My husband marvels at my ability to compartmentalize. He wonders aloud how at work in the emergency department I can pivot from minute to minute so seamlessly- from holding the hand of a patient while breaking a new cancer diagnosis, to educating a medical student on the wide differential diagnosis of an 80-year-old with dizziness, to running an emergent resuscitation where a patient may or may not survive. Honing that skill and working in that environment for 9 hours at a time for 20 years creates a pattern of practice and cognitive processing that becomes hard-wired. Particularly mind-bending is witnessing the death of a patient and having to move on to the next room within minutes to continue the rest of a busy shift. To a lay person like my husband, witnessing a person’s death would be a monumental event. One that brings with it the emotional gravity of being present with a human being passing away and one that wouldn’t easily lead to moving on quickly to the next room.
I heard the term “detached empathy” several years ago and I think it came to define my theme of practice in the Emergency Department and in the ICU. It seemed to be an ideal balance- show empathy but don’t get involved enough that it hampers my ability to do my job well. I convince myself that I can be open and present with patients. I can listen to them and comfort them in my short time caring for them. I provide a brief but meaningful connection for them while at the same time giving only so much as I can. But palliative care teaching has taught me I am not as present as I think I am. I may show them kindness. I may stop running long enough to make them feel heard. I may sit with them and hold their hand briefly while they shed tears. But I’m not really present. I don’t really listen and I don’t truly open myself up to a sharing relationship with them. The compartmentalization that I have worked to perfect makes the deep and open practice of palliative care a challenge. Un-wiring 20 years of patient interaction and cognitive switching takes time and effort and a self-awareness that I am only beginning to recognize.
Articles on narrative medicine are a good analogy to what is required of palliative care providers in practice, particularly someone like me. Attention, representation and affiliation aren’t just themes important in narrative competence. They define what is imperative in a listener and caregiver. To be fully present, to be open as an empty vessel in order to accept someone else’s story, to be reflective about what we have received, and to create mutual bonds with our patients. These are the skills that require training and diligence and undoing our previous thought processes. These are the skills I strive to learn.
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