Statistics say that, mid-way through internship, the average intern will have seen ten of their patients die.
We will watch ten people with families and friends and hobbies and pets and memories pass away. Some of them will fade peacefully. Others will fight the inevitable until their last breath. Some plan their funerals, others plan a future they won’t have.
And I’m not sure that anything in medical school prepares us for dealing with death.
When my grandmother passed away two years ago, I knew how to grieve. I knew what was expected of me. Denial, anger, bargaining, depression, acceptance. I holed myself in my room watching seasons of The Big Bang Theory, cried at her funeral, drank too much at her wake. The guilt of not visiting her enough, the realisation that my biggest fan was never going to see me graduate. As hard as it was, it made sense.
The process of grieving for a stranger is different. When my consultant told one of my patients and her family that death was imminent, I felt that I wasn’t allowed to cry or be sad. I had no right to mourn a patient that I’d only met a few hours ago. I knew nothing about her, I hadn’t been a part of her life.
Yet I was on the verge of tears.
It took me a while to realise that that was okay. That sadness is a normal emotion to feel and that maybe, that was my way of coping with what was happening.
While I don’t think there’s a right way of coping with death as a medical student, I do believe that it’s something that universities don’t talk about. So much of medical school is focused on staving off death that we forget that everyone passes away.
Here are my tips for coping with death as a medical student.
- Allow yourself to feel. Death can bring on a whole host of emotions: sadness, anger, guilt, and maybe even gratitude. All of these emotions are okay and valid. Let them come and go and if you find yourself overwhelmed, give yourself space.
- Self-care. Dealing with death is scary and awful. Not all patients pass away peacefully. Find a way to look after yourself in these situations. Go home after placement and make a good cup of coffee or watch a favourite movie. Go for a run if that’s your thing.
- Debrief. If you need to vent, vent. If you need reassurance it, seek it.
- Don’t compare your reaction to that of other people. On one rotation, I constantly compared myself to my registrar, who seemed unfazed by death. I felt like I was overreacting and that I should be able to deal with this. It took me a while to understand that death impacts everyone differently, and that there was no perfect way of coping.
- Say your goodbyes. For all my patients who have died, I say a few words in my head as I leave the room – something along the lines of ‘I hope you had a wonderful life’. For some people, they may say a prayer, others will simply smile or nod.
This isn’t an exhaustive list, but I hope that this may give some guidance about coping with death as a medical student – remember, you are never alone in medicine.
Dear Ms B,
We didn’t know each other well. You might recognise my face from rounds, I was the girl in the corner holding your numbers, looking at the ground or out the window. I occasionally asked you how you were, and you always told me the same thing – pain, so much pain. And I didn’t know what to do. I wanted to hold your hand, but my head always made excuses. I had to continue on the round, I had to be professional, I had to maintain my distance. But I always thought about you through the day. I thought about how I wanted to sit by your bed and hear your stories, capture your last days on earth, capture the rich life I’m sure you lived.
I was there when your family was told the news. I saw how they reacted to your prognosis, and I wished you were awake to see it – not to see the pain your children were in, but so that you would realised just how loved you’ve been. I half-smiled at your son as I left the room, unsure of what to say, knowing that no words could take away his sadness, his grief, or his anger.
There’s nothing I can do to cure you. I’m just a medical student, and even if I was a doctor, there’s no medicine to make you better. We can make you comfortable, we can give you pills and injections and fluids and hope that you’ll be peaceful. I hope you’ll be peaceful. I hope that whatever awaits you on the other side is beautiful and that this illness that haunts you is gone. I hope that you can see your children and protect them as they go forth, and that you know that you were loved. You were cared for. You meant the world to someone.
I hope you enjoyed the journey. I hope that your life has been filled with smiles and joy. I hope you found a way to make the world a better place during your stay. I hope that, in your final moments, you remembered the good times, the days filled with happiness.
And you may never know this, but you made a difference to me. When I see another patient approaching their final moments, I will stop and talk. I’ll ask them how they are, if there’s anything they need, about their life, their children, their loved ones. I promise that I won’t just be a doctor, I’ll be someone who makes them feel valued. I’ll make them feel that their last moments are being remembered.
I’m sorry that I didn’t do that for you.
All the best,
My Life as a Med Student.
“Is that her femoral artery?”
I met my lover late one night,
Stethoscope on my chest, BP cuff on my right,
And as he held my hand, on his resident’s command,
He summoned up all his might -
"I’m a doctor-in-training", he said,
Resting his body against my bed
"And is it too soon to make you swoon?
Because I know we’ve just met -
But you make my heart thump so hard
That cardiac arrest is on the cards,
Fast my blood flows for my soul knows
That true love has caught me off-guard.”
What was there to say but yes?
To a lack of experience he had confessed,
Yet I was fine with the nerdy pick up lines
Because for me adoration he had professed -
But he’s rare with actual compliments
Instead choosing to thank my ‘rents
For their chromosomes, their centrosomes
…I think good will was meant?
And even when he finds the right words
It sounds completely absurd
To hear “My dear, your telomeres
They have never faltered!”
All my girlfriends think I’m single
Because I never bring him out to mingle -
He works long hours, rarely showers,
And in small talk, the only lingual
Skills he has pertain to nerves of the tongue,
And if there’s pathology he has the lungs
To speak and speak for a more than a week,
As if other meddies he were among!
Surgery sets his heart on fire
More than my wanton desire,
Causing a fuss with his bloodlust
Whenever I want my body admired,
So when he’s making love to me,
I know he’s thinking of anatomy
Not what goes where, or how he fares,
But is that her femoral artery?
“Found it!” he cries instead of my name,
As if our activity is not a game
Of take-a-peek but hide-and-seek
Where physiology is the aim!
Still I know he’ll never cheat
Because he never has the time to meet
Another girl to take for a whirl,
And besides, I know I have them beat
With my ample mitochondria, cranial hypertrophy,
A million neurotransmitters and long phalanges -
Subcutaneous tissue, it’s never an issue;
So I’ll let him study our mutual biochemistry
Because he gives me atrial fibrillation,
Ventricular contractions and palpitations,
Every single date my muscles fasciculate,
Forever he’ll be my doctor, and I, his patient.
[An old poem I had lying around. It never fails to amuse me.]
- You will look like a pretentious twit. But before you cry out, consider the model of socialisation familiar to first years and anyone cramming for final exams. Acting like a doctor is a crucial step to becoming a doctor, and House and Dr Cox are doctors who are also pretentious. Therefore, in order to become a doctor, you must wear your stethoscope out in public.
- Doctors get upgraded to business class when flying. How else will the flight attendants be aware of your pending-doctor status if you don’t wear your steth?
- There’s scope for, ahem, roleplaying.
- Think of the pick-up lines. “Excuse me miss, but you just made my heart skip a beat. Care to hear?” “I’m offering free health checks to all attractive males… and you most certainly qualify.”
- If you plan on going into surgery or psychiatry, this may be the only opportunity you get to wear your stethoscope. How many surgeons have you seen wear a stethoscope on ward rounds?
- "Stand back, I’m a doctor" sounds much more impressive if you look like one. And no one will question your doctor qualifications if you’re wearing a stethoscope.
- It’s a great party trick. In fact, the last two parties I’ve been to, I’ve whipped out my pretty little stethoscope and conducted full cardiovascular examinations on my friends. Not only do they get free healthcare, but it makes you seem super intelligent because you can tell them that their hearts are normal.
- Eavesdropping. Forget holding glasses up to walls or casting listening charms—if your friends are having a super secret conversation next door, you can simply hold your stethoscope to the wall and listen to all the dirty gossip.
- It’s great revision for clinical exams. If you’re wearing your stethoscope on a long train trip back from the country, imagine how many times you can listen to your heart and lungs. You’ll be a pro at identifying normal breath sounds by the end of it—and if you’re game, you can always practice on the other passengers. I’m sure they’ll appreciate it.
- Hitting someone with a stethoscope hurts. Therefore, wearing your stethoscope on those long walks between hospitals, residential colleges, and sophisticated drinking establishments means you always have a weapon on hand should you find yourself in less-than-pleasant company.
Please note, this is an entirely facetious list. Don’t wear your stethoscope outside the hospital, please.
I saw a little band named fun. on Friday night.
And between the shuffling to try and get a good vantage point (I’m really short, okay?), one thought kept popping into my head: I wish I’d paid more attention to the moments that didn’t matter.
I get caught up in med school. I do the unforgivable, I place my self-worth and self-belief in the feedback I receive until it’s late at night and I’m alone with my thoughts that tell me it’s not worth it, nothing’s worth it. My life becomes a series of achievements which I’ve failed to meet: didn’t clerk enough patients, didn’t do enough research, didn’t impress the doctors enough, didn’t know enough.
So, being the ever-composed medical student that I am, I started crying during the encore.
We fight and fight for med school. Our entire lives revolve around being a doctor. Getting the marks to pass, to get an internship, to get into specialty training, to pass our exams: when does it stop? In the grand scheme of all things med school, these moments matter. But are they more important than the moments that don’t matter, the moments that pass us by?
I look back on this year so far and I see loss. I see three overdoses, two psychiatrists, a psychologist. I see disordered eating, I see hiding in tutorial rooms, too afraid to deal with people. I see a failed assignment, questions I couldn’t answer, laying in bed with my heart racing out of time, scared of waking up in the morning and going back to the hospital.
But then there are nights spent at concerts, driving around the city at three am looking for food, falling asleep on a friend’s floor. Days spent dancing with hand puppets and baking scones.
Moments which don’t matter to med school. Late-night Facebook chats won’t get you a career.
But these moments will help us survive med school.
This is fun. Photo primarily included because the lead singer is the cutest thing I’ve ever encountered.
I’ve always wanted to be a doctor so I could make a difference. I felt that, by being a doctor, I would be able to make certain changes—I could reverse the trend towards psychopharmacy and perhaps encourage psychotherapy. I could open up a little clinic and work with young people who were experiencing mental illness. I could change themed school curriculum, I could promote self-care in medical students, I could create a more supportive environment. But, most of all, I wanted to be able to use my experiences to change the way we practice medicine.
For me, medicine means the opportunity to change the world.
This idea was not received well by my ethics tutor.
The system doesn’t need improving, he said. Personal experience, experience outside of med school, has no place in the practice of medicine. Doctors aren’t doctors to create change.
I disagree. It doesn’t matter what profession you’re in, whether it be nursing or teaching or government. We have the capacity to take our role and society and use it to make the world a better place. Every responsibility we take on has the potential to be used to make a difference. Our experiences, good and bad, can motivate us.
I have an eating disorder not otherwise specified, otherwise known as EDNOS. If you come across me in the street, or see me on ward rounds, you will not see this. I don’t look like I have an eating disorder, which means I am very unlikely to get help. At my medical school, we get about an hour of teaching on eating disorders across the entire degree, which focuses only on anorexia nervosa. Many of our psychiatric placements are at hospitals without eating disorder beds—we are producing doctors with little to no knowledge about this very serious class of mental illnesses.
I’m a patient who is dealing with the emotional sequelae of EDNOS. The guilt, the obsessional thoughts, the failed exams because I was too busy counting calories in and out to study. I’m also a medical student who can see our teaching is inadequate in this area. I believe I can take these two experiences and use them to try and improve teaching so that the next generation of doctors know that eating disorders are more than just the inability to eat.
This is what medicine means to me—what does medicine mean to you?
I’ve spent the last few weeks on psychiatry placements. It’s been crazy, confronting, and not the ideal place to be when you’re struggling with your own mental health issues.
A friend was telling me about her psychiatry placement recently, and the way she spoke indicated how much it had affected her. She’s normally very giddy and very child-like, but when she talked of her patients, she was solemn and soft-spoken. She told me this story weeks and weeks after she’d met this particular patient—she hadn’t been given a chance to debrief.
That’s when it struck me. As medical students, we’re given little, if any, support. We see the best and the worst of the human experience on the wards. We see mothers give birth, but we also see parents lose children. We watch as people are given hope, but we also see them lose it. We’re allowed to read the stories of our patients’ lives, but they don’t always have a happy ending.
This isn’t to say med school is bad. But without support, it can be devastating. There is a reason why medical staff have higher rates of mental illness, of substance abuse, of suicide, compared to most of the general population. Perhaps this predisposition towards insanity is exactly what makes for a good medical student: we’re perfectionists, we’re people-pleasers, we’re somewhat masochistic with our long days and even longer nights, notes sprawled across our desks.
I believe that we need to promote wellbeing in the medical culture. I believe that, as medical students, as healthcare students in general, we need a place where it’s okay to talk about patient experiences and the emotions they inspired. We need to make it okay to cry after a long day of observing life and death within hospitals. Self-care needs to be something that is taught alongside clinical placements, not as a tokenistic gesture in the pre-clinical years.
I know that getting up tomorrow and attending to the psychiatric wards will be a battle. I know that talking to the patients will be triggering, and it will be hard to hear their stories. But if I walk out to my car on the verge of tears, and breakdown on the drive home, I know that’ll be okay. Because it’s okay to be affected by your patients. It’s okay to need to talk and to be emotional. It’s okay to take a night off studying if you find yourself needing to get away from medicine for a few hours.
Take care of yourselves out there.
Med school can be really tough sometimes, and it’s easy to feel completely alone. And often, we know when our colleagues are having a bad day, and perhaps we’re not comfortable asking them if they’re okay or if they want to talk.
But it’s really important to create a sense of community in med school. No one quite knows the struggle of anatomy and placement and patients as well as we do.
These are the little things colleagues have done for me when I’ve been down. These are the things I remember and honestly, these are the reasons I haven’t quit med school. Small actions make all the difference.
- Shout your friend coffee. Nothing says ‘I’m here for you’ quite like a cup of caffeine. And, of course, it gives you an excuse to chat and be there for a struggling colleague.
- Bad jokes. And I mean really, really bad jokes. Example: Have you heard about the movie Intussusception? It’s about a bowel within a bowel within a bowel.
- Text messages and instant messaging. They don’t have to be deep and meaningful. I spent half an hour arguing with a colleague this evening. The topic? What will happen if I’m a student and he’s my intern. (Apparently, I’m working every day and I only get ten minutes for lunch. This is how we show affection.)
- Respect. If you’re assigned to present a topic in a tute, actually do the work. There’s nothing more insulting than creating good notes for your colleagues, while they have no intention of reciprocating.
- Birthday cake. They don’t take long to make (you can use the baking time as study time!), and a round of ‘happy birthday’ can brighten anyone’s day. And there’s sugar involved.
- Acknowledge their existence. We can’t know everyone in med school really well. But if you recognise them, say hi. Ask them how they are and how they’re finding the course. A quick discussion might brighten their day.
- Share resources. After you graduate, no one will care what marks you got or if you were valedictorian (except maybe your grandkids). So, if you stumble across a great website or textbook, let your colleagues know.
- Smile. Smiles are universal, and contagious. Hospitals can be sad places, so cheer is always welcome. And it makes you seem friendly and approachable, and interpersonal skills are what will make you a good doctor. Not your ability to name the branches of the brachial plexus.
Your challenge: do one nice thing for a colleague tomorrow. Even if it’s just waving at the in the corridor.
Let’s change the culture of medicine. Let’s start a revolution and foster a sense of community.
Truth: most of my friends will be graduating from med school next year.
I won’t be. Despite having (almost) four years of university under my belt, the very notion of being a doctor terrifies me.
Instead of doing my final year, I’ll be doing a research year. With a bit of luck, I’ll be doing something in paediatric psychiatry, looking at somatisation disorders.
Deep down, I know I’m not ready to graduate. I’m not ready to take on the big bad world, and that’s okay. I turn twenty-two this year, but I feel as if I’m only beginning to come into my prime—I’ve only had my driver’s licence for three months. I’m only beginning to get proper treatment for what has been an eight-year battle with depression and anxiety and possibly borderline personality disorder. I’m only starting to work out who I am and what I want and I know that I’m still a couple of years away from being comfortable enough to say I’m a doctor.
Being a doctor is hard work. Long hours, overtime, and your work never leaves you. I come home from placement and think endlessly about the cases I’ve seen, if there was anything we missed, how I need to improve. And then there’s being an adult as well—budgets. Cleaning. Laundry. Remembering to send birthday cards. Plus there’ll be studying for places in specialty training schools and constantly keeping up with the new developments in medicine.
I’m not ready for that. I spent most of my high-school and early university years avoiding people and relationships, finding myself unsteady on my feet. I don’t want to be like that as a doctor. I don’t want to be an adult without ever experiencing what it’s like to be a young person. I want to have late nights and do silly things and achieve my non-medical dreams. I want to have a life before I settle down to be a doctor.
It’s taken me a long time to come to terms with this. Part of me believes it’s trivial to put my medical career on hold so I can write novels and ethics proposals. But on the other hand, I don’t want to be dead before thirty. I want to be well enough to survive medicine. Yes, I’m afraid, but at the same time, I’m proud of myself.
I’m more than medicine, and I hope you are too.
Last week, I spent a few hours in a palliative care unit.
As medical students, we’re fixated on the living. What drug can cure that symptom. How surgery can remove the cancer. Where we can find a bed so that the patient with diabetes can have her complications managed.
Rationally, we know that everyone dies. We dissect cadavers in our anatomy classes. We read about fatal diseases in our textbooks and see pictures of brain tumours and mangled hearts cut open.
But still, we believe we can save everyone.
The last patient we saw was a little old lady, pictures of her family on a pinboard next to her bed, fresh flowers on her bedside table. A blanket was drawn to her chin, and she smiled at everyone in the room, desperate for some recognition of her existence. I don’t know how much she knew about her prognosis; I doubt she knew what the doctors thought yet.
To me, she looked well. To me, she didn’t look like a woman predicted to die within a fortnight.
I couldn’t look many of these patients in the eye as I walked through the wards, all I could say was a muttered thank you as I left one patient to attend to the next. I didn’t know what to say. I’m lucky. I haven’t experienced much death in my life. I’m yet to see a patient die or a patient code. I know these to be inevitabilities, but I still look at each patient with hope.
Perhaps the hope to live isn’t universal. Perhaps, for those for whom death is imminent, the hope to live is replaced by the hope to die peacefully, in a way that is the least confronting and the least horrifying for their loved ones. Perhaps they want to stay as calm as possible, as coherent as possible, and without the pain that has plagued them for their entire illness.
Perhaps medicine isn’t about operations and pharmaceuticals. Maybe it’s just about helping patients and their bodies survive, and die, in peace.