Some days it’s harder

I’m a little down today. I’ve told you before that I take care of my own patients in hospice. I’ve also told you about watching patients and friends lose their battles with disease.

This week I had serious talks with several people about end-of-life issues (the details of which I can’t really share at the moment). I’ve also had to tell someone about an abnormal lab result (a very bad one). In fact, the best news I’ve delivered all week was telling someone they had mononucleosis (rather than something worse).

I’ve found, in my limited experience, that terrible illnesses don’t change people that much. If they were cheerful healthy folks, they tend to be cheerful (albeit appropriately sad and angry) sick folks. If they were curmudgeonly when well, they will usually be cranky when ill. Occasionally, some transformation will come over someone when they are confronted with a mortal illness, but I don’t think this is the norm. When thinking about these things, it is very tempting to wonder how I would deal with such a thing myself, but if I’ve learned one thing in the last decade as a physician it is this:

Don’t go there!

Empathy is a good thing, a necessary thing, but you cannot be an effective physician if your empathy turns into true identification. It is paralyzing. Everyone worries from time to time about what could happen to them if this or that illness struck, but doctors are in a bad position. We know too much. It’s far to easy to come up with realistic scenarios of our own demise. This is especially true when dealing with ill patients who are like is, in age, education, ethnicity, etc.

We don’t really talk about this much. I mean, we talk about “not going there”, but we don’t often acknowledge to each other what it means to “go there”. As someone who teaches young physicians, I deal with their irrational fears all the time. Every lump, bump, cough, in the mind of a young doctor, is the seed of their own death. It takes a while to build up a bit of a skepticism about your own ability to evaluate your health. It also takes a while to find the right balance between empathy and identification—how to feel for the patient, without feeling like the patient.

Still some days it’s harder. I was talking to a friend today (a fairly new friend, as it turns out) who is going through a particularly rough round of chemo. I grew up with her husband, she has a kid my kid’s age; it’s very easy to identify with her. If she were a patient, I would try to throw up that flexible fence with empathy on one side and pathological identification on the other. But she’s not my patient. Where do I build my fence?

I don’t. Sometimes it’s possible to over-think things. She’s one of the “cheerful” ones. She’s not crazy, not stupid, not in denial, just a good person with a good attitude and a lousy disease. When it comes to friends and family, sometimes you’ve got to set aside the white coat and allow yourself to laugh and cry with someone, allow yourself to get close to someone even if you don’t know where life is heading.

It’s not always an easy ride, but it sure is better than the alternative.