On being a fixer
Courtney Winsie Chan
I think that all doctors are a little bit like Bob the Builder. We’re attracted to medicine because we want to build the differential, cement symptoms into an illness script, and stabilize people who feel crappy into feeling a little bit less crappy – but at the end of the day, we are people who like to fix things. We are taught to keep an empathetic – yet professional – distance between the fixer and the fixee, an attempt to establish some semblance of boundaries so that we ourselves don’t fall apart while we do the job. We’ve each built a toolbox of go-to phrases, divided neatly into, “Things I Say to People Who are Probably Fine”, “Things I Say to People Who are Less Than Fine”, and “Things I Say to People Who are Dying”. We’ve committed these maneuvers, in the form of prewritten mental scripts, to memory. They help us do our jobs. And that’s good – sometimes.
I didn’t sleep very much the night before my Heme-Onc rotation. It was my second week of rotations, and I was absolutely terrified of the idea of talking to and about patients experiencing death and dying all day. I met with Dr. Park that morning at 9AM, and just as with any other ambulatory rotation, we started our day by going over the list of patients for the day. Ms. Smith, here for her follow up labs for MGUS, Mr. Jones, here to check on how he was holding up post-chemo, Ms. Doe, here 8 months after her diagnosis of stage IV multiple myeloma. And the list went on. As someone who had hated learning about the intricacies of B cells and T cells and immunoglobulin deficiencies in preclinical, I begrudgingly went through the labs, my head swimming in IgM titers and SPEP results that I would somehow need to translate into a language patients would understand.
Dr. Park and I briefly went over their charts and chatted before she assigned me three patients I would see prior to her joining – the woman with MGUS, the man post-chemo, and the woman with stage IV cancer here with her family to discuss end-of-life care.
I saw the last woman first, thinking she would be the most difficult and would need the most time. She was here with her husband, sister, and daughter on Facetime, to discuss end-of-life care given that her cancer was refractory to all treatments and she on transfusions only to prolong the inevitable. It was a sobering conversation. We talked in depth about her quality of life, her family’s wishes, and her own. Dr. Park silently nodded to me afterwards before we put on brave smiles and moved onto our next patients. Yet I was naïve to think that that that patient would be the hardest.
Dr. Park excitedly asked me if I wanted to break happy news to my next patient, which I desperately needed after the first conversation. His labs and PET results had come back normal, indicating that he was finally in remission after six grueling months of chemo. I came into his room with a big smile, telling him I had the pleasure of breaking some good news.
He sighed in relief when I told him, his shoulders releasing some of the heavy weight the words “cancer” had been bearing for the past few months. Yet his relief was temporary. When I asked him how he was feeling, he smiled weakly, and responded with the exact opposite of what I’d expect of someone who just found out they don’t have cancer: “Not good”.
We spent the next 30 minutes talking about how his son recently committed suicide. About how afterwards he moved in with his narcissistic mother, how he felt obligated to care for her since she had a terminal illness, how he hated doing so when every day she made nasty, biting comments about his son. We talked about his guilt – in failing to “save” his son, in being a bad son himself because he resented his own mother. And after two years of PURCH lectures on empathy, standardized patient encounters on breaking bad news, PHQ-2s and PHQ-9’s, the only words I felt appropriate to muster were, “Dude, that sucks.”
There was a pause before we broke into laughter. It was a ridiculous thing to be laughing at, and to most, frankly inappropriate. But I responded “off the record” and shared my own story about living with a mother who was difficult to love. I told him that I could tell him all the things they tell med students to say – “I’m so sorry”, followed by redirecting to what he was “really” here for, an empathetic 30-second stare followed by a pitch about community resources and counseling, a gross generalization for doctors to never share personal details about themselves, and to always, always redirect. We laughed at the ridiculousness of it all and mused about how in the end, sometimes life just sucked. He was already seeing a therapist weekly. He went to support groups. He had friends he could talk to about it, but at the end of the day, they never really understood. Despite all of that, he and I concluded that, yeah, it did, in fact, really suck. Dr. Park came in, we finished the physical exam, and we scheduled his follow-up appointment. Before we left to see yet another patient, he looked at me, paused, and mouthed “thank you”. And then we left.
For some reason, out of all the patients I have seen in the past few months, I still think about this one months later. I realized that I was projecting my expectations of what hearing “You’re in remission” would feel like to me or my loved ones, when, for this man, cancer was the last thing on his mind. When I think back on it, I was not only surprised, but even a little disappointed when he didn’t celebrate, or thank us profusely, or shed tears of joy the moment he heard the word “remission”. I had expected that fixing him would make him happy. I was wrong. For this patient, he was fixed, but not healed.
No amount of going into my little toolbox of go-to comfort phrases was going to heal him. He taught me that no matter how hard we are taught to suppress it, medical professionals all experience our own set of emotions independent of the people we care for. We also all have expectations of how people “should” act when hearing both good and bad news. While we learn in med school how to respond as professionals, little do we learn about responding as humans. He taught me that sometimes it's okay for us to respond to patients' needs and emotions with emotions of our own1.
In the past few months, I have learned that despite all the fancy labs and imaging and referrals, doctors cannot fix everything. The biggest lesson I have learned is to sit with the discomfort in the moments where we can no longer do our jobs as “doctor” and settle for just doing our jobs as “fellow human”. It is enough. We learn about validating, reassuring, redirecting, and coming up with solutions, but rarely do we talk about the cases in which it’s okay to say, “I can’t solve that, but that sucks”2. Rarely do we take off the mask of “professionalism” and answer not as a physician, or a UWorld ethics question, but as a human acknowledging that another human is in pain3. Rarely do we ditch the roles of fixer and fixee, and realize that when we cannot heal, sometimes there is power in just sitting, acknowledging, and verbalizing that it does, in fact, suck. Among the corporatization of medicine and mountains of EMR, being mindful of how we connect with patients in our limited time can not only anchor and ground us against burnout, but also remind patients that we are in fact human too4.
Doctors want to fix things. We always will, and that’s a good thing. Our gears start turning the moment someone has a problem; we start thinking about the next questions to ask, the next tests to order, the next treatments, the next ways to alleviate the pain. We are in the business of diagnosing and solving and taking away pain; it’s what drew most of us to the profession. But if I’ve learned anything over the past few months, it’s that sometimes people don’t want solving. Sometimes pain doesn’t need remedy, only acknowledgement. It’s a privilege that, in this profession, patients allow us – complete strangers - into the worst moments of their lives and trust us enough to attempt to fix them. With that privilege, maybe it’s okay for us to take off our Bob the Builder hats once in a while, to look at all the crap, and say “You’re right, dude. That sucks.”
Courtney is a fourth-year medical student UMass Chan in the Population-based Urban and Rural Community Health Program (PURCH) Track. She graduated from Washington University in St. Louis as a John B. Ervin Scholar for leadership in diversity, with a B.A. in Philosophy-Neuroscience-Psychology: Cognitive Neuroscience and a minor in Biology.
