Today’s inane image of the day:
When I was in my Senior year of college, I subscribed to the New Yorker in an effort to stay up-to-date with current events as well as prepare for the verbal section of the MCAT. Consistently, my favorite articles were by the surgeon, Dr. Atul Gawande. The piece, Letting Go, really left me feeling unsettled and uncomfortable. Reading Sara Monopoli’s story of her journey from being a healthy, expectant mother, to a Stage IV lung cancer patient, forced me to consider the reality of being mortal.
At some point, I let my New Yorker subscription expire, but I still sought out and read all of Dr. Gawande’s books: Better: A Surgeon’s Notes on Performance, Complications: A Surgeon’s Notes on an Imperfect Science, and The Checklist Manifesto: How to Get Things Right. Each of them were thoughtfully written and served as insightful primers for my medical training.
Sometime at the beginning of my fourth year, I noticed an announcement about Dr. Gawande’s new book, Being Mortal: Medicine and What Matters in the End. At that point, I had already secured a position as a Theme Issue Editor for the AMA’s Journal of Ethics [JOE] and setup an independent study in ethics. My philosophy has always been to immerse myself in subjects that I didn’t feel comfortable with so that I could force myself to learn the material. Throughout medical school, we had a sampling of ethics case studies and a longitudinal curriculum in the subject, but I never quite felt comfortable with applying the principles to real cases. I remember countless times when I would hear about a terminal patient in the ICU and having a general idea of what felt right, but never really knowing why or how my perceived course of action was or was not ethical. Having trained as an engineer, I entered medical school with a background in binary answers. However, I quickly learned that what made medicine both beautiful and frustrating was the grey area.
The research I did for my JOE application and the independent study in ethics helped me build some confidence in applying ethical principles to real-life cases. It also provided a bit of exposure to one of the most common dilemmas that physicians face: conversations and decisions at the end of life. This all being said, it seemed like perfect timing that Dr. Gawande addressed exactly this in his new book.
Although I purchased the book on Amazon back in December 2014, admittedly, it took me nearly 2 months to finally read it cover to cover [my excuse being that I was still in the midst of interview season, then was out of town and then subsequently started on my Emergency Medicine clerkship]. Sara Monopoli’s story appears in the book alongside Gawande’s personal struggle with his father’s deteriorating health. Gawande’s account of having to assist his parents make difficult medical decisions for his father reminds the reader that despite years of medical training, conversations about end-of-life are still awkward, uncomfortable and unsettling.
There’s a lot of hope in Gawande’s book – I think that’s what made it feel like an easy read. One of the main points surrounds the question of goals of care – an important consideration in the role of a healthcare provider, but also as a family member. It is important to understand what our loved ones value and how they wish to live when they are at the end of life. The hospital is a cold, unfamiliar, dirty place, yet so many individuals spend their last days with invasive lines and tubes in every orifice. Where is the dignity in that scene? It is in our hands as the next generation of healthcare providers to ensure that our patient’s goals of care are discussed and enforced when the critical moment arises.
I recognize that not all of you will want to commit to reading the entire book, so if you fall into that category, at least take an hour of your life to watch the Frontline episode on Being Mortal. It brings many of the stories in the book to life and is well worth the time. Whether you’re in medicine or not, everyone will eventually encounter a time when difficult conversations need to take place. Be prepared.