Four codes for compassion and survival in medicine

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.