A Physician's Lament

By Sherwin B. Nuland, M.D.

The scene is all too familiar. I have witnessed it--and been a participant--more times than I care to remember: a small team of physicians and students on rounds stops at the door of a patient in the last stages of a disease that has eluded all efforts at a cure. After an awkward hesitation, the senior member turns to the others and says, "She's probably very tired and needs her rest. It's better not to disturb her. Let's just go ahead and see how yesterday's colectomy is doing." The others nod, and they move on to the next room.

Every one of the group knows what has just transpired. The students have already begun to understand that modern medicine is action, that its excitement comes from the challenge to intellect, to technological skills, even to personal daring. The greatest victories go to those who diagnose brilliantly, who are undaunted by the most intimidating confrontations with disease, so long as there is a possibility of cure or at least improvement. These are the biomedical gladiators, and their arena is the hospital. Unlike the gladiators of ancient Rome, they always win. Well, almost always--and only for a while.

When there is no victory, however, the challenge is gone, and most lose interest. Worse yet, they have suffered one of their rare defeats, and they handle it badly. They were not chosen to be defeated, and they are not trained to deal with it. They have been trained for the certainty that theirs is a noble war against death.

It begins with the selection process. Medical school admissions committees look for winners: the highest GPAs, the highest scores on the Medical College Admissions Test, the most glowing reports about undergraduate achievements. They like to see stratospheric numbers and florid adjectives. In view of this emphasis, it is a wonder that they manage to admit as many idealistic young people to the profession as they do. But there are not enough, and every one of these students wants to be a man or woman who knows how to triumph over great odds. When the time comes to lose, as it inevitably must, doctors will too often turn away from the evidence of their perceived failure because they don't know how to behave when faced with it. Few will think to hold a dying woman's hand. They will move on to the colectomy in the next room.

The faults in the selection process are compounded by the faults in training. Today's medical or surgical residencies are like years on end of Marine boot camp, where the values of the group are instilled at the expense of the values brought to the experience by each individual entering it. In the presence of teachers who exemplify the fighter-pilot mentality of success in the face of mortal danger, the idealism and even the humanity become imperiled. Too often, they are leached out in the long indoctrination. The best become like their teachers: they worship at the shrine of scientific objectivity, and they wrap themselves in a mantle of depersonalization that allows them to carry on despite the carnage around them--all in the name of victory over death.

But what if no victory is possible? At first the defeated physician withdraws psychologically, then physically. He rationalizes that consolation is best left to clergy and family. Truth be told, it is difficult to face the evidence of failure, and difficult to face one's own fears of death and impotence, which psychologists tell us are often a major motivation in choosing a medical career. The next room--the one with the successful colectomy--is a safer place, because it holds proof of our enduring power.

In truth, other kinds of victories are possible. We cannot defeat death, but we can conduct a campaign against suffering. Some physicians--the experts in palliative care who take as their challenge not only the physical but also the emotional and spiritual comfort of their patients--have chosen this as their calling. They are no less scientific in their efforts than the rest of us, but they are better able to see each individual as a whole person, living and now dying in the context of an entire lifetime of experience.

But to provide comfort to the dying, one need not be restricted to the specialty of palliative care. Those patients who come to the other kinds of medical experts for the most advanced treatment of their disease have a right to expect far more than mere technological efforts. There is no inconsistency between the ability to achieve great diagnostic and therapeutic victories and the ability to provide comfort when those victories are beyond reach. We must begin by becoming more willing to recognize the moment when our efforts only serve to worsen an irretrievable situation. Having acknowledged that such a time has come, we must abandon not the patient but the barricades on which we have been fighting the inevitable. For many of us, this is the most difficult moment of all. But it can be made easier by looking to the rewards that accrue, for us and for those who depend on us for the relief that we can bring them.

We who are accustomed to looking the other way when faced with an absence of curative options must resume the pastoral role that doctors bore so well before today's miraculous methods existed. We need not change our approach to the pathology of disease, but it is imperative that we assume greater responsibility for the totality of our patients' lives. If we cannot heal in one way, we must learn to heal in another.

Dr. Sherwin B. Nuland is a clinical professor at Yale and author of several medical books, including How We Die