Learner's Review

Rachel Conrad

 

A Relationship with Patient Zero: A Learner’s Experience with a Pivotal Patient Death

Rachel Conrad
 
 

The first patient slipped away in August of my intern year, during our exhausting initiation into medicine wards. His primary care doctor called a few days after his discharge to tell me that he was found dead shortly after leaving our hospital. Since this patient had few relations and the city morgue was backlogged for months, we would not expect to hear the results of his autopsy and would never know the cause of his death. I spontaneously stammered that we, a team who had unexpectedly grown fond of a patient transferred to our service following alcohol intoxication and surrounded by rumors of drug-seeking behavior, felt “heartbroken”. His doctor, a dedicated physician tirelessly serving a swath of desperately needy HIV-positive patients, immediately responded, “I certainly hope not!”.  Our attending, a gentle and thoughtful fatherly figure with glasses balanced delicately on the tip of his nose, ticked off the patient’s many risk factors on his fingers: HIV, substance use, coronary artery disease, marginally housed, questionable adherence. My compassionate resident, in shock, wondered aloud if the patient felt scared or alone when he died on the street.

The next death was the worst. One that no one on our team could ever expect to “recover from”, whatever that means when referring to an experience that shakes the core of our sense of safety, predictability and competence. Controversy and confusion surrounded both the admission and discharge. When risk management called us in to ask why our patient died hours after discharge, I sobbed throughout the meeting, which, in retrospect, seems unprofessional, although I’m not sure what decorum is expected from an intern confronted with our ultimate fragility and helplessness. There was not a teammate to process with, a narrative to piece together, or a guidepost to closure on my psychological horizon as the residents and attendings on the case distanced themselves for fear of liability and consequences.

Every year at our national meeting, in a room of compassionate, thoughtful teachers and learners who have struggled through their own traumatic patient deaths, I share these stories. And every year, others are desperate to tell their own stories. It’s clear that our experiences with death are one of the most stressful components of our training, that these experiences have a significant emotional impact on learners, and that we feel unprepared for the feelings that overwhelm us when a patient dies.1-6

Many trainees' ultimately become desperate for our attendings’ validation, approval and support, maybe the “father complex” harkened in historical psychoanalytic thought emerging amidst our helplessness and confusion.5, 7, 8  Unfortunately, many faculty feel unprepared to help their learners cope and are often distant after they lose a patient.9 As a result, many learners cope with these distressing emotions about their patient’s death in isolation and feel that their needs are unmet.2,8-11

The teacher-learner relationship can be a liability or a salve after a traumatic experience. Teachers may take a nurturing role that models compassion and acceptance, an academic role that focuses on dissecting the case and reviewing the patient’s risk factors or simply withdraw from their learners. While learners may need their teachers’ emotional support, our institutions rarely provide preparation or guidance for that critical role. The teacher-learner relationship in academic medicine may benefit from integrating the Buddha’s ancient wisdom, “Let death be your greatest teacher.”

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