The ECG machine continuously belted out a strip, each peak representing his heart rate, each peak increasingly later than the one before.
By Tan Chin Yee, Duke-NUS MD/PhD Student in his first year of PhD
The room was full of the patient’s family members, young and old. Some were in tears; others knelt by his bedside in prayer. Buddhist music filled the room, overriding muttered conversation. His wife wept silently by the bedside, stroking his hair which nested over his sunken temples. The ECG machine continuously belted out a strip, each peak representing his heart rate, each peak increasingly later than the one before.
I tore off the latest strip and showed it to the Staff Nurse. She told me, “In this case… there’s nothing much we can do… usually they pass away in a few hours.” She then continued ticking boxes on her notes. I was confused. Was she not going to head over and address the family right now?
I jogged over to their attending physician, Dr X, who was having a meal in the rest area. “I think the family wants you there...” I explained the patient condition, and presented the ECG strip to him. He barely looked up and asked me, “Is this your first death?”
I nodded. I told him again, “I think the family needs you there, fast.”
“Let me just finish this sandwich – it’s quite nice.” He said between munches of chicken and avocado. I strode across the aisle back to the room of grieving relatives and a man at death’s doorstep.
His wife asked me the third time, “So is the doctor coming? His Oxygen level is dipping, maybe we have to turn it up”, referring to the machine which showed the Oxygen saturation at 74%.
I had a hard time putting on a face that looked hopeful, knowing that turning it up won’t help. At the same time, I prayed that she couldn’t glean my conversation with the attending physician from my eyes. “Yes Ma’am, he will be on the way shortly; he’s busy...” She did not look too convinced. I proceeded to the bedside, and started praying for his passing to be as pain-free as possible.
I met the patient, Mr L, on day one of clerkships. He was a retired civil servant who had suffered from dizziness for a few weeks. That was the first indication of a hitherto occult cancer strangulating his brain from the outside, having spread from the lungs. His code blue was called midway during rounds and I, the medical student, was assigned to run his trolley over to ICU after the initial resuscitation, and later ensure that his distraught daughter and wife were comforted and kept updated.
"I believe that a doctor’s job is to be as strong as their temperament and life circumstance allow them to be. They have to constantly fight the urge to self-preserve, the urge to shy away from patient suffering."
In the ensuing weeks, I had come to know him as a cherished father and husband, and in that time I had witnessed the transformation of a tanned, muscular and tough-talking officer into a speechless ghost of a man, clothes draped over cachectic limbs. I had grown to know and connect with Mr L on his deathbed.
I looked up. The ECG machine was chiming. It belted a flat line, indicating he was in cardiac arrest. But officially, he had to be pronounced dead. Those standing around were still deep in prayer, clearly not registering that their beloved had left their presence. I tore off another strip and ran across the aisle.
At 8pm, Mr L was pronounced dead. His wife let out a wail of grief which resonated with that of my heart. I could not stay any longer. Shrugging off my white coat, I stuffed it into my bag and strode off aimlessly. In the background, I could hear the fading voice of Dr X reciting a well-practiced to-do list of the logistics of body-collecting, mortuary location and funeral arrangements.
I would have liked to think I was the better, more empathetic individual, compared to Dr X. After all, I was with the family till the very end, whereas he had more business with a reheated dinner. On a daily basis, I sat by his side comforting visitors, while he adjusted medication from a computer. What truly troubled me was what he had said earlier, which struck a chord. “Is this your first death?”
It made me feel vulnerable, in a way implying that it was neither wise nor doctor-like to suffer together with a dying patient and his relatives. In a metaphorical sense, Dr X and I both represent each bank flanking the aisle of meaningful patient care.
We often read in social media posts shared by friends in the healthcare profession about complaints from patients, or hear from wise bearded tutors on Wednesdays how doctors increasingly fail to show empathy. We are educated in classrooms on how important it is to be empathetic and are even taught empathetic statements to say.
Bearing a conviction to do well by our patients and equipped with the tools, we enter the wards in starched white coats armed to the teeth with empathy. Somewhere along the way, we cross over the aisle from the patient’s side, to the place behind the computer where Dr X sits.
I felt I did right by my patient. But it was simultaneously clear to me that Dr X was doing right by all his patients. In a regular day where a typical doctor has to care for a ward full of patients and subsequently many more in the clinic, perhaps it is less wise to take an immersive approach; if one avails himself to the torrent of his patients’ suffering, he will find himself incapacitated with emotion.
I believe Dr X and those like him started somewhere not far from where I began, and eventually arrived at a state of equilibrium, where emotional well-being is preserved, allowing them to be present for another day to help patients, without baggage from yesterday’s adversity.
A recent article1 by Dr Louis M. Profeta further strengthens this notion, stating that doctoring need not always be done with compassion; doctors need not always suffer with their patients.
I admit I do not yet have sufficient experience with people to definitively prescribe exactly where to stand along the aisle between distance and presence. There probably isn’t one point which all doctors can adopt. However, I am convinced that building a wall is not the solution for doctors.
I believe that a doctor’s job is to be as strong as their temperament and life circumstance allow them to be. They have to constantly fight the urge to self-preserve, the urge to shy away from patient suffering.
In order to treat other humans, one has to stay human. And to stay human, one has to suffer humanly pains. I probably got myself too affected by Mr. L’s passing and if I had the responsibility to care for twenty other patients, I’d have failed them terribly. But over time, I need to grow into the doctor who does not put up walls, who is conscious of his weakness, one who strives towards self-awareness and emotional fortitude.
Tan Chin Yee is a student in Duke-NUS’s Hybrid Longitudinal Integrated Clerkship Programme, during which medical students undergo immersive learning in inpatient and outpatient settings, and gain integrated cross-disciplinary clinical experiences.