Stepping lightly over boxes of medical experience

A multi-vehicle trauma! This is what it is all about, Ithought, as I followed my senior resident to the stairs.  While my age placed my training against a St.Elsewhere’s backdrop, my excitement was more consistent with the modern,high-energy ER soundtrack.  The emergencyroom itself inspired excitement, and as a third year medical student I had notyet developed the healthy fear that affected more senior, and more answerable,members of our surgical team.  As weapproached the cubicle I noted that the patient was small, maybe two yearsold.  Red froth bubbled from his mouth asthe emergency room staff frantically removed his cervical collar.  I heard the word ‘tracheotomy’, and someonesaid “hold him down!” as his arms reached into the air. I grabbed his hand andheld tight, grateful that I had found a mission that I could handle.

To my surprise, the hand gripped back.  And suddenly… time stopped.  Small fingers wrapped around my finger, and atonce I was sitting with a small boy, stillness around us.  I looked beyond the red froth, to see hisclear, blue eyes gazing forward.  Nolonger aware of the work to be done, I began to understand a tragic story.  Through pieces of conversation I realizedthat the boy’s mother and father lay dead on gurneys in cubicles behind me,victims of a drunken driver.  In a flashI could see all of what our experience on earth offered: life and death, hopeand despair, beauty and horror.

After 15 years, I still feel heaviness in my heart as Iremember that night. I have not attempted to describe the scene before, but Ihave sometimes felt the moment’s essence, as a secret part of what has sincebecome ‘me’.

I have many secrets. I remember the 5-year-old girl who I met in the oncology clinic, withnewly diagnosed leukemia. I silently winced in pain at the smile on her smallface, an innocent unaware of the needle-sticks ahead of her.  She sat with her mother, whose expressionbetrayed the knowledge that her daughter would be forced from the world whereshe belonged; a child’s world of security and happiness.  I remember the seven-year-old child who diedof sepsis in our recovery room after hours of attempted resuscitation, and Iremember the horror that filled the room as we accepted the futility of ourefforts. And I wonder, how have these secret images affected me?  Am I a better doctor, or parent, or friend, ordo I now carry a seriousness that has driven some of my personality inside, andbeyond reach?  Will I be a better psychiatrist?  Am I more tuned in to pain, or has myexposure given me a resigned, grim acceptance of suffering?

For much of my life, my approach to learning was that alllearning was good learning.  My goal wasto face life’s experiences as a sponge, seeing as much as I could see, andexperiencing as much of life as possible. My assumption was that humans had the capacity to keep the wheat anddiscard the chaff; to assimilate the positive and to disregard the negativeaspects of experience.  The end resultwould be a ‘complete’ personality, free of bias, unfettered by misconception,and nourished by the ultimate sustenance of personality, information.

At some point my early opinions about learning becametempered with caution.  I began to seethat in regards to learning, experience, and personality, at least in my owncase, I am what I eat.  As much as Iwanted to believe that I was capable of learning only the desirable aspects ofexperience, I saw that my personality was affected in ways that I hadn’t predicted.  I remember briefly facing these questions asa college student, when I wondered, in 1970’s fashion, if there was in fact anyevidence that people were ‘smarter’ after formal education. I thought moreabout the topic during a period of my life when I actively meditated, as Ibecame aware of the constant parade of thoughts that drifted through myconsciousness, despite my best efforts to limit them.  This view of personality as an unorganizedcollection of experience is more Eastern, more consistent with what I have readof the developing ego, and more consistent with my experience as a parent ofteenagers.  Some things, once learned,cannot be unlearned.  Some badexperiences are unconsciously assimilated and eventually inhibit function, muchlike adware on a Windows 98 computer. Memories accumulate like boxes of artifacts in a darkened basement.  In my own case, half-opened boxes litter thefloor, and some emit frightening noises.

As I work toward becoming a psychiatrist, I would like todevelop an understanding of the biases that shape my attitudes; biases thathave the potential to interfere with neutral observation and reflection.  It is easy to identify the obvious examplesof personal experience that interfere with the neutrality that I desire.  For example, I can easily recognize thebarriers that stand in the way of my feeling compassion for the playgroundbully.  And the death of one of my bestcollege friends during the attacks of September 11 undoubtedly affects myopinions of America’srole in the world.  But while inpsychiatry we learn to identify personal and historical events that have shapedour attitudes, I wonder if work and training experiences are incorporated inpotentially prejudicial ways as well, perhaps beyond question because of theirendorsement by common medical experience. I would like to identify the ways that my experiences in medicine andpsychiatry change my view of the world, in order to have foresight into biasthat will develop in the future.  Ofcourse, unique character traits result from experience in all professions; as Isit in the auditorium prior to my daughter’s band concert, the principal,oblivious to the ages of the assembled parents, reminds us to remain quiet andrespectful during the concert.  But withadmitted narcissism, I see the experiences faced by physicians as particularlymemorable.

The experiences faced in psychiatry training, while lessovertly dramatic than the world of CPR and tracheotomies, force one toincorporate a different type of emotional experience.  In my short training, I have been moved bythe isolation of schizophrenia, by the emptiness and despair of depression, andby the ravages of families wrought by addictions.  It is often difficult to come to terms withreactions to psychiatric experience because of the lack of formal resolution.Psychiatric diseases for the most part are not cured, and yet are not fatal bythemselves; so there is no exclamation point to treatment successes andfailures, and less opportunity to place experience on the opposite side of theline that protects our present world view from the tragedies of the past.  There is also a learned frustration thatdevelops as we accept that the will of our patients does not always coincidewith our desire to help.  And again Iwonder, what have I begun to ‘understand’ about mental illness?  Can I make a difference?  What is the meaning of life in the face ofsuch suffering? 

At these moments, I try to find gratitude for theopportunity to seek psychodynamic understanding.  The beautiful, horrible experiences of lifeweave tapestries, unique to each of us and to each of our patients, with fibersvisible only to those willing to see them. And in the tapestries lie the questions, and the answers to thequestions, and the answers to all of the questions to come.  To study the fabric of these tapestries is tostudy the essence, and the meaning, of life itself.  It may be asking too much to weave our owntapestries by design, but one can be aware of the admonition of Aldous Huxley,that experience teaches only the teachable.

And once again, we are back to the original question.  Is all learning beneficial, and are allexperiences enriching?  Is it true thatwhat does not kill us makes us stronger?  Perhaps the answer is moot, sinceno matter our preferences, experience finds us. Maybe I can make an occasional decision as to what to remember, or facelife’s challenges and disappointments with the respect required to easecynicism. Perhaps I can embrace the feelings and the meanings of life events,rather than attempt to diminish their awareness.  Perhaps all I can ask for is to findexperiences with my eyes open, and to place my boxes in a well-lit room, where Iwon’t trip over them.