Author: Andrew Thurston

Moments Matter 01: Be Kind to Yourself

Be forgiving, be understanding, be respectful. Be kind to yourself. It’s hard to be kind and forgiving and understanding and respectful to others if you don’t practice first. Start with yourself! Trust me, you’re a perfect test subject – and you’re always right there, so easy to find.

Be kind. Others may not, but you know what? If they see you being kind to yourself, then maybe they’ll do the same. And kindness will spread, its roots will grow deep, and soon you’ll stand in a field of it.

Kindness. Such a beautiful flower.

To Feel or Not To Feel

Here’s another thing that comes up quite often: what do we do with our own emotions? Is it ok for us to cry with our patients? What if we get “too close?”

We all have feelings, we all have emotions, it seems a little strange typing it. Our white coats aren’t shields: things get through, heavy things and sharp things and things that stick with us for the rest of our lives.

I imagined it a relic of olden-times medical education, the concept that emotions make us less objective and affect our decision making, but I still hear it with concerning regularity. As if having emotions is somehow bad, or makes us worse doctors.

It doesn’t. Being able to connect with your patients emotionally is important, medicine is about coming up with a plan that aligns with your patients’ goals and values and you can’t do that without exploring the emotions that drive them. It doesn’t mean you have to feel what your patients feel, that’s where this thing called empathy comes into play.

But if you do feel something more, that’s ok. We’re all human. It’s ok to cry with your patients, to feel sad or overwhelmed. It’s ok to laugh with your patients, to give them a hug (pre-COVID?), to look at pictures of their kids. It’s ok to feel angry if something doesn’t go well and happy if it does.

Of course, it’s certainly possible to get “too close,” to become emotionally over-invested. I think frequent self check-ins and reflection are necessary, and healthy, especially if you live at such a busy emotional intersection. Debriefing, and working closely with a supportive team, helps tremendously, and I couldn’t do the work I do without either.

But it doesn’t mean you avoid emotional connection for the sake of objectivity or better clinical judgment. It doesn’t mean you suppress it, or ignore what you feel. We shouldn’t feel guilty, or shunned or shamed, for crying. We aren’t any less in medicine for being human.

In fact, if we can somehow find a way to live in that emotional space, to sit with and embrace what our patients feel and what we feel in a healthy and productive way, then I’m convinced it only makes us better at the work we do.

Better. Healthier. Happier.

What I Want

An impassioned discussion with my residents this week led me down a rabbit hole of introspection, and I found myself revisiting times and places I have been along the way.

One thing that keeps popping up is the misperception that as a palliative care doctor, I “want” my patients to embrace hospice and to forgo CPR at the end of life. This isn’t true.

I sometimes joke with my residents that with the wealth of resources and knowledge at our fingertips, it would be easy to hand out hospice to everyone like Oprah giving away new cars. “You get hospice! And you get hospice! And you get hospice!”

But that’s not what palliative care, and certainly not what hospice, is about. I don’t “want” all of my patients to funnel into hospice, or forgo CPR.

What I want is to get to know my patients better. To be the best advocate I can, to help them make informed decisions for themselves based on their goals and values. I want to figure out how they define quality of life, learn about what gives their lives meaning. I want to help them protect what matters most in life, and in death.

Advocating for someone who is fully informed and has thought it through and wants aggressive measures at the end of life because it is who they are, because it’s interwoven into the fabric of their identity, because it’s how they want to live and die doesn’t mean I’m not doing my job as a palliative care doctor.

That is my job, as a palliative care doctor.

seconds to empathy

One of the myths of modern medicine is that there isn’t enough time to really talk to our patients. The day is only so long, things are so busy, there are five new admissions and I haven’t eaten anything all day. The wheel that is acute inpatient medicine keeps spinning, and we must spin with it or find ourselves crushed underneath. I get it – I’ve been there myself. I remember feeling at times like it was all I could do to hang on and not slip off the ride.

I remember as a resident wishing that my patients would acknowledge how hard it must be to do what we do – to practice medicine, to feel overworked and at times under-appreciated, to be around death and dying all the time. But then some of my patients did acknowledge it – usually with words like “I can’t imagine doing what you do all day long” – and I found myself feeling profoundly guilty. It wasn’t about me, after all – I shouldn’t burden my patients with my emotions. I wasn’t the one lying in the hospital bed.

Looking back on these moments, what I’m struck by most is not the role reversal but how easy it is to forget that we are all human, and how easy it is to remember. Sometimes it only takes a word, or a gesture, to remember our humanity. It takes really no time at all: seconds, to show empathy.

For those who feel there isn’t enough time to talk to each other in the hospital, my thought is that it doesn’t take long – just an acknowledgment here or there that we are human, and not defined by disease or title. Saying something like “that was a really tough situation” to a colleague or “tell me about your dad” to a patient’s child takes moments at most, and can help ground our work in the most common of purposes: to be nothing more or less than human in everything we do.

an exercise in reflection: landscape with the fall of icarus

I’ve been involved in reflective reading exercises since fellowship – I find it a great way to decompress the tension in the work that I do, and look back on how caring for others affects how I care for myself and my family. The premise of reflective reading is simple, and wonderful – in studying art and literature, we are able to reflect on and re-examine the work that we do through a slightly different lens. Pioneered by the Center for Civic Reflection (http://civicreflection.org/), reflective reading is a powerful tool that helps us explore our values and beliefs, our choices and commitments, and take a healthy pause in our daily routine.

Consider the following painting:

icarus

Landscape with the Fall of Icarus is a painting attributed to Pieter Bruegel, c1558. It depicts the Greek myth of Icarus, son of Daedalus. Daedalus – creator of the Labyrinth that housed the Minotaur of Crete – gave Ariadne, daughter of King Minos, a ball of string to help Theseus escape the Labyrinth and defeat the Minotaur. As punishment, Daedalus and Icarus were imprisoned in the Labyrinth. Scraping together what he could from dropped feathers and wax, Daedalus fashioned two pairs of wings and planned a daring escape from the island. As they were about to take off, Daedalus warned Icarus not to fly too close to the ocean or his feathers would absorb the weight of moisture and he would fall, and not to fly too close to the sun or the wax would melt. Icarus, filled perhaps with the joy of flight or the hubris of youth, flew too close to the sun, melting the wax and destroying his wings. He fell to the sea and drowned.

Have you found Icarus in the painting? Two thin, white legs splashing in the water?

What were you first drawn to when you looked at the painting?

There are many people depicted in the landscape – why do you think no one is jumping in to help?

What does this say about suffering, and the role suffering plays in our lives? About the way we react to the suffering of others?

For a moment, think about a time when you felt like a bystander to another person’s suffering. How did this make you feel?

Feel free to leave thoughts/reflections in the comments section!

a metamorphosis

It’s not uncommon to hear that a loved one has been transformed by their illness. Physical and physiological transformations aside, something happens when the expected course of life is slowly and gradually pulled away from center. Personal identity is redefined and repurposed – there is a subtle attrition of traits that renders us, in many ways, a patchwork of our former selves. In some cases we become known more by our disease than by our dreams and desires. “I am Cancer,” a young woman told me once, “and nothing more.” It was heartbreaking to hear.

I see this transformation most often now with indolent cancers, and with dementia. It’s as if a person’s life – once full bodied and intricately carved – gets whittled down to the bare essentials. We recognize that we are looking at a life, but the finer details – those unique and storied elements – have been scraped away.

Several weeks ago I helped care for an elderly woman with dementia. She had developed pneumonia, and was slowly climbing out of a devastating delirium. Her family shared that over the past three years she had been changed by her disease – she was no longer outgoing and social, she no longer loved to play cards or tell jokes. Even her face was more sallow in parts, as if what defined her personality had been drawn out of her skin. Discarded in a syringe.

I’ve seen this pattern many times before – a terrible chronic illness leads to an infection which leads to a hospitalization then a nursing home then another infection and so on, sometimes for years on end.

And life is suddenly redefined by lengths of stay.

But this family asked me something I wasn’t expecting. “How do we talk to her?” they asked. “It’s like she’s a completely different person, speaking a completely different language.”

I didn’t have a good reply. I think I said something about sharing a few of her favorite memories, speak to her in a way she would appreciate and find comfortable, bring in her favorite music, decorate the room to look more like home.

But if effective communication is about adapting our style to match how our loved ones best communicate, how do we do this when they are transformed by an illness? When the person before us is different from the person we knew? When the way they communicate is changing with time?

our time spent talking

A good deal of what we do in life is talk. The typical person speaks 16,000 words a day (1) at roughly 150 words per minute. With average life expectancy in the United States nearing 80 years (let’s say 75 spent really talking), the average person spends 3,000,000 minutes talking over the course of a lifetime. That’s 50,000 hours, or 2,083 days – almost 6 entire years spent in the act. This is only a rough estimate, of course – politicians probably speak much more, mimes much less – but still, that’s quite a bit of talking.

A lot can be said of what we say, but perhaps even more can be said of how we say things – the way we communicate, our non-verbal cues, our temperament in turbulence. Our messages may change with time and experience, but how we communicate reveals a lot about who we are as individuals. It speaks to our priorities in life, our patience, our generosity at times – at others, our insecurity. Our fear. 

If we could somehow be more aware of how we communicate, perhaps we could communicate better – and perhaps those 3,000,000 minutes could be time spent, not only sharing our thoughts and dreams with others, but bettering ourselves as well. 

My hope is that this site can be a forum to explore how we communicate with each other about the things that matter most – a place to share stories and experiences, and perhaps learn a bit about ourselves along the way.

1) Matthias R. Mehl, Simine Vazire, Nairán Ramírez-Esparza, Richard B. Slatcher, and James W. Pennebaker. Are Women Really More Talkative Than Men? Science 6 July 2007: 317 (5834), 82.