Jeanne Bereiter, JAMA. 2008;299(18):2129-2130
THE YEAR MY GRANDMOTHER DIED, I WAS WORKING AS A family physician in a small arctic city that didn’t have a veterinarian. There were ten physicians in town, and we all did what we could when animals became sick or injured. I was absurdly proud the day I started my first intravenous line in a terrier, who made it through a bout of parvovirus thanks to IV rehydration. I was doing fairly well with people too. It was my first job after residency, and I was alternately terrified and exhilarated by the emergencies I was handling and the pathology I was seeing—intra-abdominal pregnancy, gunshot wounds, dislocated shoulders, delirium tremens, botulism, frostbite. By midwinter, I had hit my stride and thought I could handle anything that came my way. I was on call in the emergency department one night in February when my mother phoned. My grandmother was in the hospital with a sudden massive myocardial infarction. Her physicians wanted to know if the family had any directives regarding resuscitation. My grandfather had dementia, so it was up to my mother and uncle to make the decision. They barely knew what the physicians were asking, and both lived thousands of miles from the Kansas town where my grandmother was being treated. “We’ll go with whatever you think,” said my mother. “Can you call the hospital and decide what should be done?” My family is not demonstrative. We say “I love you” at the end of telephone conversations, but never in person. I wasn’t sure how my grandmother felt about me beneath her Midwestern reserve, but I loved and admired her fiercely. She had driven a Ford Model T at the age of 13 and went to graduate school at a time when few women did such a thing. Now she was dying, worn out by caring for my grandfather. I felt a rush of tears and shoved them back. I telephoned the hospital in Kansas from the nursing station. I could have gone to a back room, but I half consciously knew that the sight of the busy ED would keep me focused. Even so, my heart was pounding as I dialed the numbers my mother had given me. I identified myself as “Doctor Bereiter” to the woman who answered the phone and was quickly put through to my grandmother’s physician. “How bad is it?” I asked. We discussed blood pressures and ECG tracings and enzyme levels, and my heart rate slowed to normal, even as I realized that my grandmother would not live through this myocardial infarction. She was being kept alive with a dobutamine drip. The situation was hopeless. Resuscitation would be futile. Calmly, I thanked the physician for the information and told him that I would advise my mother and uncle to make my grandmother a no code. He agreed that that would be the best decision, to avoid subjecting my grandmother to any unnecessary pain. “One more thing,” I said. “You mentioned that she is conscious.” “Yes, she is, intermittently,” replied the physician. “Well, could you tell her that her granddaughter Jeanne called and that I love her,” I said,myvoice suddenly so tremulous with tears that I could barely choke out the words. The phone was a black blur. In the midst of my grief, I was astonished. Everything changed when I stated my first name. I became a granddaughter, not a physician, a granddaughter who was saying good-bye to her grandmother for the last time. I blinked the tears out of my eyes and conjured up a mental image of my grandmother’s laboratory results. I thought about how I would explain them to my mother. It was as if I’d turned on a switch. The tears and the thickness in my voice immediately went away. This is crazy, I thought. I’d always known that medical training had taught us to suppress our emotions in order to function, but I’d never realized to what extent. I could shut off grief even about my own family. This was tremendously interesting, but meanwhile, I had an emergency department full of patients. I worked all that night. It didn’t occur to me to ask anyone to take my shift. My mother called to say my grandmother had died peacefully shortly after I spoke to her physician. By the time I went home the following morning, fatigue had overtaken my urge to cry, and my predominant feeling was sad pleasure that I had done what I needed to do to save my grandmother from having her ribs broken during an unnecessary resuscitation attempt. It was my gift to her, one I could make because I am a physician. A month later, I was working at my outpatient clinic when a man rushed in, frantically asking for a doctor. Outside, a group of onlookers was gathered around a black Labrador retriever lying in the gravel. “She got hit by a car,” the man sobbed. “She’s pregnant. She’s not even a year old.” The Lab was beautiful and well cared for, her thick black coat shining with the silkiness of youth. She turned a dull eye to me, panting slowly, blood oozing from her mouth. She seemed to know that there was nothing I could do to save her. Laying a hand on her soft head, I looked up at the man and realized, to my intense surprise, that I was crying too. “I’m sorry,” I said. “It looks like she has internal injuries.” Usually when I spoke of medical matters, my feelings shut off. But this time I continued to cry. How could I still be crying? “It’s okay,” said the man. “I thought it might be too late.” He crouched down beside his dog and petted her as she died. It didn’t take long. Back in my clinic, I closed the door to my office, laid my head on my desk, and sobbed. I cried for a long time. I cried for the beautiful dog, and for her owner’s grief. I cried for the unborn puppies, and then I cried for my grandmother, and for all the other patients I hadn’t been able to save, all the other grief I had witnessed. I cried all the tears I’d been too busy to cry before. So this is what it’s like to have natural human emotions, I told myself in wonder, and then I cried for the loss of the ability to cry when something sad happens with a patient. I was a physician, not a veterinarian. I hadn’t learned to shut off my feelings when dealing with animals the way I had with people. The death of a beloved dog was sad, so I cried, the way anyone would cry. The medicalization of my feelings was species specific. I thought about the night my grandmother died and how my feelings turned on and off depending on whether I was “Jeanne” or “Doctor Bereiter.” Turning off feelings allowed me to function professionally, and my tears for the dog showed me how medical training had altered me. I was changed, and there was nothing I could do about it. There were vast areas of experience in which I would no longer have normal human emotions. My professional response to human tragedy allowed me to discuss laboratory values and clinical symptoms, to use my intellect, and to make decisions. It was necessary, yet it cut me off from the realm of others’ experience and from the emotional coherence I had possessed prior to my medical training. Something opened inside me when I cried for that dog. I wish I could say that I learned in that moment how to make my emotional switch smoother, but I didn’t. It took years to learn the fine-tuning, when to trust that I could let myself feel and not fall apart, when to pull back on my emotions. When we speak of the art of medicine, we usually do not think of how we manage our feelings. But that is indeed an art, and it lies at the heart of medicine.
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這是上個月帶我們的老師最近與我和學姊分享的一篇文章，是一個上個月一起照顧的病人讓他想起這篇文章。
看完之後，我很感謝老師，藉由文章讓我回想整個照顧病人的過程，以及從中領會的一些想法:
記得剛開始接到這個病人，只覺得很奇怪，不曉得他為什麼要住院、為什麼會收進來教學病房。因為看病歷寫的就是個肺癌併腦轉移，正在做化療但因心情劇變且出現一些功能性退化的病人。而且當我問完病史、做完PE之後找不出什麼positive finding後，我又更加苦惱和疑惑了。
之後他的情況起起伏伏時好時壞，心情部分曾因為能夠繼續做化療而轉好，就像出現一線曙光，那幾去看他，總是見到太太特地為他煮青菜牛肉，他吃的津津有味，太太在一旁看了也是喜上眉梢。
但生理上徵象卻騙不了人，步態不穩精神不濟日亦嚴重，即便排了影像檢查也找不出原因。病人會關心家屬會著急，於是我也因為沒辦法給他們一個確切的答案而追著老師問究竟答案是甚麼?我們還能再做甚麼?
其實這種感覺我第一個月還到內科就曾經有過，我也是對某個”我看起來”好像還有救，因為”幾天前看起來還好好的”的病人，最後團隊卻決定放棄積極治療轉為palliative care，感到不解。
後來我懂了老師的意思，慢慢能理解是為了哪些考量而做出種種決定和處置。而且從最後的結果，我也知道終究還是老師的經驗，有時候甚至可以說是一種直覺，才能在當下的情況，帶給病人和家屬一個在做好最壞打算 (理解實情)的情境裡，去為剩下日子做最好準備的答案。
病人的太太在老師告知先生情況可能不會太好，可能要帶著尿管回家……等預後消息那幾天，陸陸續續跟我講過一些話。到現在我都還記得那種起雞皮疙瘩，痠麻感從背部蔓延到頭皮的感覺。她說，他們自美返台時走的急，本來還打算等病情穩定下來，要回去把事情處理安頓一下，沒想到，這一回來，竟然成了單程機票…她本想等先生能夠自己走路，不用帶著尿管時，要帶他去郊外走走看看，畢竟這些年來先生總忙於工作，壓抑自己的情緒和壓力，她覺得一定要好好讓他放鬆開心一下，可是這些計畫似乎也都不可能了…….
有部電影叫”明日的記憶”；病人的太太跟我講完話抱著我哭了一下，雖然病情不同，但那時我覺得這電影好像在我面前活生生上演著……
文章裡，有些話讀起來特別深刻，像是…..medical training had taught us to suppress our emotions in order to function. 還有這個醫師為了不能就懷孕的小狗而潰堤時，一併想起了這些年所禁錮的情感，無論是對病人，還是失去的至親，…I cried all the tears I’d been too busy to cry before. So this is what it’s like to have natural human emotions, I told myself in wonder, and then I cried for the loss of the ability to cry when something sad happens with a patient..………I was a physician, not a veterinarian. I hadn’t learned to shut off my feelings when dealing with animals the way I had with people. The death of a beloved dog was sad, so I cried, the way anyone would cry. The medicalization of my feelings was species specific.
我們才剛進臨床，每天早上學著用最簡短最有效率的方式把病人的病情，短時間內最有意義的變化報給老師聽。常常在情感上那一塊就自動省略，或者因為”相對重要性”不若飆升的血糖、驟降的血氧、漸趨模糊的意識，而一併被濃縮掩埋進一連串數字和專有名詞裡。像作者說的: Turning off feelings allowed me to function professionally…. My professional response to human tragedy allowed me to discuss laboratory values and clinical symptoms, to use my intellect, and to make decisions…..It was necessary, yet it cut me off from the realm of others’ experience and from the emotional coherence I had possessed prior to my medical training.醫學倫理課程常常在討論這方面的問題，質疑、挑戰、批評這一切看似再稀鬆平常不過的程序太沒有感情，太欠缺人性化。不過沒真的進醫院看到、經歷過，我想討論再多case，理論再精闢，我們也不會懂，也不會知道這其實沒有絕對的對與錯，也不能體會其中的道理和奧秘；因為這本不是紙上談兵能涵蓋的範疇。
謝謝老師提醒我們，願意跟我們分享這篇很棒的文章。懂得適時切割、結合工作與情感，真的是一門大學問。也許接下來這幾年，面對這樣的情境，我還是無法立刻進入狀況，做出適當判斷，理解師長們的決策；不過當我的經驗再多一點，當我能夠看得更深入更透徹，希望我能將分寸拿捏得更恰當，能收放自如，同時不會忘記在我剛當clerk的幾個月裡所看到、體會到、向老師學到的一切。
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