"I have done that," says my memory.
"I could not have done that," says my pride, and remains inexorable.
Finally my memory yields.
When I awoke in bed at King County Hospital in Seattle, I assured myself that I was just dreaming. It was my fourth month of internship. One of my patients, a chronic alcoholic with liver failure, had persistent bleeding from enlarged esophageal veins. In spite of our best efforts, his condition was progressively worsening. I awoke upset from dreaming that had I taken his pillow and smothered him. My thought was that we needed the bed for another patient. Even today, this memory remains disturbingly real. I have no grounds to suggest that I contributed to his later death, yet there is still present a sense of failure that I need not dispel. This dream provides a shorthand reminder of ways I might fail in medicine.
In retrospect, I would have been diagnosed with posttraumatic stress disorder (PTSD); however, at that time, all psychiatric diagnoses were reactions applied to people grouped by similarities but not typed with disorders. I did not have far to look for sources for my reactions, which I still find of more concern than the syndrome I developed.
Eighteen months before this dream, after completing my third year of medical school, I accepted a position as summer "extern" at a rural community hospital in Massachusetts. It was my first hands-on experience of medicine outside the shelter of school. As was common in the 1950s, the hospital doctors were only available on call from home; therefore, because I was present when the need arose, I delivered babies, managed patients with heart attacks, provided the first interventions for serious accident victims brought in from the nearby Massachusetts Turnpike, and tried to help until a doctor arrived. Most were rewarding experiences. One woman whose baby I delivered as she arrived at the emergency room named the baby after me. I looked forward to being qualified as a doctor.
One night the nursing supervisor who managed the emergency room whenever there was a patient called me to see a young woman. She had been run over by her boyfriend’s car after she lay in its path to keep him from leaving her. She was in shock from internal bleeding. There were tire marks across her abdomen, running from just under her ribs on the right side over her pelvis on the left. In moments such as this, we do more things at once than we can write about. I drew a blood sample as I started an intravenous infusion to replace her lost blood volume. I asked if the doctor on call had been asked to come in—he had—and the surgeon as backup. No, I was told. Only a doctor could call a surgeon. We agreed to ask the surgeon to come in. The nurse also agreed to call the laboratory technician so we could cross-match the blood we had on hand, the X-ray technician, and staff for the operating room. She agreed to do these things while I worked with the patient. Shortly afterward, the doctor and surgeon arrived, examined the patient, who seemed to be maintaining her breathing and blood pressure sufficiently that she would reach the operating room alive, and then withdrew, asking me to continue what I was doing for the patient.
Time passed—all too much time, it seemed—without blood being delivered to the patient, the X-ray technician appearing, or for the preparations to take the patient to surgery to begin. I asked the nursing supervisor where the blood was. "The doctors canceled the orders and had me call everyone and tell them it wasn’t necessary for them to come in." I struggled to find words to respond. At the time, I sensed that we both struggled to corral our feelings and thoughts. This situation seemed an impossible break with what I had just learned in 3 years of studying medicine. I remember asking the nurse to stay with the still-conscious patient so I could go and talk to the doctors. I found them in an adjacent room and asked, "What will we do?"
"We don’t want to treat this kind of patient here.…It won’t be necessary for us to get involved.…There is nothing we can do.…You should stay with the patient to see what happens. There’s no point in sending her on to Worcester; she won’t make it." All of these phrases have never left my mind since that night.
I saw no alternative except to do as I was instructed. I did not say, "We can try," but I still hear the words in my mind when I think of those moments. "We can try," seems important in medicine. At the time I spoke silently to myself, "I am a student. They certainly know more than I do about these situations." Saying this was neither satisfying nor reassuring. I went back to the patient and kept the fluids going. In about 30 minutes, she became unconscious and then died. After she was no longer breathing and there were no heart sounds, I asked the nurse to call a doctor to pronounce her legally dead.
The state medical examiner agreed that I could attend the autopsy. We found a 3-inch laceration in her liver but only minor bleeding, one fracture posterior and one anterior in the left pelvis that had been drawn closed by muscular contractions, and a tear in the internal iliac artery over the posterior fracture site. The patient died from blood loss into the abdomen through the torn artery. "Why didn’t they open her abdomen and sew this up?" the medical examiner asked me. "I don’t know," I said, relating what I was told and defensively noting that I was a student.
In many ways, I felt responsible, even though no responsibility was suggested. I wanted to shed tears, but I would not allow myself to do so. Tears, I thought, are not in a doctor’s formulary. Years later, I understood differently when another resident told me how Yale Chief of Medicine Paul Beeson had wept when he could not save his resident, a young doctor, from a drug-resistant infection.
In the shadow of this summer, my fourth year of medical school was less clear for me than the others had been. To avoid some clinics, I took an afternoon job teaching an organic chemistry laboratory at Roger Williams College in Montreal, went through the motions, watched my class ranking fall, and went to my internship. I avoided lessons in clinical medicine that I did not want to learn.
For the first 2 months of my internship, on a psychiatry rotation at the University of Washington’s University Hospital, I talked with patients and teachers and rediscovered a place for my interests in patients and the diseases that affect them. I spoke to no one of the previous summer. Nor do I remember those events to be of great significance years later in my personal analysis, perhaps because there are no memories to recover and no doubts to resolve. The events and my reactions remain too clear. My conflicts draw on deeper personal roots that I followed in analysis, and I still view my reactions as aversions to failings in moral courage, medical skills, medical training, and what it means to be a physician that I witnessed that day and did not wish to see again. Whatever psychiatric disorder might have been present in me seems shallow and out of focus compared to the circumstances I chose not to abide.
In the third month of internship, I was back in trouble. The internal medicine resident who supervised my work found me lacking. Unfortunately, the feelings were polarizing and reciprocal, so I mainly did his bidding while waiting for better days. He said one morning, "Get a stomach tube in that stroke in bed 3 and get her out of here this afternoon to a nursing home so we can get some better teaching cases." That she was learning to walk and eat with her left hand did not matter; I passed the tube into her as she watched and gagged, unable to speak from her stroke. I made a call to social workers, she was shipped out, and the bed was free.
While taking orders, I think I released in myself a part of the medical training I hoped I could avoid. I did not realize the changes until my dream a few weeks later pointed out the realities. As Robert Petersdorf, the new chief of medicine at the university’s King County Hospital, reinforced for me as he questioned us in rounds: knowing the latest discoveries reflects well on one—a game I was adept at playing from medical school—while being distressed over how we use technology does not lead to a place in a residency program. I chose to arm myself with skills so that I would never have to stand by unprepared, but I feared myself all too willing to lose my soul for success. In those transition years from school to specialty training, memories, nightmares, loss of interest, avoidance, fear that I would fail in some ways and not in others, indecision, and distractions introduced to avoid conflict would today be diagnosed as PTSD, but they each remain dynamic interactions with events for me.
Later in my internship, I was back on an internal medicine ward at the University Hospital in Seattle. We had a patient who was losing blood into his gut through his intestinal walls. Testing showed no unaffected areas, surgeons saw no feasible interventions, and internists could reach no diagnosis that suggested a way to stop the blood loss. The blood bank notified us that at the current rate of use they would be out of suitable blood by midday Sunday. Today was Friday. We presented the situation to the attending physician, Wade Volweiler. He listened, went over the findings with us, and walked in to see the patient. He examined the patient and asked him to excuse us from the room. In the hall he said, "We have to tell the patient that there probably will be nothing more we can do but try. I would like to give him the decision if it is all right with you—unless one of you has some other ideas we should discuss." We did not. We went back into the room.
Dr. Volweiler asked the patient if he might sit on the bed to talk with him. At that time, we were trained not to sit on the patient’s bed out of respect. This break with protocol signaled to me a different, informal, personal, shared moment in the relationship between doctor and patient. His sitting on the bed still expresses to me that someday each of us will be in that bed. Dr. Volweiler explained the situation and said gently but directly to the patient that he thought he would want to know that we saw little likelihood of his surviving, so the patient could arrange to speak with his family before the apparently inevitable moment of crisis. He pointed out that the patient had a choice: he could receive whatever blood was available, or he could choose a time to stop adding new blood and leave some blood for others who might need it. The patient thought for what seemed longer than it was then asked if he could arrange to be with his family Saturday morning and to stop the addition of blood at noon Saturday. I was off duty that weekend. When I came in Monday morning, a new patient was in his bed. I still feel pain, tears, an unreasonable senselessness, helplessness, loss, and injury to unreasonable pride or expectation for what we might do as doctors, but I mainly respected this patient’s courage and dignity—each a reaction to this traumatic stress. I also feel a debt for a gift that made my life uniquely richer: I learned that even at the limits of science, in extremes of suffering and sorrow, we can be decent with each other and with ourselves, and I saw how to be different. Years later, sadly, when I stated to a chief of medicine who had trained at the University of Washington how I owed a debt to Wade Volweiler for showing me what it means to be a physician, he described my mentor’s role in later years as not mainstream and marginalized to his office. I thought it sad that this chief could not share my perceptions.
Ten years ago, I read a story about William Osler, the much-venerated model for physicians during my training at McGill University. During our medical school years, W.W. Francis had shared many personal memories of William but not this story, perhaps because it occurred in Oxford. William was asked to see a young child with diphtheria who was not eating and seemed headed toward death. William was preparing for the graduation ceremony at Oxford, so he put on his academic robes and stopped to see the child in this dramatic regalia. The child was delighted at the sight of this colorful doctor. After completing his assessment of the child’s condition, William ordered some soft food and fed it spoonful by spoonful to the child. After the child finished eating, William went to graduation. Each of the following days, William called on the child in the same academic robes and continued to feed the child until the diphtheria inflammation resolved sufficiently that the child ate on his own.
In his earlier years, William made medicine at McGill University scientific but also left us a legacy of how to work with people. In this Hippocratic tradition, people do not become invisible in the presence of disease. I doubt that technology will ever replace the efficacies of some Hippocratic traditions of practice or at least of William’s embodiments of them. He combined scholarship and knowledge with concern for the person as the conditions of practice. For me, this means somehow understanding PTSD as both a disorder and a reaction.
Events of our times reawaken these old conflicts of disorder with reaction for me but with each way of thinking valid only in context with the other. I feel I am back in that emergency room some 50 years ago when I hear the words of soldiers in Iraq who are labeled by the media, with medicine’s approval, as having PTSD because they exclaim, "I don’t want to die here!" and panic, cannot forget shooting someone who did not stop when approaching a checkpoint, or cannot stop thinking about saving colleagues who seem certain to die. I sense in them what I found in myself and many times over in practice—a disorder only at the conclusion of an out-of-control cascade begun by natural human reactions. No one wants patients to die when medicine could try to save them; no one wants to die in Iraq. Before I bury the complexities of many individuals’ diverse reactions behind labels of disorders, I want to ask each person one-on-one if he or she believes each of us will want to take every measure to survive and help others survive. Could it be that this soldier thought himself—or was actually caught up—in circumstances in which others betrayed his trust in them? Did he—unlike that patient who waited for help that never came to the emergency department—flee the helpless inevitability imposed by others who had already fled their personal responsibilities for the anonymous safety of roles and "we"? Before I fixate on disorders, I want to discuss with the person about to be labeled or to be self-labeled, whether by placing others in positions where they have no choices, do not leaders incur responsibility for what happens on their watch if others follow orders? If these words do not reassure a soldier who follows orders and commits no crime, I expect I would stridently argue with him or her that a soldier protects a checkpoint as his duty, much as we physicians occupy our stations with senses of duty. The mistakes that ensue from mandated procedures are the failings of planners. How unjust I found labels of disorder to be in the past when simple inquiry revealed facts to be otherwise and vastly more complex. Why should I expect these problems of diagnosis to be any different now?
Public policy labels the many different human stories and reactions of veterans as disorders with alacrity. This labeling serves systems willing to offer only waits of many months to see doctors who then have time only for another meeting months later and only drugs—not themselves—to fill the gaps. In my years of practice, I never saw one disorder or type. Perhaps because I had the time to inquire, I saw many different people with many different reactions and many different routes to healing as best they could the memories of personal traumas. Psychiatry’s now-out-of-fashion reactive diagnoses stayed alive for me over these years as reminders that diversity, not uniformity, characterizes the lives of organisms. Now government policies encourage us to imprint lives as disordered and to fail veterans with the conveniences we find by homogenizing diversity into disorders. Thousands of different stories become one diagnosis. I fear that psychiatry conspires in this because over the last 50 years, overcommitted to the homogenizing perspectives of disorders, we have lost our grasp on how to understand an individual.
Only biochemicals have predictable and regular disorders. Only people have diversely individualized diseases. Only biochemicals show unvarying patterns in their reactions. Only people show uniqueness both genetically and historically and provide the diversity that characterizes life through lives that dynamically build in time, never to repeat the past in exactly the same ways. This diversity displays how we as whole beings differ from our molecular parts.
Disorders imprint a lifeless uniformity on experience. Disorders are appropriate for derangements of molecules but meaningless for individuals. Today veterans are as much victims of labels and stereotypes as the patient in the emergency room or the stroke victim in bed 3 were. Then people disappeared behind stereotypes of "not wanted here"; now people disappear into a stereotyped "disorder." We are physicians to both people with molecular disorders and unique individuals, just as Darwin made us biologists of molecular and whole-organism processes. Darwin found it necessary to think in new and different ways to capture how unique organisms differ from their molecules. Why can psychiatry not support us in these difficult balances of molecules and living? Disorders describe our molecular abnormalities, and reactions preserve us as individuals—always diverse, always personal, always uniquely encountering life, always needing to balance impersonal explanations with personal understandings.