Stepping lightly over boxes of medical experience

A multi-vehicle trauma! This is what it is all about, I thought, 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 emergency room itself inspired excitement, and as a third year medical student I had not yet developed the healthy fear that affected more senior, and more answerable, members of our surgical team. As we approached the cubicle I noted that the patient was small, maybe two years old. Red froth bubbled from his mouth as the emergency room staff frantically removed his cervical collar. I heard the word ‘tracheotomy’, and someone said “hold him down!” as his arms reached into the air. I grabbed his hand and held 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 at once I was sitting with a small boy, stillness around us. I looked beyond the red froth, to see his clear, blue eyes gazing forward. No longer aware of the work to be done, I began to understand a tragic story. Through pieces of conversation I realized that the boy’s mother and father lay dead on gurneys in cubicles behind me, victims of a drunken driver. In a flash I could see all of what our experience on earth offered: life and death, hope and despair, beauty and horror.

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

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

For much of my life, my approach to learning was that all learning was good learning. My goal was to face life’s experiences as a sponge, seeing as much as I could see, and experiencing as much of life as possible. My assumption was that humans had the capacity to keep the wheat and discard the chaff; to assimilate the positive and to disregard the negative aspects of experience. The end result would 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 became tempered with caution. I began to see that in regards to learning, experience, and personality, at least in my own case, I am what I eat. As much as I wanted to believe that I was capable of learning only the desirable aspects of experience, I saw that my personality was affected in ways that I hadn’t predicted. I remember briefly facing these questions as a college student, when I wondered, in 1970’s fashion, if there was in fact any evidence that people were ‘smarter’ after formal education. I thought more about the topic during a period of my life when I actively meditated, as I became aware of the constant parade of thoughts that drifted through my consciousness, despite my best efforts to limit them. This view of personality as an unorganized collection of experience is more Eastern, more consistent with what I have read of the developing ego, and more consistent with my experience as a parent of teenagers. Some things, once learned, cannot be unlearned. Some bad experiences are unconsciously assimilated and eventually inhibit function, much like adware on a Windows 98 computer. Memories accumulate like boxes of artifacts in a darkened basement. In my own case, half-opened boxes litter the floor, and some emit frightening noises.

As I work toward becoming a psychiatrist, I would like to develop an understanding of the biases that shape my attitudes; biases that have the potential to interfere with neutral observation and reflection. It is easy to identify the obvious examples of personal experience that interfere with the neutrality that I desire. For example, I can easily recognize the barriers that stand in the way of my feeling compassion for the playground bully. And the death of one of my best college friends during the attacks of September 11 undoubtedly affects my opinions of America’s role in the world. But while in psychiatry we learn to identify personal and historical events that have shaped our attitudes, I wonder if work and training experiences are incorporated in potentially prejudicial ways as well, perhaps beyond question because of their endorsement by common medical experience. I would like to identify the ways that my experiences in medicine and psychiatry change my view of the world, in order to have foresight into bias that will develop in the future. Of course, unique character traits result from experience in all professions; as I sit 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 and respectful during the concert. But with admitted narcissism, I see the experiences faced by physicians as particularly memorable.

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

At these moments, I try to find gratitude for the opportunity to seek psychodynamic understanding. The beautiful, horrible experiences of life weave tapestries, unique to each of us and to each of our patients, with fibers visible only to those willing to see them. And in the tapestries lie the questions, and the answers to the questions, and the answers to all of the questions to come. To study the fabric of these tapestries is to study the essence, and the meaning, of life itself. It may be asking too much to weave our own tapestries 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 all experiences enriching? Is it true that what does not kill us makes us stronger? Perhaps the answer is moot, since no matter our preferences, experience finds us. Maybe I can make an occasional decision as to what to remember, or face life’s challenges and disappointments with the respect required to ease cynicism. 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 find experiences with my eyes open, and to place my boxes in a well-lit room, where I won’t trip over them.