- Email: [email protected]
Eulogy
Perspectives
The art of medicine Eulogy I retreated into the cold to find Ms Henderson’s memory. I had gone to Boston’s Museum of Fine Arts earlier that evening as part of my residency programme’s humanistic curriculum. Almost unique among American residencies, the trip was created to teach first-year physicians the power of reflection through art. Following the organisers of the trip, my colleagues and I weaved our way through displays, our path expanding and contracting between open spaces and low-arched hallways. We paused at preselected art works to observe and discuss through group exercises. At one point, we stopped at a marble sculpture, a tomb effigy of a woman resting on her casket. We were asked to take some time for silent reflection, and my eyes scanned the chiselled lines before resting on the woman’s intricate expression. One of the organisers asked for volunteers to share their experiences of the death of patients. Voices rose around me, but their words blurred as I sat silently, eyes fixed on the sculpted face so peaceful it almost appeared to be smiling. The organiser chimed in again, reminding us that she was stimulating discussion by intentionally withholding background information about the sculpture before us. For this piece, however, I didn’t need any. I knew I was looking at Ms Henderson. Ms Henderson was hunched forward reading a magazine when I first entered her room. I introduced myself and asked if she knew why she had been admitted to the hospital. “Of course”, she said as she extended a hands towards me, “for difficulty breathing and my irregular heartbeat”. Over the next week, I grew to know Ms Henderson well. She was a retired widow who had survived all the family she’d ever known. After her son died unexpectedly, she began living alone, receiving help from her health-care proxy, Sharon. Because Sharon was her only remaining friend, Ms Henderson cherished the days they spent together outside in nice weather. Life alone, however, had taken its toll on Ms Henderson’s health. Because of poor vision, severe scoliosis, and difficulty with medications, her performance status declined as her symptoms progressed. Her dates with Sharon grew less and less frequent. By the time I met her, she had already had several protracted stays in hospital. Despite this, Ms Henderson was unflappably steady and warm. Whenever I visited, she flipped excitedly through her magazines, asking my opinions about celebrities so she could find a nice lady for me. When we discussed serious matters—the severity of her symptoms, uncertainty about their causes—she would put her reading aside, draw me in close, and affirm that she trusted me. Later, when I stopped her diet after she choked on bread, she clasped my hand tightly and assured me she understood. Even when she www.thelancet.com Vol 382 November 30, 2013
became so drowsy that I had to draw blood from her wrist several times a day, eliciting moans of pain each time, she was unwaveringly positive and warm. One afternoon, I was notified that Ms Henderson had a special request. Both curious and concerned about what someone who never complained might want, I headed towards her room. She appeared fatigued, but the overhead monitors flashed reassuring numbers. I leaned over the bed to bring my face into view. “Dr Josh, you know I don’t ask for much”, she said. I squeezed her shoulder gently and told her that I knew. She apologised for bothering me before continuing. “Well, I was just wondering, could I have a cup of coffee?” She cleared her throat with a cough, sending ripples through her neck. She told me how the last time she had coffee was weeks ago with Sharon, and how—though things weren’t going well, and partly because she knew they weren’t—she really wanted one. Nothing special, she whispered as her eyes searched mine, looking for affirmation. Just one cup. Knowing how bravely she had tolerated everything, I wanted to acquiesce. But remembering her therapeutic goals of care, I also felt clear responsibility to stand firm. I reiterated my aspiration concerns, and a wave of disappointment washed through Ms Henderson’s face. I looked away for a moment, suppressing the urge to change my mind. As Ms Henderson summoned a characteristic smile, I apologised for not being able to do more. She told me she understood, and I squeezed her shoulder and promised to make her a cup myself after she improved. I couldn’t have known that I would never speak to Ms Henderson again. Her breathing would decline over the next 2 days, her heart rate rapid and refractory. She would become progressively disoriented and confused, signals that her disease was finally overcoming our efforts. After several days, Sharon would decide that Ms Henderson’s condition was no longer consistent with her overall goals, and we would pull the lines, shut off the monitors, and stop her medications. Sharon would wait at the bedside until she had to leave for another family obligation. And 7 hours later, I would receive the page that Ms Henderson—the first patient in my short career to die under my care—had finally passed away, alone in her room. I stuck around after the museum tour and found a seat on the outer steps of the building. The area was empty, and I sat quietly with my thoughts. Eventually, they drifted back to Ms Henderson and the moments after her death. That day, after asking a colleague to delay the morgue, I had quickly poured a cup of coffee and entered her room alone, unsure of how to spend the time but inexplicably confident that someone should be by her side. I pulled up a chair, 1775
Photograph © Nov 30, 2013. Museum of Fine Arts, Boston
Perspectives
Tomb Effigy of Elizabeth Boott Duveneck, Frank Duveneck (1848–1919) and Clement John Barnhorn (1857–1935) Object place Florence, Italy, 1894, marble (overall: 71·1 x 218·4 x 100·3 cm, 3229·6 kg [28 x 86 x 39 1/2 in, 7120 lb].) Museum of Fine Arts, Boston. Gift of Frank Duveneck, 12.62.
quietly unnerved by how naked the room seemed without its monitors and lights. I studied Ms Henderson—hair neatly combed, hands folded, her expression disarmingly calm—and remembered afternoons exchanging stories and laughing over gossip magazines. I thought back to her request, her eyes searching mine for something far more substantial than coffee. I wondered what I would have done if I had known that would be our last conversation. For a while I sat silently, watching swirls of steam rise from the cup until something that felt like relief began to form in my chest. Eventually, a colleague peered in and told me it was time. I nodded and glanced at the coffee, now still and cold. As I stood to go, however, I was struck by an intrusive, peculiar thought: that with Sharon gone and no friends or family on the way, I ought to say a few words—a eulogy of sorts— about Ms Henderson. Part of me felt the sheer absurdity of the idea and almost wanted to laugh. Standing alone beside my patient in a dark room, another part of me felt uneasy about speaking about a woman I had only known so briefly. Yet another part of me sensed the possibility of that moment—of the profound meaning that appeared to be at stake, and of what it might teach me about myself and the endeavour of medicine. I fought the impulse to go and cleared my throat. I gathered several magazines into a neat pile next to the coffee. Leaning over them, I thanked Ms Henderson aloud for reminding me that medical science is at its best when guided by meaningful human values; that when upheld, those values can produce the kind of peaceful death that is coveted yet rarely achieved; that despite the inevitability of death, the ways in which the process of dying affirms those values matters; that the effort to ensure that is a 1776
consummate, necessary art. I reassured her that I would carry her memory with me, to help me become a better doctor for others. The room fell silent, and I imagined Ms Henderson drawing me close with a smile and telling me that she believed I would. I studied her face one more time before turning slowly and waving the nurse in from the hallway. Sitting on the museum steps, I realised how invaluable experiences like the museum trip can be for new physicians. They create opportunities to physically and emotionally remove ourselves from clinical environments—places that can be too stressful and busy for meaningful reflection. By highlighting creative expressions of joy, suffering, life, and death, these experiences can allow us to appreciate the art that so profoundly marks our profession. As in my case, they can remind us of formative experiences with patients, deepening their impact and strengthening our commitment to values and practices. In these ways, these experiences promote more than reflection and learning. They encourage us to be gradually transformed by our work, and to be better prepared to care for the sick and suffering. As such, programmes like the museum trip should be integrated into medical education. They can be difficult to arrange for new physicians, trainees faced with the countless responsibilities of patient care, and exceedingly steep learning curves. The achievement of professional competencies, however, is decidedly based on humanistic values; such values should be reinforced early on to properly guide emerging efforts in other aspects of medicine. If reinforced systematically, appreciation for humanistic values can teach new physicians unique epistemologies: ways of knowing that are distinct from propositional biomedical learning, but just as crucial for patient care. Instead of imparting facts about pathophysiology, these ways of knowing can help to teach frameworks of humility, patience, and perspective needed to appreciate patients’ values. As medicine rapidly evolves, artful application of science cannot be compromised. Meaningful patient-centredness is crucial. And experiences like the museum trip, although only part of the solution, can help our community preserve these values. I stood up and looked back at the museum doors. No one else was in sight, and I nodded silently, appreciative of the experience and the memory within it. I exhaled through a long breath and turned towards home, my breath billowing into life against the dark sky.
Joshua M Liao Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, MA 02467, USA [email protected] All names in this essay have been changed to protect patient confidentiality.
www.thelancet.com Vol 382 November 30, 2013
The art of medicine Eulogy I retreated into the cold to find Ms Henderson’s memory. I had gone to Boston’s Museum of Fine Arts earlier that evening as part of my residency programme’s humanistic curriculum. Almost unique among American residencies, the trip was created to teach first-year physicians the power of reflection through art. Following the organisers of the trip, my colleagues and I weaved our way through displays, our path expanding and contracting between open spaces and low-arched hallways. We paused at preselected art works to observe and discuss through group exercises. At one point, we stopped at a marble sculpture, a tomb effigy of a woman resting on her casket. We were asked to take some time for silent reflection, and my eyes scanned the chiselled lines before resting on the woman’s intricate expression. One of the organisers asked for volunteers to share their experiences of the death of patients. Voices rose around me, but their words blurred as I sat silently, eyes fixed on the sculpted face so peaceful it almost appeared to be smiling. The organiser chimed in again, reminding us that she was stimulating discussion by intentionally withholding background information about the sculpture before us. For this piece, however, I didn’t need any. I knew I was looking at Ms Henderson. Ms Henderson was hunched forward reading a magazine when I first entered her room. I introduced myself and asked if she knew why she had been admitted to the hospital. “Of course”, she said as she extended a hands towards me, “for difficulty breathing and my irregular heartbeat”. Over the next week, I grew to know Ms Henderson well. She was a retired widow who had survived all the family she’d ever known. After her son died unexpectedly, she began living alone, receiving help from her health-care proxy, Sharon. Because Sharon was her only remaining friend, Ms Henderson cherished the days they spent together outside in nice weather. Life alone, however, had taken its toll on Ms Henderson’s health. Because of poor vision, severe scoliosis, and difficulty with medications, her performance status declined as her symptoms progressed. Her dates with Sharon grew less and less frequent. By the time I met her, she had already had several protracted stays in hospital. Despite this, Ms Henderson was unflappably steady and warm. Whenever I visited, she flipped excitedly through her magazines, asking my opinions about celebrities so she could find a nice lady for me. When we discussed serious matters—the severity of her symptoms, uncertainty about their causes—she would put her reading aside, draw me in close, and affirm that she trusted me. Later, when I stopped her diet after she choked on bread, she clasped my hand tightly and assured me she understood. Even when she www.thelancet.com Vol 382 November 30, 2013
became so drowsy that I had to draw blood from her wrist several times a day, eliciting moans of pain each time, she was unwaveringly positive and warm. One afternoon, I was notified that Ms Henderson had a special request. Both curious and concerned about what someone who never complained might want, I headed towards her room. She appeared fatigued, but the overhead monitors flashed reassuring numbers. I leaned over the bed to bring my face into view. “Dr Josh, you know I don’t ask for much”, she said. I squeezed her shoulder gently and told her that I knew. She apologised for bothering me before continuing. “Well, I was just wondering, could I have a cup of coffee?” She cleared her throat with a cough, sending ripples through her neck. She told me how the last time she had coffee was weeks ago with Sharon, and how—though things weren’t going well, and partly because she knew they weren’t—she really wanted one. Nothing special, she whispered as her eyes searched mine, looking for affirmation. Just one cup. Knowing how bravely she had tolerated everything, I wanted to acquiesce. But remembering her therapeutic goals of care, I also felt clear responsibility to stand firm. I reiterated my aspiration concerns, and a wave of disappointment washed through Ms Henderson’s face. I looked away for a moment, suppressing the urge to change my mind. As Ms Henderson summoned a characteristic smile, I apologised for not being able to do more. She told me she understood, and I squeezed her shoulder and promised to make her a cup myself after she improved. I couldn’t have known that I would never speak to Ms Henderson again. Her breathing would decline over the next 2 days, her heart rate rapid and refractory. She would become progressively disoriented and confused, signals that her disease was finally overcoming our efforts. After several days, Sharon would decide that Ms Henderson’s condition was no longer consistent with her overall goals, and we would pull the lines, shut off the monitors, and stop her medications. Sharon would wait at the bedside until she had to leave for another family obligation. And 7 hours later, I would receive the page that Ms Henderson—the first patient in my short career to die under my care—had finally passed away, alone in her room. I stuck around after the museum tour and found a seat on the outer steps of the building. The area was empty, and I sat quietly with my thoughts. Eventually, they drifted back to Ms Henderson and the moments after her death. That day, after asking a colleague to delay the morgue, I had quickly poured a cup of coffee and entered her room alone, unsure of how to spend the time but inexplicably confident that someone should be by her side. I pulled up a chair, 1775
Photograph © Nov 30, 2013. Museum of Fine Arts, Boston
Perspectives
Tomb Effigy of Elizabeth Boott Duveneck, Frank Duveneck (1848–1919) and Clement John Barnhorn (1857–1935) Object place Florence, Italy, 1894, marble (overall: 71·1 x 218·4 x 100·3 cm, 3229·6 kg [28 x 86 x 39 1/2 in, 7120 lb].) Museum of Fine Arts, Boston. Gift of Frank Duveneck, 12.62.
quietly unnerved by how naked the room seemed without its monitors and lights. I studied Ms Henderson—hair neatly combed, hands folded, her expression disarmingly calm—and remembered afternoons exchanging stories and laughing over gossip magazines. I thought back to her request, her eyes searching mine for something far more substantial than coffee. I wondered what I would have done if I had known that would be our last conversation. For a while I sat silently, watching swirls of steam rise from the cup until something that felt like relief began to form in my chest. Eventually, a colleague peered in and told me it was time. I nodded and glanced at the coffee, now still and cold. As I stood to go, however, I was struck by an intrusive, peculiar thought: that with Sharon gone and no friends or family on the way, I ought to say a few words—a eulogy of sorts— about Ms Henderson. Part of me felt the sheer absurdity of the idea and almost wanted to laugh. Standing alone beside my patient in a dark room, another part of me felt uneasy about speaking about a woman I had only known so briefly. Yet another part of me sensed the possibility of that moment—of the profound meaning that appeared to be at stake, and of what it might teach me about myself and the endeavour of medicine. I fought the impulse to go and cleared my throat. I gathered several magazines into a neat pile next to the coffee. Leaning over them, I thanked Ms Henderson aloud for reminding me that medical science is at its best when guided by meaningful human values; that when upheld, those values can produce the kind of peaceful death that is coveted yet rarely achieved; that despite the inevitability of death, the ways in which the process of dying affirms those values matters; that the effort to ensure that is a 1776
consummate, necessary art. I reassured her that I would carry her memory with me, to help me become a better doctor for others. The room fell silent, and I imagined Ms Henderson drawing me close with a smile and telling me that she believed I would. I studied her face one more time before turning slowly and waving the nurse in from the hallway. Sitting on the museum steps, I realised how invaluable experiences like the museum trip can be for new physicians. They create opportunities to physically and emotionally remove ourselves from clinical environments—places that can be too stressful and busy for meaningful reflection. By highlighting creative expressions of joy, suffering, life, and death, these experiences can allow us to appreciate the art that so profoundly marks our profession. As in my case, they can remind us of formative experiences with patients, deepening their impact and strengthening our commitment to values and practices. In these ways, these experiences promote more than reflection and learning. They encourage us to be gradually transformed by our work, and to be better prepared to care for the sick and suffering. As such, programmes like the museum trip should be integrated into medical education. They can be difficult to arrange for new physicians, trainees faced with the countless responsibilities of patient care, and exceedingly steep learning curves. The achievement of professional competencies, however, is decidedly based on humanistic values; such values should be reinforced early on to properly guide emerging efforts in other aspects of medicine. If reinforced systematically, appreciation for humanistic values can teach new physicians unique epistemologies: ways of knowing that are distinct from propositional biomedical learning, but just as crucial for patient care. Instead of imparting facts about pathophysiology, these ways of knowing can help to teach frameworks of humility, patience, and perspective needed to appreciate patients’ values. As medicine rapidly evolves, artful application of science cannot be compromised. Meaningful patient-centredness is crucial. And experiences like the museum trip, although only part of the solution, can help our community preserve these values. I stood up and looked back at the museum doors. No one else was in sight, and I nodded silently, appreciative of the experience and the memory within it. I exhaled through a long breath and turned towards home, my breath billowing into life against the dark sky.
Joshua M Liao Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, MA 02467, USA [email protected] All names in this essay have been changed to protect patient confidentiality.
www.thelancet.com Vol 382 November 30, 2013