In Shock Read online

  “She’s beautiful,” I’d comment.

  “Isn’t she?” they’d reflect back.

  “I am so sorry…” I’d trail off, thinking I was heartbroken for her, and for them, and that she wouldn’t get to know her mom.

  I spoke in fragments. I would summarily reject every sentence I drafted and revised in my head. All I could write were apologies. I felt complicit in her death, even before she died. I would hate myself and medicine for years for not being able to save her. Worse yet, they could see my disappointment in my own failure. The vector of my grief was focused on her inner circle.

  “We know you did all you could, and you all did so much,” they would say to comfort me. “We are so grateful for everything you’ve done. You have no idea what it meant to us, to have your support though all of this.” They were embarrassingly more articulate in their grief than I was.

  I couldn’t have felt less deserving of their gratitude. It stung like salt on my still-open wounds. Not knowing what to do with my feelings, I built a tower in honor of my patient inside of me, stacking failure upon shame onto blocks of grief and blame. A tower bound to topple.

  Externally, I was the walking embodiment of bouncing back, of steadfast resilience. Looking at me, no one would guess what I’d been through. My hair was growing back, and I was fully back at work, standing with a net to catch the next person whose turn it was to take a fall. And yet I’d exit the elevator ten floors early if an instrumental of “Ring of Fire” came on over the speakers. I’d become nauseated by certain combinations of lab values, or groups of organs failing. I was suffering again from nightmares.

  Like some cosmically charged magnet, I attracted pregnant, critically ill patients to my unit in numbers that were statistically improbable given random chance alone. They seemed to arrive just as the heaviness of the absent baby began to weigh me down. Just when I would accrue a bare notion of regret, they would roll into my unit. And in a moment, I would wake from the dream of my ghost life.

  With each patient, I poured everything I had into their care, despite somehow knowing that failure couldn’t be diluted. The loss of my HELLP Syndrome patient proved to be almost unbearably difficult to shoulder. It wasn’t just that she was my first official patient as a fully formed critical care physician. It was more than my identification with her because of our shared diagnosis. When I was sick, and so desperately vulnerable, I knew I was completely dependent on others to keep me alive. I worried that if they didn’t care enough to do what it took, to do everything perfectly right, that I would die. A death by disconnection and benign neglect. I believed that once I was a doctor again, I could save my patients through sheer force of attention. I promised myself I wouldn’t miss any clues or bypass any opportunity to help them inch toward recovery. I had never considered what it might feel like to try that hard, care that much, and still lose.

  When I was sick, I believed my team had complete control over my outcome. But here I felt I had no control. I would have done anything to save her, and still I had lost her. I had to acknowledge that in many ways, both symbolic and concrete, I had lost myself. I had failed myself. I had to acknowledge that, despite my best efforts, I would still sometimes fail. I would see that despite what I had told the OB resident, that even when the good outcomes did outnumber the bad, they wouldn’t make even the slightest dent in the darkness that bled from the bad ones. That shame is unique in its wholeness, an impenetrable black orb that deflects light.

  I don’t think I could have named the emotion I felt as I sat with my patient’s family as shame. I knew I had a vague sense of worthlessness, combined with guilt. I had heard repeatedly and understood objectively that I was not in any way to blame. I also understood, objectively, that she had a horrific, crushing disease that few survived, and that no one could have changed her trajectory or prevented her death. I also knew it was my job to alter the trajectory of patients with horrific, crushing diseases. I had failed. I donated to a charity in her honor, in a rudderless search for absolution. Instead of forgiveness, I received large crystal plaques from the HELLP Syndrome Society to commemorate my failure. I knew that my connection to her case was making the loss more difficult, and in this way I felt perhaps I had been reckless. I hadn’t maintained the cool clinical distance I’d been instructed to carve out. Could I have? And who would it have served if I had managed to maintain some perfect state of detachment? I’d never know. I’d abandoned my armor at the bottom of the sea when I had to learn to breathe underwater.

  * * *

  That loss, like a funeral veil, imbued everything around me with a dark cast. I would sit silently through M and M, our shorthand for Morbidity and Mortality conference, as we discussed the past month’s failures. The department systematically reviewed each case where an error led to a preventable death or morbidity. We critiqued and analyzed the choices and protocols, looking for system-based issues, which if corrected would improve future outcomes.

  I’d stare at my colleagues and wonder about everything we weren’t discussing. How it felt to be responsible for a bad outcome. How it felt to make such an awful disclosure to the family. How it felt to round on the patient day after day, confronted by the concrete aftermath of your choices. It seemed a terrible blind spot that we did not discuss the toll those errors exacted on us.

  Medicine is not oriented to recognize trauma in its own. We do not debrief our team or even ourselves after a code. We do not pause and assess the emotional well-being of our colleagues after they lose a patient, the way we pause to assess the root cause of errors. We were trained to leave the thin veneer covering our colleagues’ emotions undisturbed. We have utterly no idea what to do with shame. We have built no confessionals.

  * * *

  As doctors, we are taught to both conceal our emotions and not to indulge the emotions of others very early in our training. I first heard this characterized in medical school. Our anatomy professor gave a lecture focusing on Sir William Osler, the father of modern medicine. Osler, born in 1849, created the first residency program for specialty training of physicians. He was the first to bring medical students out of the lecture hall and to the bedsides of patients. He is credited with establishing the tradition of clinical training. And though Osler is revered for the value he placed in the patient’s voice, the lesson for the day was “Aequanimitas.” Osler regarded this trait as the premier quality of a physician. It represented an imperturbability that was described as manifesting in “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.” It was the stoic posture you held while your colleagues discussed your error. A structured distance from your own emotions. In today’s language we’d call it centering yourself, but taken several steps further—fully centered and not ever allowing the emotions of others to jostle you from your position.

  The message imparted to us was that in order to have clear judgment, one must maintain distance and coolness. We were taught that to be a good physician, we had to cultivate a certain reserve. We aspired to be good physicians and accepted at face value that lesson, handed down as if a trade secret. They were setting the groundwork for the detachment that was expected of us on the wards.

  As a medical student, my pediatrics rotation required that I spend two weeks in the pediatric ICU of an inner-city children’s hospital. I found it utterly impossible to be detached or reserved in that unit. Every child there represented a tragedy from that evening’s local news: house fires, attempted murder-suicides, meningitis outbreaks. The acuity of the sadness there, the precision of the grief, was impossible for us as students to ignore.

  When we expressed sympathy for the suffering of the patients or families, it was shut down by our supervising physicians. “You’re supposed to be the doctor,” we were told, “you won’t be able to care for them, to do what needs to be done if you let yourself feel every sadness that comes through these doors.” Despite their fatalism, we suspected they must have once been
just as open as we were. So we were left to wonder, had they learned the lesson by feeling every sadness, only to be helpless and paralyzed as a result? Or had they entered training with a wall already constructed? We didn’t know. We only knew we couldn’t ask.

  The demeanor modeled was a coolly distant authority, with little value placed on empathy. “Caring” was the purview of nurses and social workers. The mantra was, if you want to treat disease, become a doctor. If you want to care for patients, become a nurse. Practical, academic rounds continued undeterred by misery or heartbreak.

  But we were so young, and we’d yet to be truly indoctrinated to the clinical sterility our short white coats symbolized. Even just wearing the coats felt strange to us. They externally identified us to others as something we knew ourselves not to be. They aligned us with a profession before we had assimilated into the group. They felt more like costumes than clothing. So we gave them utilitarian functionality. We stuffed the pockets full of miniature versions of texts we needed. We armed ourselves with reflex hammers and flashlights. We weren’t yet doctors, but we had all the paraphernalia. We could pretend.

  When a child with a severely malformed heart died, my classmate and I paused at the end of the bed. She held my wrist as we both struggled to take in the death. Neither of us had ever seen a child die. We had just witnessed the team go to heroic lengths in an effort to save him, and now we were expected to walk away, to let the nurses prepare his body for his parents to view. We were locked together in a moment of shared, solemn grief. The attending walked toward us, after notifying the family of his death, and chastised us harshly.

  “Do you know what you’re doing?” she asked. I thought I did know, but sensed she didn’t want an answer.

  “You,” she began, pausing to lock each of us in her gaze, “are behaving in a way I would characterize as immature and reckless. If you allowed yourself to get close enough to this child that you need to mourn his death, which, by the way, if you knew anything about medicine, you would know was a complete inevitability … if you feel close enough to mourn him then you are irresponsible. Period. How do you expect to care for the other children in your charge?” She paused, and again I understood she did not expect an answer.

  “Right. You can’t. Make no mistake, you have chosen to put every other child in this unit at risk with your own stupidity.”

  I caught my friend’s eyes and looked away with embarrassment. I struggled to take in what the attending had told us. We were irresponsible and reckless. We were stupid and immature. We lacked judgment and we were making a terrible mistake. Our mistake had horrific consequences. I believed her. I was so sad I couldn’t focus on the next patient’s needs, except if I viewed them as a distraction from my sadness. So it seemed there could be some truth to her suggestion that our sadness could endanger our other patients. Some truth to the possibility that if we felt our feelings we would kill the people we were supposed to help protect.

  At the time, I believed her contempt was directed entirely at us. Looking back, I wonder whether she was scolding herself as well. It seemed impossible to me that she could have succeeded in never feeling any emotional connection to those children or their outcomes. We promised ourselves, when we were in positions of authority, that we would figure out a way to be different. Oppression, by its nature, breeds the power necessary to mount a resistance and to overthrow itself. But that would take years.

  In the interim, we learned quickly to shut it down. After all, any and all signs of emotion were immediately met with an assessment of “perhaps this is too much for you. You may not be cut out for this kind of work.” We learned that crying happened in closets or on the drive home, but always alone.

  We’d duck in after a horrible delivery and we’d cry helplessly. And as we wiped our eyes and attempted to regain our composure, we’d realize there were no safe spaces. Because in the hospital affiliated with our medical school, supply closets were sometimes used as staging areas for those black-and-white shots of dead babies paired with stuffed animals. We would be startled to find the baby at eye-level, propped up on a shelf, while someone gathered the remaining items for the obligatory remembrance box. We’d feel disgusted by the lack of reverence. Paralyzed by the irony that in staging a photo meant to venerate the sanctity of life, we could denigrate the baby and our own humanity in the process. We could find no spaces in which to heal.

  I thought of the disillusioned OB resident, crying in the corner of my ICU room, worried that he wasn’t cut out for the work. I sunk into the recognition. My room was the safe place he had come to heal. He’d been taught the exact same empty nonsense I had been taught: that there was no room for emotion. We were easy targets. Our need to belong made us each uniquely susceptible. Like any outsider, we found it seductive to think that if we could play by the rules, we could belong, we could be accepted as one of them. We were told the goal was to conquer, suppress and internalize our emotions. We had no idea that there might be an alternative. We did not know we could cultivate a space for those feelings to be unpacked, understood and allowed to foster connection. That there was reciprocity in empathy.

  We created illusory selves. We internalized their archaic rules and collectively attempted to forge new respective identities. We took their instructions and wrapped ourselves in them like bandages, leaving our true selves to suffocate beneath. This covering was destined by its own contingency to be unsustainable. For the most part, we’d each find a means of unearthing ourselves later. Our feelings would surface, like bubbles of gas in a liquid. Some of our classmates found reencountering their feelings unbearably difficult and instead attempted to re-drown them in alcohol and addiction. Some left medicine for alternate careers. Some committed suicide.

  Because shame and guilt and sorrow always float.

  Shame doesn’t strike like a fist. It rots its way in. Shame unravels us at our most fragile seams. It burns holes in our façade and allows light to shine on our self-doubt. It whispers to us, reminding us that we are imposters and, by the way, are not actually fooling anyone. It’s unique in its devastating ability to make us feel exposed and worthless. Compounding that, our training bludgeons out of us even our ability to have empathy for ourselves. We learn to stop feeling our feelings, just as we are trained to disengage from the feelings around us.

  We may try to delete the feeling, like an unflattering photo. We may dig a hole and try to force it in, like a rigored corpse. Some of us may attempt to submerge it, or rebuild the tower of ourselves on top of it. But it remains the foundation, contaminating the groundwater and corroding through every layer.

  * * *

  Physicians are uniquely harsh in our self-assessments. As an internal medicine resident in New York, during my infectious diseases rotation, I was assigned to supervise an intern who was having difficulty performing his assigned duties. He was anxious at baseline and had made a few errors, which resulted in his receiving a poor performance review. His competency was being examined by our program leadership. His every order and presentation were scrutinized for further proof that he was unfit. Anxious and on edge, and knowing he was being watched, he began to unravel. He neglected to act on a positive blood culture result, he wrote a few incorrect orders and misinterpreted some lab values. No one was harmed; each error was caught before it reached the patient. It is difficult to even categorize the mistakes as near misses, but they were each taken very seriously, as a matter of procedure. I was asked daily by a chief resident to elaborate on how he was doing. Each day, I reported that he was decompensating further. He began mumbling to himself. He was sent for a formal psychiatry evaluation. By the end of our month together, the decision had been made at some anonymously high level to hold him back. He was told he would have to begin a structured remediation program and likely repeat his intern year.

  He was told that news on the Friday of the long Fourth of July holiday weekend. He called me three times in sequence at 5, 6 and 7 p.m., and I didn’t answer the phone out of irri
tation, guilt and avoidance. Sometime on Sunday, he killed himself three different ways. He didn’t believe he deserved to be held back; he believed that his mistakes warranted a sentence of asphyxiation, lethal injection and severed arteries, and he dutifully carried it out. We didn’t find him until Tuesday, when he didn’t appear to repeat his intern year.

  “We killed him,” I told my friends when they expressed their horror or pity. They shook their heads, believing my responsibility was misplaced. I was absolutely certain in my conviction. “We killed him with our suspicion and judgment. None of us could have withstood the scrutiny of the lens he was under.”

  We were predictably told by our mentors, “Listen, clearly he just wasn’t cut out for medicine. Some people aren’t.” There were whispered suggestions of mental illness. The shared narrative of inadequacy and shame was perpetuated. As if resilience were a binary trait that one possessed or lacked. As if resilience didn’t require a culture that is committed to fostering dialogue, building spaces for shared disclosure, and empathy. A culture designed to help us heal ourselves so that we may better attend to our patients.

  It made no sense: we belonged to a profession that should have anticipated failure at every turn. The complexity of the medical system made failure an inevitability. The human body itself is designed to fail. Senescence is embedded in our genetic code. Our patients would die; it was an unavoidable reality. So if we knew this, then why hadn’t we built resiliency into the system? Why was each person’s grief treated as an unexpected aberration? A culture that cultivated resilience would be prepared to meet a whole range of experiences, and it would draw upon a community to allow all members to survive.

  When a second intern dove out of his apartment window, falling to his death onto the scaffolding beneath, it was his friend and our classmate who ran out to him. He rushed out to feel for a pulse, only to feel exposed bones, extruded by the fall. We received his broken body in our own emergency department. We heard the echoes of our training, reminding us that if we felt the sadness, we wouldn’t be able to care for other patients. We were trained to stop feeling death. Even that of our own. I called my mother from the call room and managed, “Another one, another one of us killed himself.”