Lessons in teaching

Amandev Aulakh

The Contact Precautions sign halted us with bold lettering as we approached the patient’s room. Almost automatically, our hands reached for the hand sanitizer as they had done so many times. I dutifully laced up the thin translucent yellow gown behind my neck and, as I pulled on the rubber gloves, I looked over to the medical student.

“Do you have any questions?”

She shook her head and as she adjusted her gloves, I was aware of the creeping sensation of apprehension in the pit of my stomach. It was not the first time that I had led an end-of-life discussion. It was not even the first time that the medical student had been part of such a discussion. However, it was the first time that she was going to lead this conversation.

I could still vividly remember my first experience speaking with a patient’s family on my own as a medical student. We were in a small windowless room in the intensive care unit that resembled a closet. I sat on one side with family members lining the opposite wall. Their somber faces looked at me, their tired eyes seeking answers to questions, and I felt like they could sense my inexperience despite my white coat and stethoscope. Beads of sweat trickled slowly down my back as I started to speak, my voice shaky and uncertain. I remember longing to have someone there with me, to fill in the spaces when it became harder to articulate that there was no way to reverse their loved one’s condition.

This experience stayed at the back of my mind as we entered the cool, dark room. My eyes took a moment to adjust to the dim light and my ears registered his agonal breaths before the room came into focus. Family members stood around the perimeter of the room. I was suddenly aware that almost all eyes had shifted toward our entrance and my pulse quickened, slightly uneasy with being the focus of their attention.

One woman sat opposite the bed. While she had turned her head to the door, her eyes did not rise to meet us. Instinctively, I knew that she was the patient’s wife. Her weary body language betrayed the journey that she had seen her husband take over the past few months. It was evident in the slump of her shoulders, in the way that she wrung her hands, in her blunted response to yet another intrusion into the final moments with her husband.

The medical student caught my gaze, her eyes asking for permission to break the silence. I gave her a small nod. Tentatively, she walked to the patient and placed her hand on top of his.

“We’re so sorry to interrupt, but the doctors that are looking after you have asked us to come see you. We’re from the palliative care team.” She introduced herself and I did the same before I approached the patient. I took his warm hand in mine. It remained still under my touch. His heavily lidded eyes stayed fixed on the ceiling, unblinking.

I moved away from the bed and stepped back behind the medical student. Performing a routine task like taking blood pressure still made me nervous if I was being watched. I hoped that staying out of her line of sight alleviated this. We had been together on the palliative care team for a few weeks, and in that short time she had found her niche. She was ready for this moment.

She spoke calmly, not showing any signs of anxiety. As she described what the patient and his family could expect at the end of this journey, I became aware of the subtle changes in their expressions. The medical student noted this as well and paused before she started again, her already gentle voice softened slightly.

A second voice asked a question and my eyes scanned the room: it was the patient’s wife. The medical student started to respond and then her voice faltered. She took a small step back and I saw the uncertainty in her face as she tried to find the words, her eyebrows furrowing slightly. For the first time, she looked nervous and I could see myself as that medical student in the intensive care unit when I looked at her.

The pause grew and I realized that this was the dance that all of my supervisors had engaged in. Waiting for the right moment to step in, knowing when to wait a little longer. We locked eyes for a moment and when she looked away, I then spoke.

When I finished, there was silence again. The medical student looked to me and without expressing words, we knew there was nothing more we could tell them. She went to the patient for a second time and gave his hand a squeeze before she approached each family member. I followed her lead and with each hug, whispered thank you, and handshake, it was progressively more difficult to maintain my composure.

The harsh bright lights of the hall assaulted our eyes as we emerged from the room. Suddenly, I felt overwhelmed by the lights, our antiseptic garb, the feeling rising in my throat. My gloves came off with a snap and I struggled with the gown. There was no dignified way to remove the flimsy disposable gown and I resorted to tugging it sharply before the thin material yielded and gave way. Tears had started to well in my eyes.

“Let’s find a room to debrief.” I managed to choke out the words and she nodded. I walked briskly down the hall, my eyes focused straight ahead as she trailed slightly behind me. I pushed open doors as we made our way through the long corridor until we found what we needed: an empty room.

We sat at the long table opposite each other in silence. A tear slowly dripped down my cheek as my eyes focused on the table. I had wanted to tell her that this was not my typical response to these conversations. I was not routinely brought to tears but this patient’s experience resonated with me. His condition had deteriorated swiftly since his diagnosis a few months ago. It was a harsh reminder that none of us was immune to this, that we could be blindsided by a terrible illness at any time.

A cough across the table brought my attention back to her and I looked over. Her teary face mirrored my emotions and I realized in that moment that this was the lesson that I could convey. We are not robots. We have the privilege of witnessing the most intimate moments of our patients’ lives. Giving ourselves permission to be moved by our work was part of this transition from medical student to resident to physician. In some situations, you just need to cry.