Grief: A Case Study

Day 1: After I get off the phone, two parts of me diverge in some way. One part sees clearly, even identifies the things it predicts will cause me regret and anguish, remembers to pack an extra skirt in black in case my little sister doesn’t have one, starts planning for how best to take care of my family. The path seems laid out before me: “These are the steps to grief,” this version of me says. “They will be hard but once you take them you will be okay.” I buy tickets to Austin, and make a to-do list: Email your rotation coordinator. Arrange for someone to take care of the cats. Pack the shirt Dad gave you for Christmas, the last time you saw him (will ever see him).

But the other part of me slips herself in, always unexpectedly, at least every half an hour, and cries until my eyes are sore. (Samuel Beckett's words enter my thoughts: I can’t go on, I’ll go on.)

Day 2: On the way to picking up my little brother at the airport I talk to my husband about platitudes in grief. I had always wondered whether my metaphysical agnosticism would collapse in the face of irrevocable loss, but here it is staunch, and chafing at statements that plaster meaning over tragedy, that try to say that this thing that happened wasn’t entirely, completely, wholly wrong. Anger prickles at the back of my throat.

Every time I sob it launches me into a coughing fit. Lumberjack starts to store cough drops in his pocket.

Day 3: The rage is overwhelming, and I don’t know where it’s coming from, shifting in and out from hour to hour. I’m mad at everyone. I’m worried they won’t honor him well enough. I become possessive of my grief, thinking there must be some right way to do it so that I can rectify the anguish I feel for not telling my Dad a million times more often how much I loved him while he was still here to hear it.

I snap at my sister, then Lumberjack, and then I hide away, hating myself. In my Dad’s office I scan in dozens of pictures of him, and tears slip out of my eyes for hours straight. I’m careful not to let them touch the pictures. I suck on cough drops for dinner.

Day 4: In the morning in my Dad’s office I experience a meta-mourning, because the path I thought I saw forward is obliterated, and it hurts that I’ve lost the grief I thought I’d have. I tell Lumberjack I expected to be good at this. I apologize over and over that my grief makes me ugly and mean. He holds me but I can’t see a way out anymore. It hurts to breathe. (I can’t go on.)

Day 5: (I’ll go on.) At the visitation my mother sobs while she says, “It’s not really him. He’s not here anymore.” When I see him the same tears I’ve cried all this week come, but I’m mad at the edema that made his hands not his, at the funeral home that made his face not his, at my medical education that reminds me his ribs and sternum are broken, his heart beaten: not his. It truly isn’t him. I thought seeing him would help me believe he was gone, so that I’d be spared over and over the stab of re-remembering.

I stand in front of everyone and say imperfect words about my father that are wrenching. When I’m almost through I let myself look up and see that everyone is crying. I feel some of the anger leak away. And I let myself hope that my dad really is somewhere where he can hear how much I miss him, how I feel the space of his magnitude.

Day 6: I watch my brothers, my father’s sons, carry his casket. I had dreamt that he was here, for us to tell him all the plans for the service. In the waking life I re-remember again. My brothers all cry. Lumberjack hands me a cough drop. There’s a twinge at my side as I watch two sailors fold a flag meticulously.

All of my father’s beautiful, huge family together makes me feel he’d be proud, but in the evening it starts to peel off again, into cars and planes. The twinge deepens.

Day 7: I step on a scale and realize I’ve lost ten pounds. “Consolation prize,” I think to myself before I realize I’m wasting away with nothing else to think about besides grief. I slip into a familiar place where sadness doesn’t show in my face, and eat enough pizza for dinner.

Day 8: I wake up at 6am to the pain in my side stabbing now, localized and tender to palpation. My medical knowledge says I’ve coughed so hard I fractured a rib. Still I wonder if it’s my grief transmuted.

But I rate the pain at a 7 or 8 out of 10 and I know that’s certainly not enough.

I can’t go on. I’ll go on.

Honoring the Hype

Someone asked me what to do if your career in medicine feels boring, you feel like you're only doing it because it's the right thing to do, and working part-time or choosing a specialty with good hours feels like hedonism. This is what I wrote in response.

If you think your career as a physician is boring, you need to take a long hard look at what you’re doing. The longer I reflect on what it means to be a physician, the more I understand it to be a calling. It’s truly a vocation, and I apply that word because I don’t think that it should be done by people who don’t feel compelled to don that yoke.

I’m not saying you need to be hyped for your career 24/7, or even every year of your life. But you’ve gotta have a little hype – that hype allows us to pick ourselves up on days it’s really tough, it makes us honor the privilege and responsibility of having lives in our hands, and it, hopefully, compels us to do better for our patients with a measure of humility.

There isn’t a heavenly ledger that catalogues your gives and your takes from this world. We are all giving and taking – in fact each act of giving is an act of taking in some way, too, and vice versa. That’s what being a member of this human race is. You shared your bread with your sister and you gained generosity. You taught your brother and you gained a student. Your mother gave you life and you gave her motherhood.

To harp on a similar concept, there is no purely selfless motivation for pursuing medicine. Guilt will only take you so far before it corrodes.

I know that guilt makes up some of the fuel that powers my own motivation, but there are many other things too. Ambition, drive. And a deep, insatiable love and curiosity about humanity that means I care deeply about people, and also find a great joy in connecting with them. Do you see how that has some selfishness in it? I really want to help people, and also this way of helping people is one I find deeply satisfying and stimulating. It incites passion and drive in me. All of these things are roiled up together into the reason I’ve stayed on this medicine track.

(And you know what? I’ve checked in with myself every step of the way, to make sure I still wanted to be on that track. Before starting med school, I gave myself permission to quit if I started to hate it, if I didn’t think it was right for me. And so I took that seriously, and feel ever more confident on this path. I’ll continue checking in as my life moves forward.)

This is why I don’t think there’s a purely selfless reason to pursue medicine, and I am suspicious of people that claim they have one.

Now the reason I’m talking about this is because it matters for patients. I’ve been saying this for a long time now, but please believe that I really mean it: a doctor that doesn’t have some hype, that doesn’t feel connected to their career and therefore doesn’t connect to patients – in other words, a doctor that’s burnt-out – that doctor isn’t a good doctor. S/he might show up to work every day, might diagnose and prescribe as indicated by the clinical guidelines, might dot all the i’s and cross all the t’s. But the more and more studies we do, the more we realize how essential the relational component of medicine is. Having a doctor that’s well improves patient health. It’s just a fact.

So if working part-time is what it takes to maintain your hype, then please work part-time. If specializing instead of entering primary care is what it takes to maintain your hype, then please specialize. Etc! When you see a patient, ask yourself if you’re there in that room with that patient, fully mindfully present, human-to-human; if you’re not, figure out what you need to do to make it happen.

I’m not saying you need to quit if you’re not feeling the hype 24/7. But I am saying that you should take care of yourself, and not make a decision based on guilt, and really try to know yourself in this career. Nosce te ipsum; know thyself.

I sincerely hope that helps.


Books I hope you read: When Breath Becomes Air

When Breath Becomes Air, by Paul Kalanithi

Whether we like it or not, and whether we are aware of it or not, when we decide to become doctors we choose to ask the problem of death into our lives more bodily, more substantially, than most people. Paul Kalanithi took that to the extreme when he decided to become a neurosurgeon, and he wrestled with the problem of death – helping to guide patients across the landscape of health and disease which brings us so close to it – just as he wrestled with the problem of human meaning by choosing to become a physician after studying literature. His openness and vulnerability in discussing these problems in his book reflects not just a remarkable wisdom but also a rare and clear-eyed bravery, especially as the problem of death became personal for him.

Dr. Kalanithi talks in several places about the struggle at humanity’s very basis, and then he reinforces this foundational idea throughout the book when he talks about his own struggle. This constant striving really is essential to being human, and it reflects the conflict between life and death that we are all perpetually trapped within, and which he himself must face more readily than most of us ever will.

Living life means a constant balance between grasping and acceptance. We all must find our values – find the right way to spend our lives reaching while facing the knowledge that eventually, at some unknown time, everything we’ve reached will be taken away. Accepting death but knowing that the answer isn’t to stop the struggle – that’s life’s great challenge.

And Dr. Kalanithi faced it, and demonstrated it, beautifully. He takes the reader on our own, heartbreaking version of it. We get to know him, we grow to admire and appreciate him and his life, and this all the time knowing that his days are limited. I think knowing that Dr. Kalanithi died before he could see his book finished, but also having this version in my hands here in front of me, played out that never-ending challenge like Sesame Street teaches you how to tie your shoes.

This book was, ultimately and fundamentally, enough. I wish that Paul Kalanithi could have lived years and years longer to have written many more words for us, and I also accept that he didn’t. I am so grateful to him for baring himself open, for helping me figure out what it means to be a doctor, and for teaching me this really important lesson.