I AM an oncologist. I’m 67. The end is in sight, and I’m comfortable with that. In October last year, together with my many battle-weary coevals, I “celebrated” 40 years of medical practice. I’ve thus been reflecting even more intensively than usual, on those dimly-lit decades and, inevitably, the student years that preceded that graduation.

It’s been a struggle. In this I’m not alone. At least, I imagine this is the case, but of course we in medicine rarely talk of deeply personal matters. I was ill-prepared to be a medical student. I was a kind, bright and vigorous 18-year-old who eventually survived this trial by fire, but only just.

At 19, I found myself in a room with 20 cadavers, some headless – the first of the terrible sights. I think my tutor felt this was an ordinary day, but it wasn’t for me. I did not tell my family. The secrets and the desensitisation had begun.

Of course, we endured interminable lectures, exams, tutorials, then clinical exposure, with rounds and clinics. There was the inevitable use of humiliation as a teaching technique (which taught us many things, including emulation). Then we encountered further “dreadful sights” ‒ the failed resuscitation of a 30-year-old mother, the mutilated dead on arrival, the patients with sudden infant death syndrome with inconsolable parents, and so many more. We were not well supported. We learnt to harden up and hollow out.

By observation, we learnt that our survival depended on the real or pretended eradication of empathy. There were no lectures on the management of “a heart bursting with sadness” (“cardiorrhexis dolorosa” ‒ I learnt to like obfuscation). By graduation, I was an insensate zombie. I am sure medical education has improved over the years, but perhaps not enough.

Internship (unsurprisingly) proved more of the same. My first ever patient, a 14-year-old boy, Robert, dying of acute myeloid leukaemia post-transplant, permanently pancytopenic, alone in a single room. The ward round stopped at the door. Bizarre hand signals through the glass. We move on. No one knew what to say to Robert or his single mother. Beyond tragic and shameful.

My role, as the most junior, was to daily change his cannula. On day one, I entered the room, dutifully gowned, gloved and masked. He was alone. I had no idea what to say. So, I sat. It was peaceful in that room, deeply so. I stayed a while enjoying the silence. Robert then said: “You can relax in here. I know I’m dying. I speak to a young nurse every night. It must be hard on you doctors. But I’m not afraid. I’ve had a good life. My mother loves me deeply. So does my grandmother. They will look after one another”.

I was a bad zombie. I wept. This was a big lesson for me. Perhaps the biggest. I learnt about presence, silence and listening.

So, fast forward 25 years to 2002.

At that time, I was a good oncologist (I think), but I was burnt out, melted down and broken. Nobody seemed to know except my psychiatrist. In my busy clinic, I was trying to pretend to be empathetic, and also wondering if this was to be “the day”. At home, I had an altar to my self-destruction – three methods, to be certain. I’m obsessional by nature, like so many of us.

As John Lennon said: “Nobody told me there’d be days like these”. But I survived, mostly through meditation, lots of it. Eventually it proved very effective, along with some rationalisation of work life. My sense of agency improved. Orthodoxy was of little true value.

In my recent reflections, I see clearly some of the causes of this great suffering – my suffering and, I suspect, that of others – including the great omissions from our medical education. Dereliction of duty of care, nothing less. Placing the vulnerable, knowingly, in harm’s way.

We were not taught about the experiential codes ‒ the “secrets” of a flourishing and compassionate life. What codes? The discoveries of ancient Eastern and Western philosophers over the millennia. Nothing new!

The First Code: our self

Through mature reflection and meditation, we are able to understand and experience our luminous inner world, our essential nature and the rich meteorology of our emotions, and, in so doing, become resilient, robust and self-compassionate. Alexithymia – the subclinical inability to identify and describe emotions in the self – is replaced by emotional literacy. We are then able to hold our sadness with loving kindness. In this process we are supported unconditionally by our medical institution.

The Second Code: the other

We learn to deeply understand that others experience similarly complex lives and profound feelings as we do, and thus, through this sense of connection, we nurture our vast capacity for compassion. We learn to be fully present and to truly listen. It is in this mindful space that transformative healing (cognate with “wholeness”) for both parties can take place. Here death can be discussed without fear.

The Third Code: our life

We become aware of the preciousness of each moment of each life. We understand our great sense of responsibility, reflecting frequently on our progress towards authenticity and on our impact on the lives of others in our service to humanity and the world. We will learn the curse of excessive business, which deflects our attention away from the present moment. We begin to accept uncertainty, unknowability and impermanence.

The Fourth Code: our mortality

We reflect on, and may eventually understand, our mortality and that of all beings, and thus savour the wonder of life itself. Through this process, we may experience an all-embracing wisdom.

This is the timeless core of medical practice. Without the pervasive thanatophobia – the fear of death – it is likely that the dying process would be managed with greater sensitivity and humanity. We would all benefit from this tender openness. The dying have so much to teach us.

Of course, these codes interact in so many synergistic ways.

Through the experience, understanding, embodiment and practice of these codes we may develop a new relationship to the tuition and practice of medicine. We would emerge from medical school with a supported confidence in the knowledge that we are truly valued. Indeed, there would be recognition of the energetic freshness, cheerfulness and curiosity of the young. There would be no sense of fearful isolation. Hours and conditions of work would be humane with regular opportunities to attend to inevitable distress in a safe environment.

There would be a deeper sense of caring for each other through our personal crises without the dread of stigma. By applying the codes, we are likely to identify our burnout at the early smouldering stage, seek help without delay, receive immediate compassionate assistance and, through our resilience, recover quickly and fully. Indeed, by transcending a personal disaster, one may well become a better doctor (the “wounded healer”). Those who help us benefit too.

Relationships with many patients would become more mindful, compassionate and profound, with the expected benefits to all parties. We may find that the sense of duality fades, as we each gaze deeply into the other and ourselves, with very little separation. Always a memorable experience for the two sides of “the one”.

The four codes are timeless and vital and with good faith can easily be incorporated to a medical curriculum and thereafter into a life.

Me, you, life, death. Simple!

Dr Jonathan Page, FRACP, is an oncologist with the Northern Beaches Cancer Service, Manly Hospital and the University of Sydney. Through personal mid-life decline and the generosity of his patients, he discovered the vital healing role of the psycho-spiritual domain. You can read more about him here. You can email him at jpage1@tpg.com.au

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.

14 thoughts on “Four codes for compassion and survival in medicine

  1. Dr Stephen Barnett, GP and Clinical A/Prof University of Wollongong says:

    Thank you Johnathan for your deeply personal and meaningful article. It is so true that the personal, the emotional, the spiritual and the human are the core of what we do and why we do it. Yet this core can be so easily forgotten and suppressed as we work with the constant distress of our patients. I have often wondered why we don’t embrace formal peer mentoring/debriefing, enshrined in our practice and our CPD. Psychologists undertake regular, formal peer support and debriefing and it seems to be a key way for them to maintain their own wellness and perspective. In medicine we cope with informal peer support on the run, if we can get it, in the tearoom or in a shared moment in the middle of a busy day. Surely the medical profession could learn something from our psychology colleagues?

  2. Anonymous says:

    Accurate description of doing medicine. Well done. Massive applause from one. Hope you are heard.
    GP Melbourne

  3. Simon Byrne says:

    Thanks Jonathan for sharing so much. I’m a psychiatrist. The deaths we see are mostly suicides, which we often feel responsible, or blamed, for. But I don’t think that’s the worst of it for us. Our desensitisation is around the harsh and neglectful treatment of people with mental illness. Some people used to think that when we closed the asylums everything would get better. But it didn’t. Now it happens in emergency departments, inpatient units and in “the community”. I believe the answers lie in the path you describe: deep awareness of oneself and of the “other” as living, suffering, mortal beings. I try not to have patients any more (let alone “consumers”), just “persons” who come to see me. We do have peer review in psychiatry, and it does help.

  4. Anonymous says:

    Dear Jonathan, what an insightful article.
    I feel the ability to help each other and be supportive in the workplace amongst all groups of caring people – allied health, nurses, doctors, PCA’s is being eroded with time frames – patients move along the conveyor belt of false time frames in each unit and no one cares for each other or the patients. Patients have become DRG’s and overstayers and we as health care providers are ranked on our patient per hour output. We must allow team members time to help each other, bond and care what happens to their colleagues and this will help our empathy towards patients and improve our sense of self. Don’t underestimate the tea room shared moments as they debrief a situation that could flair up. I do agree with Stephen’s comments wholeheartedly but will add that some clinicians aren’t in tune with themselves to be able to self report to caring mentors or hierarchial structures of debriefing.

  5. Anonymous says:

    Thankyou for provoking discussion. Your emotional experiences are not universal. I came into the dissection room, found what I expected and got on with my studies. I think my upbringing of the separation of spirit from body at death insulated me from your experience. My dissection room emotions in no way decreased my ability to empathize with the patients, cry with them and walk the journey of disease with them.

  6. Anonymous says:

    great article, brought back memories of my younger self hiding in a corner to shed some tears over a neonatal death. No support from my supervisors or acknowledgement of my distress.
    I feel we are not given permission to express our own feelings of distress and doubt , and have to provide support to others in our team. Pressure to be seen to be coping still exists.
    Efforts to provide mentors and support to younger trainees is happening , but I don’t know how free these trainees feel to express vulnerability. I think there is still stigma in expressing a need for help.

  7. Michael Shanahan, formerly Physician Manly District Hospital says:

    Thanks Jonathon. You were a very good person to work with, and my patients felt the same.

  8. Michael SNOW says:

    To all readers…

    A pertinent comment from my sherpa & mentor… that being, me, myself and I 🙂

    A ” Healthy Self” can be expanded as… “health thy self”

  9. Michael SNOW says:

    oops… meant heal thy self = “healthy self” 🙂

  10. Anonymous says:

    Interesting but not universal. Those that didn’t suffer quite so much perhaps are better suited to trauma care and surgery but I don’t know how Jonathon coped with oncology!
    I still think I empathize with my patients but as a surgeon, one has to live with the outcomes of our proceedures;some work, some don’t.
    Congratulations though for bringing this to our attention. Perhaps the changes in technology have something to do with the harshness of his training and the fact that expectations of “cure” are so much more widespread now.

  11. David Woodhouse says:

    I can empathise with your view of life and mortality.
    I am an OBGYN. I’m 72. The end is in sight, and I too am comfortable with that. In January this year, I was diagnosed with a couple of relatively asymptomatic but rather lethal malignancies. The usual round of chemo and surgery but in the end, as someone said “the horse has bolted”. It is a situation which does tend to focus one’s concentration on matters mortal.
    The only fear I have is that I will become irrelevant; my only purpose being to fill up the appointment calendars of my medical attendants. I watch them, their registrars and residents and I see echoes of myself in another time. The worried and the hurried.
    But do I not also feel a sea change? I do believe they have found empathy. The defensive moat of the medical desk is gone with a simple rearrangement of the furniture. Eyes meet and are held… no busy scribbling of notes with blank face. The “clinical gaze” described by Michel Foucault seems to largely gone or is well hidden and they ask about me the person, not the carry bag for some academically challenging disease state. They reach out and actually touch. I can live in hope that the sea change may become a tsunami.
    As for me? Many years ago there was a medical TV program called Ben Casey. That betrays my age. At its beginning a disembodied hand wrote in chalk on a blackboard the symbols for Man, Woman, Birth, Death and Infinity. In my old age it seems to have bubbled up from my memory bank and seems to resonate with the principles espoused here. Man (me), Woman (all my patients were of that gender), Birth (well, that was my life and livelihood), Death (it comes to us all) and infinity I will leave to the existentialists.
    I went to the geriatric gymnasium and returned to work. My returning strength and rediscovered muscles gave me back my self-esteem and my work gave me purpose. Superficial? Perhaps so. But most important they have given me the ability to empathise with myself.

  12. Anonymous says:

    Thank you for the thoughtful insights. I guess burnout will happen to everyone who cares enough for long enough – there is no way out of it. However my demise was CAUSED by the degree of dishonesty and arierre pensee in which I have been accused of having a mental illness that is clearly not the case. The individuals involved (and they know who they are!) simply did not share my work or moral ethic and thought that caring too much for patients was a mental illness! I am still fighting their dishonesty and will continue to do so until either I die or they apologise. I think I know which will come first.

  13. Anonymous says:

    Thankyou Jonathan for your thoughts.
    At age 60 I have sometimes enjoyed my life as a GP and been impressed by many patients ability to cooe and find meaning in life,s pretty unexpected and sometimes horrible situations.
    I think we as GPs are probably the most unsupported people as we have such time pressure and patients expect more and more and the paperwork is consuming too much time.
    Because we are funded only when seeing patients and have no salary and proper funded administration and education time we tend to just keep pushing on til we collapse.
    I think we should all have access to supervised time with a valued colleague to discuss difficult patients with and check up on our own mental health and coping skills.
    Its surprising that in this day and age we dont have a formalized system for this and we are the porer for it.

  14. Dr Dannielle Kolos says:

    So many comments that are so recent! I will be the first on the 5.12.18. I am 70 years old and a practising doctor since I was 20. I have been trained in many disciplines, including surgery, and finally found my niche in general practice. Here it is possible to consider a client’s situation not only from a medical point of view, but also psychological, professional, social, moral and spiritual , (and maybe more) mind sets.
    As I recognised the defects of my understandings, I undertook various extra disciplines which allowed me a broader understanding of human conditions. One which I found particularly enlightening, was the study of family therapy. One experienced a laundry basket of all the available therapies. One was able to settle with the one or two that one felt most comfortable with. This one for me was the study of intimacy – the nature of intimate relationships, how to facilitate the emergence of intimacy, and how through intimacy people accept each other, warts and all, and are able to blossom into empathetic and compasionate individuals. More significant than the encouragement of intimacy, is understanding the natural development of intimacy, unhindred by subconscious prejudice and judgement. Through intimacy, a person is able to change according to his/her own innate wisdom. There is still time.

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