilitator, a former surgeon, gave us a lot of good advice and framed the situation in the context of our development as doctors: for most of us, our first inclination was to shield ourselves from the emotional trauma of having to deliver the bad news. While not unexpected as a reaction, as doctors, we are expected to do better. For me, I had no choice on whether or not to deliver the news, and some part of me that aspires to care for very sick patients (those hovering between life and death) was telling me that I was ready for the task at hand. Another part of me, knowing that I have been a sick patient and that I had also experienced the trauma of the death of my mom (i.e. a prolonged period knowing that she was going to die soon), compelled me to believe that I have some sort of mettle that most medical students don’t (because so many have never been so close to death before entering the anatomy labs).
Nonetheless, despite these notions of confidence, as I sat down on the table next to the patient, it didn’t come naturally, and though I didn’t stutter or blank, I felt that the words were heavy as they came out of my mouth. I first tried to provide a little context, and then I delivered the news simply. But when he asked, “But you told me it would work?” in reference to the treatment, I knew that although I might have done better than others in this situation, I had lost sight of what it means to be a doctor. For a moment, I was wrapped up in my own feelings, focused on my own sadness for my patient, my inability to cure him of his disease, and my inability to know what to say to help him find some peace from the anguish. For me, one of my aspirations in becoming a doctor is to be able to stand beside those standing on the edge between life and death and help lead them back to the light. Now, though, I realize more than ever that revitalizing patients is only half of what we do – the other half is being there for patients when they are dying. However, that doesn’t mean that our job is over, or that there’s nothing we can do. For a second, I wondered if I should leave him alone to let him deal with the news in private (which some of my group members also thought), but something in my gut told me that I shouldn’t – that I should stay and talk to him, say anything to him, until he asked me to leave. Nothing that I thought was meaningful came to mind, though, so I asked if I could help him get in touch with his family, or if there was anything I could do for him right now.
Later, the faculty facilitator helped me figure out exactly what was behind that gut instinct of mine: it’s that people, when they’re going to die, are most afraid of being abandoned. They’re afraid that they’ll die alone and in great pain. As doctors, one thing we can do is tell them that we will be there for them, that we will be able to provide them with palliative (pain relief) treatment so that they won’t suffer, and that we will do everything in our power to help them (i.e. talk to the family for them if they prefer, provide them with hospital/hospice care, etc.). He said that I did well. I know I can do better – be there more for my patients rather than for me. Medicine is as much about death as it is about life, and it would be a shame if doctors, of all people, cannot deal with death in a compassionate and composed manner. Everybody dies: you can say that they “die alone,” but they don’t have to feel abandoned when they die. Though “human nature” often carries a negative connotation, one of the best and more admirable parts of human nature is that we don’t abandon our sick and injured – we protect and care for them. Let’s be human.