Commentary on "Absorbed".

Abstract

“Can the doctor simultaneously attend Man the molecular aggregate and Man the person; Man the unit of complex society and Man the ineffable?” —Edmund Pellegrino 1 My short poem “Absorbed” depicts the tension between the humane and scientific realms of clinical medicine through a fictional meeting between a preclinical medical student and a patient with cancer. The student is a novice to both the relational and technical aspects of a successful clinical encounter; her apparent uncertainty is expressed through the poem’s stream-of-consciousness, jumpy form. While awkwardly striving to model her idea of a good physician and focus on obtaining an accurate H&P, she neglects what is most important: the experience of the human being sitting in front of her. Though fictitious in details and chronology, this experience is authentic for medical trainees, who are frequently tasked with navigating the ever-fluid, complex science of clinical medicine (“Man the molecular aggregate”) without losing sight of the humanity of those they serve (“Man the person”). “She turned to me”—a blunt opening with the student already in the patient’s room; no pep talk from her resident, no moment to collect her thoughts, no deep breath before knocking on the door and greeting the waiting patient. This curt commencement provides a fitting encapsulation of the experience of a green student doctor, often unsure and sometimes uncomfortable with the tasks assigned by her superiors. Thrust into this new situation, unversed in the decorum surrounding a new patient encounter, the student assumes a simpler mode of relating, human-to-human rather than clinician-to-patient. This humane predisposition is revealed as the student first notices particularities about the patient (“glassy eyes” and “kaleidoscopic headscarf”) regardless of their clinical relevance. These idiomatic attributes exhibit the patient’s vibrant personal identity as juxtaposed against her “invariable uniform”—a standardized hospital gown devoid of personal expression. This observational role is quickly derailed as the student redirects herself to an analytical, objective persona, modeled to her as a good physician. After reorienting, the student “stumbles, tumbles” through the interview, which she describes as an “interrogation.” Her embarrassment about her inexperience signifies imposter syndrome, a psychological pattern in which individuals doubt their accomplishments or talents and have a persistent internalized fear of being exposed as a fraud, experienced by many new medical trainees. The prevalence of this phenomenon is evidenced by Villwock and colleagues’ 2016 pilot study, which concluded that nearly half of female medical students and a quarter of male students experience imposter syndrome and report burnout components of cynicism, depersonalization, and exhaustion. 2 This anxiety of not belonging, of being an imposter, can be further exacerbated by rationed time with patients, as modeled by more experienced physicians. The student in the poem feels not only overwhelmed and underqualified but also pressed by a lack of time to adequately navigate the intricacies of caring for an ill patient. The piece comes to a discouraging close as the patient’s experience comes to light: “Just a tissue,” she says, sniffling, revealing her sadness to the floundering trainee. Until this point, any real appreciation of the patient’s perspective beyond mere superficial observations has been painfully absent. The learner caught up in trying to be a great medical student fails to attend to the person, the whole person sitting in front of her. This patient could have just learned that her grueling treatments have been ineffective in treating her cancer. Or maybe she feels lonely and isolated because people tend to treat her differently now that she is bald and weak. Perhaps she is mourning the loss of her everyday life that has now been usurped by chemotherapy infusions, lab draws, and follow-up visits. An appreciation of this robust perspective is demoted by the trainee for any number of reasons: for instance, a lack of time, a desire to retrieve an accurate HPI to impress the attending, general anxiety about the ordeal resulting in tunnel vision centered on the task at hand. Yet, despite adequate reasoning, the failure of the student to attend to the patient’s emotional well-being is a failure to care for the patient. As Sir William Osler rightly stated, “The good physician treats the disease; the great physician treats the patient who has the disease.” 3 In light of Osler’s observation, it should be the task of medical schools to emphasize not only scientific knowledge but also humanistic considerations, such as emotional and illness intelligence, philosophical reflection, and narrative competence, when shaping the character of tomorrow’s physicians.