A Biopsy

There are certain patients who never fade from a doctor’s memory — they make
an indelible imprint on one’s training. Thinking back on these patients and their respective hospitalizations is
like gazing through a pristine window pane on a clear, sunny day. Often they
stick in our memories because one becomes emotionally invested in
them or because there is some interesting disease or singular clinical
outcome. The former patients usually affect us more deeply.

***
Blood cells from a patient with Leukemia
(Prof. Erhabor Osaro via Wikimedia – CC)

I can tell you her name, age, and favorite foods to eat and cook. I recall,
without difficulty, how many children she had, her religion, where she grew
up, traveled and met her husband. I can even recreate her hospital room in
my mind — family pictures across from her bed, a knitting kit on her
nightstand next to her laptop computer, a plastic storage bin with clothing
and candy.

She was in her fifties and had been diagnosed with

leukemia
, a cancer of the blood. There are different types of leukemia, but in
general, patients with leukemia have bone marrow that overproduces certain
infection-fighting cells, or

white blood cells
. Some of these cells function normally, but many do not. They overcrowd the
marrow, preventing it from making red blood cells and platelets. If there is a high enough number of them, they clog up blood vessels. And
eventually, the cancer kills you.

Treatment of leukemia involves rounds of chemotherapy,
potent drugs that arrest cell growth or division by acting on a specific
stage in a cell’s reproductive cycle. Each of these drugs
targets different aspects of quickly dividing cancer cells. But they also
wreak havoc on the body’s normal cells, causing nausea and vomiting, hair loss,
heart damage, kidney damage, and liver damage. Unavoidably, the therapies for
leukemia have serious, sometimes intolerable side effects.

The goal of prescribing such potent medications is to wipe out all of the
cancer cells. But it is especially important to wipe out the “stem cancer
cell” — that is, the original cell or group of cells causing this tempest. If
you can’t kill those cells, you cannot cure the cancer; they divide and produce more defective, parasitic, and deadly neoplasms. For
certain patients a

bone marrow transplant
 is the best hope for a cure. Chemotherapy wipes out one’s own bone marrow
and cancer cells to make room for the transplant, which does not contain
the same cancer progenitors. The donor’s marrow must match the patient’s
marrow; the cells produced from the transplant must be sufficiently genetically similar to the patient’s or the white blood cells from the donor tissue will attack the patient’s own body.

Our patient had gone through multiple rounds of chemotherapy, all of which
failed. She had found a match for a bone marrow transplant, though, and was
going to try a new combination of chemotherapeutic drugs to wipe out her
bone marrow in preparation for the procedure. This process takes weeks. Thus, she lived
in the hospital, receiving family along with friends from church.
During the afternoons, after rounds, I would come by and chat with her if
she wasn’t too exhausted or sick. Our conversations wandered from religion to food, travel, and family. We talked about history, too. She was a Civil War buff
and had no trouble discussing her favorite historical figures from that era
and her favorite speeches.

She possessed a seemingly infinite amount of patience and kindness given the
circumstances. I never once heard her bemoan her situation. She wanted, I think, to be treated as she had always been
treated, even as the reality of her prognosis set in. If she hadn’t had children, she once mused to me, she would have given up after the last round of chemotherapy failed and opted for palliative care. But her
children were too young to lose their mother, and so she hoped to live on.
So we hoped with her, attempting just once more to extend her life.

At a certain point towards the end of the chemotherapy regimen, we extract
bone marrow from the patient and look at the marrow under the microscope
with a pathologist. A
hematologist aspirates the sample using a large needle and spreads it onto
an approximately three-inch-by-one-inch slide. The oncologist, pathologist,
residents, and students look at the small sample of tissue. Ideally, there are very few cells and almost no cancer cells.
Otherwise, the chemotherapy has failed and the transplant cannot be done.
As the pathologist moved the slide of our patient’s marrow around, large dysmorphic cells popped into view. There weren’t a lot of them, but they
were noticeable and they were cancerous. I heard the pathologist offer up a
disappointing, “Hmmm.” No, as it turns out, the chemotherapy had not killed
enough cancer cells to make the bone marrow transplant worthwhile. Tragically, the patient would soon die.

It is strange, is it not, that this human being’s outcome depended on an
inch-wide sample of bone marrow? We do not think of people as bundles of
organs and cells but as whole, complete beings. We think of people
abstractly or even holistically — character or personality, physical and
mental abilities, age. Who cares about the cells in their marrow? What
bearing does that have on the life to be lived? But it matters much more
than it seems. This small sample ends a life or gives fresh winds to a sick
life. It is counterintuitive to the way we think, but it is how we make
decisions in medicine. We treat the person but we also treat the disease.
If the disease still exists and runs rampant within the body, the person, no
matter how admirable, familiar, and recognizable, will perish.

A Tour of the Intensive Care Unit (ICU)

I have a rendezvous with Death
At some disputed barricade,
When Spring comes back with rustling shade
And apple-blossoms fill the air—
I have a rendezvous with Death
When Spring brings back blue days and fair.

It may be he shall take my hand
And lead me into his dark land
And close my eyes and quench my breath—
It may be I shall pass him still.
I have a rendezvous with Death
On some scarred slope of battered hill,
When Spring comes round again this year
And the first meadow-flowers appear.

God knows ’twere better to be deep
Pillowed in silk and scented down,
Where Love throbs out in blissful sleep,
Pulse nigh to pulse, and breath to breath,
Where hushed awakenings are dear …
But I’ve a rendezvous with Death
At midnight in some flaming town,
When Spring trips north again this year,
And I to my pledged word am true,
I shall not fail that rendezvous.

—Alan Seeger, I Have a Rendezvous with Death

The Intensive Care Unit is an uncomfortable place. It is where the sickest patients in
the hospital reside. Because many of the patients require emergency medical interventions or close monitoring, the layout resembles that of the emergency department (ED). Patient rooms encircle a nurse’s station where computers sit on a long table. As in the ED, each room is filled with machines
projecting vital signs, EKG tracings, IV fluid rates, and other information towards the physicians and nurses. And the nurses in “the unit” (as it’s
commonly referred to) are always active, checking in on patients throughout the day and night.

There are many different types of intensive care units: some for patients with heart issues (cardiac ICU), others for patients with neurological issues
(neuro ICU), pulmonary or general medical issues (medical ICU), surgical issues (surgical ICU) and cancers (oncology ICU). What we see in each unit,
however, is equally disturbing. And what follows are the some of the things one might see (and which I have seen) in different ICUs over the course of a
day.

Image via Shutterstock

In the neuro critical care unit, one patient lies unconscious with a massive and deadly brain bleed. In another bed across the room, a patient with a rapidly expanding
brain tumor cries out in searing pain from a headache. In the cardiac intensive care unit, a patient, hours after receiving a ventricular assist device (VAD), a device which helps the heart’s ventricles pump out
blood after being weakened by disease, receives chest compressions from a nurse as he goes into cardiac arrest. Another unconscious patient in the far
corner of the room is on ECMO, or extracorporeal membrane oxygenation, after
having massive heart and lung failure. ECMO takes blood out of the venous system, oxygenates it in a machine and then pumps it back into the arterial
system, thus bypassing the heart and the lungs. In the normal circulatory system, blood goes from the veins into the right side of the heart and
subsequently to the lungs where it is oxygenated, flows to the left side of the heart and is pumped into circulation to nourish the body’s tissues. ECMO
temporarily maintains circulation until the patient’s heart and lungs can function on their own.

In the oncology unit, a middle-aged cachetic patient lies face-up in the bed, staring at the ceiling while fungal and bacterial infections cause his blood
pressure to drop and heart rate to increase. Despite the medications used to prevent these infections in cancer patients with very low white blood cell
counts, sometimes the microbes sneak by. And because chemotherapy used to treat cancer destroys white blood cells, the cancer patient has nothing left with
which to fight off the infection. Even the most minor bacterial invasion can be fatal for these patients, as it eventually was for him. Meanwhile, in the next room, another
patient had just passed away and her family crowded around her bed sobbing and mourning their loss while holding the expired patient’s
hand, hoping for the return of warmth.

Unusual sounds percolate from room to room in these dank areas of the hospital. Most noticeably, IV poles beep
constantly as they run out of their fluids or medications. Cardiac monitors sound alarms as patient heart rates dip too low, rise above a normal level, or register abnormal
rhythms. Some patients moan and scream, losing all sense of time and of themselves. Or, perhaps they curse and threaten nurses while withdrawing from
alcohol. Others vomit and pass gas. Some patients demand the impossible: “get me out of here!” or “leave me alone!” Sometimes patients need to be strapped
down to the bed because they pull out their IVs as they wail and moan and thrash about. During the day, minimal light shines into the unit and it is
tainted by the sickness and suffering which pollute the air and tint the windows. Foul smells, which I wrote about here, are most potent in the ICU. Many ICU patients,
though washed by nurses, have not bathed in weeks. The stench of sweat, stool, and blood permeates the unit when nurses change patients’ diapers,
suck accumulating mucous out of patients’ mouths, and clean up blood-stained sheets.

And if you think it’s bad for providers, imagine what patients experience. The ICU must feel like a kind of hell on earth. Sleep is rare when your
neighbors expectorate, choke, vomit, and shout, and nurses and physicians constantly wake you up, draw blood from your veins, and examine you to ensure your
mind still functions correctly. Some patients can’t eat or drink because they need surgery (it is safer to put patients under anesthesia for surgery when
they have not eaten because food will not come up from the stomach and choke the patient or travel into the lungs while they are unconscious) and so they go to bed hungry and
thirsty. A patient may even go to sleep not knowing whether he or she will wake in the morning. You may be one of those who
has a rendezvous with death tomorrow; you may be one of those who survives; you may hang on by a thread for weeks. Who would ever want to end up in an
ICU?

And yet, it is in the ICU that patients receive the most fastidious care. Nurses watch over only one or two patients and thus can keep a close eye on them.
Physicians trained in the art of emergency procedures, like intubation, are always around
and watchful. Nobody will be more attentive to your medical needs than an ICU team, which monitors every sign of life you emit: breaths, heartbeats,
skin color, blood pressure, electrolyte levels, blood counts, infectious disease cultures from your urine to your spinal fluid. The advantage of being in
the ICU is that you receive the care that you need even if it is in a frightening environment. I hope I never have to be there, but if I am severely ill at
some point in my life, the ICU is the place I would choose to be.

Empathy in Medicine

“You’ll h-h-h-have to… excuse m-m-m-me. I’m a little slow because I had a stroooooke,” he told us before we explained to him what his wife’s treatment would be.
His voice was nasal and his speech deliberate as he slowly and poorly enunciated each word. He wore sweatpants and a long-sleeved shirt with a
blue and white hat pulled down over his eyes. Stubbornly refusing to stay tucked away, gray hairs peeked out the sides of his chapeau and covered
his ears. He looked to be in his seventies. His wife lay on the bed in a hospital gown, slippers still on. She wore a winter hat that
concealed a bald scalp, one of the many side effects of potent cancer medications. Her eyebrows were gone and her sinewy frame was exaggerated as cachexia set in. She needed extra rounds of chemotherapy for metastatic cancer.

Image via Flickr: Tim Hamilton (CC)

That afternoon, I ran into the husband in the hospital lobby. He had just bought food and was going to bring it back to his wife, but he was heading the
wrong way. He asked a fellow student and me (he recognized both of us) how he could get back to his wife’s room and we pointed him in the right direction.
We watched him shuffle tow
ards his wife in the cancer ward. This couple was neither wealthy nor well-educated; they were suffering and attempting to
navigate the healthcare system as well as the overwhelming size of an academic hospital. They seemed helpless together.

It’s in such moments, as in many others, when empathy wells up in medical practice. I
could clearly imagine myself or my family members in their position. Their emotions became all too familiar and upsetting to me. I wanted to do everything
in my power to help them and to fix their situation. But this strong sense of identification seemed odd given how brief my interaction with them had been.

In reality, however, such a feeling is not so unusual. Robert Louis Stevenson, the famous nineteenth-century Scottish writer, co-authored a short story called The Ebb-Tide. It is an account of three criminals who steal a ship and the deeply
troubling moral situation they subsequently encounter. When one of them falls sick, Stevenson describes the healthy comrades’ feelings:

A profound commiseration filled them, and contended with and conquered their abhorrence. The disgust attendant on so ugly a sickness magnified this
dislike; at the same time, and with more than compensating strength, shame for a sentiment so inhuman bound them the more straitly to his service; and even
the evil they knew of him swelled their solicitude, for the thought of death is always the least supportable when it draws near to the merely sensual and
selfish.

Image via Shutterstock

Given the power of this selfless commiseration shouldn’t we cultivate it in medicine? No doubt
it will help us to act altruistically even when we see the worst in patients or colleagues, thus leading to a better bedside manner and better patient
care. Jean-Jacques Rousseau, the Genevan philosopher, saw such feelings differently,
however. In

Emile, or On Education
, Rousseau points out that empathy is really an outlet for selfish passions, even if its effects can be positive. Rousseau writes that,

if the enthusiasm of an overflowing heart identifies me with my fellow-creature, if I feel, so to speak, that I will not let him suffer lest I should suffer too, I care for him because I care for myself, and the reason of the precept is found in nature herself, which inspires me with the desire for my own welfare wherever I may be.

Such cynicism about the underlying nature of empathy still has its advocates today. In the September 2014 Boston Review, Yale psychology professor Paul Bloom questions our high regard for empathy. I recommend reading his essay and his
exchange with other scholars, including Peter Singer, Sam Harris, and Leslie Jamison.
Bloom points out the dangers of unchecked empathy: “Strong inclination toward empathy comes with costs. Individuals scoring high in unmitigated communion
report asymmetrical relationships, where they support others but don’t get support themselves. They also are more prone to suffer depression and anxiety.”
And this is especially the case, Bloom points out, in the medical field in which a doctor can lose a sense of objectivity and a cool head in an emergency.
Bloom distinguishes between cognitive empathy, which is empathy tempered by rational feeling, and emotional empathy, which can be dangerous. Bloom writes
of an older relative of his in the hospital:

He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But
emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he
is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty,
professionalism, and respect.

This makes sense. I can imagine how exhausting it must be to feel so strongly about every patient. It would cause burnout and depression. But the
psychologists Lynn O’Connor and Jack Berry respond to Bloom in the
following way: “We can’t feel compassion without first feeling emotional empathy. Indeed compassion is the extension of emotional empathy by means of
cognitive processes. Only if we have the capacity to feel empathy toward loved ones can this sentiment be generalized by the imagination and extended to
strangers.” This addition to Bloom’s argument is absolutely vital. Both types of empathy are important.

Such balanced empathy keeps the physician honest. There are many times when, in a rush to complete the work of the day or under the pressure to see every patient,
physicians take their frustrations out on patients. Empathy tames our impulsivity and gives us pause. It forces us to consider the actions we
are about to take. And we can project empathy using reason and emotion. If an elderly woman is being difficult, instead of reacting with frustration and
annoyance we can step back and ask ourselves, “What if is this were my grandmother or my mother? How would I want her physician to behave?” To do this is
not easy, but it can make an immense difference in how one interacts with a patient.

Empathy may or may not spring from selfishness, and too much of one aspect of it (like too much of any emotion) can be a bad thing. But physicians do need
empathy, both the emotional empathy that we feel towards some and the cognitive empathy that we can extend toward all. In the cogs of an impersonal
medical system, it leads to the dignified treatment of a suffering patient.

Becoming Cynical, Part 2

At this point, I have spent one month on pediatric surgery, one month on trauma surgery (a service that deals mainly with adults who need emergency general surgical procedures), and one month on general pediatrics. It’s clear already that physicians treat pediatric and adult patients very differently. Children need high levels of protein and calories in their diets, and pediatricians need to have a higher index of suspicion for congenital abnormalities,
or genetic diseases. Children also swallow small objects, and stick objects up their noses, which can cause infections, shortness of breath, or scarring of
tissue; this happens much less with adults. But beyond this, there is also a clear difference in the way one reacts to treating these two different
patient populations.

With children, the world, from a healthcare perspective, is almost always black and white. One cannot blame a newborn child for soiling a diaper or for
crying when being examined. A baby is always innocent — poor parenting or an unlucky genetic lottery pick is usually to blame for sickness. One too many
children on the pediatric service fall into these categories. Some parents beat their children so badly that a portion of the intestine ruptures. One
infant had multiple broken bones, some of which were considered “old” fractures. I imagine just reading that sentence induces the kinds of horrific shivers
I felt upon seeing this child on the service. Who do we blame when multiple tubes need to drain out different colored liquids from the intestines because
of child abuse or premature birth? Anyone but the patient. The innocence of children is inviolable and, as such, one cannot help but feel an unrelenting
sympathy for them.

With adults, however, gray areas abound. Many older patients have chronic illnesses like diabetes, high blood pressure, obesity, high cholesterol, and
cancers. Undoubtedly genetics play a role, but we also hold adults responsible for their own well-being. Smoking, poor diet, refused medications: these are
just some of the life choices that invite those chronic illnesses.

Smoking leads to lung cancer. A poor diet leads to diabetes or heart disease. Taking medications regularly for Crohn’s Disease or Ulcerative Colitis can prevent the need for
massive abdominal surgeries in which portions of the intestine need to be resected. And if the piece of colon resected was necessary for the patient to be
able to defecate voluntarily, he or she needs an ostomy, a procedure in which part of the intestine is
connected to a bag on the outside of the abdomen, where stool collects; the patient then empties the bag manually. How easy it is to dump sympathy by the
wayside! When we know who the guilty party is, how can we behave impartially? The enervation of seeing patient after patient in a similarly preventable
situation on the adult floors eases one into cynicism despite the sympathy and empathy that brought us into medicine.

And this is where the question of physician burnout also comes up. Burnout is defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment. In one Medscape survey, physicians
of all different specialties were asked whether they experienced at least one symptom of burnout. Pediatricians experienced one of the lowest levels of
burnout. Another study, published in JAMA Internal Medicine, found general pediatricians ranked lower on burnout than every other specialty except dermatology and preventive, occupational, and environmental medicine.

Many, many factors account for physician burnout and cynicism in different specialties, including lifestyle, geographic area of practice,
private versus hospital practice, and so forth, and I will continue to write about this because it can affect patient care. But among the many factors involved, I do think that the
patient population one deals with affects the feelings a physician has toward the patient. After all, it is much harder to sympathize with those who have
made mistakes and poor decisions than with those who are only a victim of circumstance.

The job of the physician, and the art of medicine, involves trying to put aside the idea of the culpable adult or the blameless child and to treat the
person as he or she stands before the doctor. This is incredibly difficult, but I suspect this push and pull is integral to the imperfect system that we
have — a system that deals with human beings and human relationships as well as with science.