The Things We Take for Granted

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Finally, after nearly five years of medical training, Paul Kalanithi1 has given me a job description: “[Your] duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”
Treatments work. Patients survive. Yet, we often cannot restore health entirely. Most of my time is spent with patients who have been hospitalized for exacerbations of chronic comorbid conditions, severe acute illness with prolonged recovery, or cancer. We deem our patients safe to leave the hospital, but they are not always getting better. Our patients are, after all, mortal. Though my foremost mission is to improve health outcomes, the challenge I face now is learning how to support my patients and cope when their prognosis is worsening.
And here I am, learning to address patients’ sickness and suffering mostly by trial and error. Thank goodness for guidance from a few willing mentors; there is no textbook for this.
These instructional shortcomings are not due to the curriculum per se. Trainees’ empathy declines during training.2 Depersonalization in residency is normal and sometimes necessary.3 Caleb Gardner4 has beautifully shown that teaching empathy poses the risk of learners using it disingenuously in later practice. This matter is delicate.
But there are avenues for improvement. Shared decision making has existed for decades, yet written examinations exclude patients’ values and goals. Standardized patient exercises do not cover complex decision making and end-of-life care. Loosely defined competencies in professionalism, communication, and interpersonal skills seem to fall short when honest conversations about what lies ahead are needed. Expectations and accountability are lacking.
In the face of suffering, I ask the question: What are the things physicians do that make patients feel cared for? Perhaps the next step is to characterize these traits and behaviors. Examples include appreciating suffering, being present, and facilitating patient ease.5 There is a right answer here.
A medical doctorate certifies knowledge in disease, yet means little with respect to understanding the person who has that disease. Like my predecessors, I will approach suffering differently than my peers. Common lessons and simple goals are needed. We are taking for granted the care of those who do not, and will not, get better.
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