Picture of Greg Costello

Greg Costello
University of British Columbia
Class of 2016

“Let [the physician] reflect that he has undertaken the care of no mean creature…”
– Thomas Sydenham

“Did you hear that Mrs. Gavin died?”

The question wasn’t directed at me, but my stomach still dropped to my shoes.

“Oh no! I haven’t seen her around for a while… Was she sick?”
“Yes, she was in the hospital for about a month. Her funeral is later this week.

At that point I stopped listening to my colleagues as my mind went back to the emergency room a few days earlier.

I was just finishing up a shift in the ED, ready to go home after a long day. As I was reviewing an X-ray, my pocket began to buzz. It was a nurse from the inpatient unit, asking if I could come and see a patient who was having some trouble. Apparently, one of the staff saw me and thought I was on call, which was not the case.

Despite my strong desire for sleep, I went upstairs. I found a middle-aged woman who was, for lack of a better phrase, “circling the drain”. Everything seemed to be going wrong with her. She was very obtunded, limiting my ability to gather a meaningful history. My physical exam was brief and focused on the issues that most concerned her nurse. I made a diagnosis of the acute problem and called the physician with my findings and a suggested plan of action. After writing down some orders and clarifying the situation with the staff, I left the ward. When the cool night air hit my face, I forgot everything about that lady upstairs; the physical findings, lab values and nursing concerns dissolved away. Everything except her name.

Even after I left my friends that morning, I couldn’t stop thinking about Mrs. Gavin. The encounter with her had been days earlier, and I knew she had not been doing well. She was indeed drawing closer to the drain, and there was very little that could be done. Certainly, no action I took did anything to speed up or slow her progression towards death. I did no harm. So why could I not escape the memory of that episode?

And then it dawned on me.

In that moment, Mrs. Gavin was, to my eyes, a series of failing organs with deranged physiology. A set of interconnected problems to be dealt with, many unsolvable with the means at my disposal. I knew nothing about her life, apart from the intricate details of that moment. And importantly, I distinctly remember the absence of any emotion that evening. No fear or anxiety, but also no compassion or empathy. And that disturbed me.

Much has been written about the apparent shift in the attitudes of medical students towards patients as they progress through their training. Specifically, it has been noted time and again that during the clerkship years these students, once demonstrating a great capacity for caring, suffer a measurable decrease in their levels of empathy. It seems that the so-called “hidden curriculum” of medical school, while bestowing the tools to be effective, competent and confident physicians, also takes something away from us. In essence, in the process of becoming doctors, we learn to forget those characteristics that once drove our endeavours.

My colleagues and I were all made aware of this phenomenon in our pre-clerkship years, and I’m sure we all strongly desired to resist this trend. Unfortunately, it seemed that despite my best intentions and efforts, I succumbed. Though I had become proficient in gathering histories, I had become numb to the stories.

A preceptor later pointed out to me that there are many reasons this occurs, all of them understandable and (some) even necessary. It would be easy to burn out if you become “invested” in every single patient who crosses your path, they said. In addition, being preoccupied with peripheral concerns can blur your vision in a crucial moment. To use a dramatic example: stopping to contemplate the humanity of your patient as they are suffering a cardiac arrest is likely ill advised. Maintaining “aequanimitas” or the “even mind” that is the cardinal virtue of a good physician as described by Sir William Osler, requires some form of mental distancing from the harsh reality of medicine. Unfortunately, this makes it easy to slip from demonstrating clinical coolness, to thinking and behaving with a hint of callousness, as I fear I did that night.

Realizing all of this, I felt deeply disheartened. Despite my preparation and desire to practice medicine with the whole person in mind, I had developed a habit of thought antithetical to that very goal.

And then, again very suddenly, I realized that all was not lost. Though she was unable to speak, Mrs Gavin still had a lesson to teach me, and I promised myself I wouldn’t miss it as I looked up the location of her memorial.

The church was packed with hundreds of her friends and family members. I sat at the back and surveyed the impressive scene as her children at the pulpit recounted story after story about their mother. Her face gleamed from a photograph next to the altar. In that hour I felt both incredible shame and deep gratitude. I was finally introduced to the unique lady whom I had treated — but in reality had failed to even see — in the hospital only a few weeks prior. In that moment I recognized that though I can never go back to that evening and change how I approached her, Mrs. Gavin gave me a great gift – an anchoring memory to keep myself from drifting back into old habits, from forgetting the person in my care.

In turn, thanks to her, I may be able to positively affect the quality of the encounters with my future patients, improving not only their health but also enriching their stories, as well as my own narrative and practice.

Please note that the name of the patient has been altered to maintain confidentiality.