The nurse, the wife, the niece, and I sat together in the small family room, quietly thinking. I felt insulated from the sounds of the busy hospital even as my pager chirped a warning that our ICU was about to get even busier. I resisted the temptation to sit on the edge of the seat and betray the anxiety I felt and the urgency of the conversation. We were gathered to discuss the critical decision to intubate a patient, a man who lay struggling to breathe in a bed just down the hall. We had been trying for days to stave this moment off with a tight facemask that forced pure oxygen into his lungs, but he had been ripping it off in his confused and deteriorating state. He was tiring out rapidly and an internal clock in the back of my mind was counting down towards that tipping point when even intubation might cause his heart to stop and actually hasten his death.
I looked at the wife and remembered our first meeting a few days earlier, when the patient first crashed into the ICU. At that time, she told me how she had been living in the hospital for two weeks, watching helplessly as his first round of chemotherapy set off a series of nasty complications. She told me that the one day she went home to get some rest was the day she got a frantic phone call telling her to come back in and this time to the ICU. I told her she had permission to not feel guilty about going home and she burst into tears of relief, sorrow, and exhaustion. We talked then about his tenuous condition and how sufficient recovery to tolerate the next round of chemotherapy was difficult but not impossible.
But in the days since he only did worse. In the disorientation brought about by his decline, he was in a constant state of fear, agitation, and anxiety. And now, at the edge of his viability, it became my job as the supervising resident to tell her that we were reaching the point of extremis: that his survival depended on breathing through a tube which we might never be able to remove, that his respiratory failure came at the end of a chain of other failing organs, and that even if he survived the ICU stay it was unlikely at his age and in his condition that he would ever recover enough to tolerate the next round of chemotherapy. So I told her what she already knew and we sat still for a moment in that waiting room, listening to my pager and the muted sounds of hospital chaos outside.
Then she cried. She cried as she told us how just a month ago he had been fishing with his grandson without any cares or illness. She cried as she told us how he had just asked his son to fetch his gun from home so he could shoot himself. She cried as she told us that she didn’t want to see him suffer, that she knew it was time to let him go, but that she still didn’t want to lose him either. I watched the niece cry and even the nurse cry as we felt the force of all her helplessness and fatigue and grief.
I have rarely felt the gravity of a moment as I did then, weighing the value of every word and pause against the ticking of that clock. We decided to let him pass, to stop our modern medical torture and transition him to hospice. And even though I and every other specialist had known from the beginning that this would be the best outcome for the worst and final situation of his life, it still felt like utter and hopeless defeat.
In that moment, I asked if he was a man of faith. His niece offered that he was, and remembered that he always insisted on holding hands and praying together before meals every Thanksgiving and Christmas and Easter. So I offered to pray for them and we did. We gave thanks for the life of love that he lived and the deep affection of family that was the reason why these moments and decisions were so hard. We prayed for the release of his suffering, that in Christ our death is not final but will be overcome. And, in an unusual moment, we even had the audacity to pray for joy.
We left the room and I rushed off to set up the incoming arrival of three sick patients to the ICU. It was so busy that I could not return to the patient’s room for several hours. When I finally sat down at a computer to plug in some orders and take care of paperwork, the nurse came up to me and asked, “Have you been back in the room yet?” I sheepishly said I hadn’t, it had been so busy…
“It’s a completely different room,” she said excitedly. “Before that conversation, it was like a funeral; now they’re talking and laughing and joking and sharing stories about their memories together. I have never seen a doctor pray like that before.” I was stunned; I hadn’t expected such a change either. I stopped by the room and drew back the curtain to see it exactly as she said. I saw the wife’s face transformed, smiling even through her puffy red eyes, the great weight having visibly been lifted from her.
I didn’t cry once throughout the entire encounter but for some reason can feel the tears brim in my own eyes now as I write about it. It has been years but the memory is still clear and bright because, to me, it is the closest thing I have ever seen to a resurrection.
“Hey, Bubbles has a gift for you. He’s been looking for you, since you saved his life,” my neighbor said casually. I was somewhat surprised; Bubbles (not his real street name) was a young man whom I met while administering first aid for an injury sustained on my block. Bubbles had a critical wound to his chest, and though there was a crowd of people surrounding him when I arrived, the only emergency personnel available was a single police officer in a T-shirt and a Kevlar vest that was trying to apply pressure to the wound. I tore frantically through the medical kit I got on e-bay, pulling out some topical thrombin bandages to stop the bleeding and trauma shears to expose the wound. That was about all I did: nothing particularly heroic or even advanced compared to the paramedics who arrived about ten minutes later. In fact, the police were among the quickest and most helpful responders, clearing the area and assisting in stabilizing the wounds. My role was fairly minimal in comparison.
Baxter was named after a Puritan minister, and I am faintly amused by this memory when I hear him yowl through the bathroom door or when his claws clumsily scrabble across our faux-wood floor. He is not quite as cute now, in the sense that his kitten-like actions are more coördinated though less graceful and less innocent. Playful nips at our fingers now threaten to break the skin, and my wife’s voluminous exercise ball was unceremoniously deflated yesterday by a single lancing stroke of his paw. I watched her own expression fall with its rapidly flattening contours of texture, and I could sense in her a momentary disappointment in Baxter.
She forgave it easily. She has always been the benevolent one, my Elisabeth-full-of-grace. Before we were married, before she moved into my little row home in the inner city, I’d watch the alley cats in our neighborhood backlot with guarded disinterest. I’d shoo them away, back among the overgrown morning-glories and soda cans and potato chip bags. Elisabeth? She was in the house less than a week before the small herd of strays learned to diligently gather around our back door and mewl in anticipation of being fed by her hand.
The neighbors laughed. Dwight, the toothiest and most charming of our hard-won local friends, smiled mischievously and asked, “You know what happens when you feed ‘em, right?” We found out two months later, surprised by small eyes peering curiously through a gap in our backyard siding. My wife wanted to adopt the kitten, and I did as well. She thought he was cute and didn’t want him to die in the chaos of urban life. I thought about how the last litter died on my doorstep, that same doorstep, one year earlier.
That was how we got Baxter. That was how we stopped feeding the other cats, mainly because I said so, which was mainly because I felt guilty. We were feeding and sheltering and buying toys for an animal when our neighbors were collecting food stamps and selling drugs just to survive. But most of them had pets too, I reasoned; they had big pit bulls and Dobermans, and Rob across the street mowed our lawn to make money to feed his dog, so it seemed alright to me.
And Baxter brought so much joy to my wife, how could I not love him? When she cooked dinners for our neighbors, baked cookies for the kids on the block, and let her beautiful maiden form rest with me in our crooked and leaky and moldy row home, how could I not learn to love the way she loved? Elisabeth made our house a home, and Baxter made it family. When gunshots and sirens outside startled him, we gave comfort even as our own souls shook, even as we were inexplicably assured by his trembling, fragile being.
So when the alarm company called us in the middle of the day, when we raced home to find the upper window forced in and gaping wide, it changed me. I felt the strangeness and hostility of the city all over again. As we followed the police in and I watched my wife rush through the house, the cold alarm in her eyes almost unrecognizable, I found something new had entered our home. I found betrayal, for everything I had learned to live and love and trust these two years in the inner city had become undone.
My wife, she found Baxter. He scratched me and drew blood. That, I could forgive.
“He wasn’t a big time drug dealer or anything, you know? He didn’t have anything worth taking. I knew him.” My neighbor stopped for a moment, clearly shaken and deeply unnerved. “Why did this happen to him? We grew up together…”
His voice faded and we sat in silence. It was twilight in summer and one of those ordinary and warm and therefore active evenings in the neighborhood. I watched as people roamed up and down the street, meandering without any goals or focused ambition, simply enjoying the night and occasionally tossing my neighbor a casual greeting. He is typically gregarious and outgoing, the life of the party at nearly every party, but in those moments he barely responded.
I had come home from a long and late shift in the hospital, a place where it is not unexpected to spend time with those who are dying. I have gotten used to sitting in the silence and humidity of grief. And so I found myself listening to my neighbor tell me the story of a young man who had been shot to death in what was rumored to be an unusual mugging. I was listening to my friend as he struggled with the arbitrariness and injustice of the event, which was not uncommon.
And I was shocked. Not because it had been the third homicide in Wilmington in two weeks, but because he himself had been mugged at gunpoint around then and yet all he could talk about was how disturbed he was about the death of someone who was, at best, an acquaintance.
“I just don’t know. This world… it’s crazy. I don’t want to be here any more…” I could hear the hesitation and weight in his voice. He had welcomed me to the block, took me in like a friend, talked about me like family, and yet even so, the same neighborhood that had brought us together was, in its unpredictability and volatility, now threatening to tear us apart.
What is it like to live in the inner city? It is intense and very much like residency life in the hospital. It is about making faster friendships and deeper loyalties than you thought possible, with people whose very lives can end in a single bad night. It is a life that is difficult for spectators to understand, and therefore one that they may feel entitled to pity or to mock. And it is like work never leaves me alone, that all the joy and grief that comes from living as if your life depended on living and doing things together can come to such a senseless end…
No wonder we sat in silence, watching the electric street lights wash away the fading day.
The patient was abruptly, unexpectedly, and neurologically devastated, leaving his family stunned and grief stricken. There was little else for the ICU team to offer, even as we worked to do everything physiologically possible to sustain life. It was late at night and as we stood in the room listening to beeping monitors and the running motors of IV pumps, the family mentioned in passing that many people were praying for him. So I asked them two simple questions: Are you Christian? Would you like me to pray for you? They answered yes to both. I led them in a short prayer, expressing no more in terms of medical prognosis or aspirations for therapy than had already been offered, but also asking for strength, wisdom, and a clearer understanding and experience with God himself. The family was marginally but visibly relieved and calmed by it, and we continued on with the grueling task of caring for the patient.
As anticipated, the patient passed away several days later. After the family left, their nurse told me, “They could not stop talking about that prayer. They said that of the dozens of physicians they have interacted with over many years, not a single one ever offered to pray with them. It meant a lot.”
Modern healthcare is conflicted about how to approach faith and illness. On the one hand, rising pressure to improve patient satisfaction must recognize the importance of faith in the lives of patients; in one small family practice study, 48% percent of patients wanted a physician to pray with them (even though 68% never had a physician discuss religious beliefs with them). On the other hand, the secularization and humanism-ization of medicine can use the ethical mandate to respect patient autonomy as an excuse not to engage in matters that could be controversial (such as faith). Fear of “abuse of paternalistic power” in the physician-patient relationship or fear of invoking religious ritual and methodologies that are virtually impossible to hypothesis-test can create a “chilling effect” on the inquiry and expression of religious belief by healthcare workers even when no hostility or indifference is there. It is as if medical practitioners find it hard to believe that faith not only exists, but that it could possibly matter more to patients than the field of medical therapeutics itself.
The earliest practitioners of medicine were clergy members. In virtually every culture, ministers of medicine began as… well, ministers. After all, what can be a more compelling reason to drive us to our knees than helplessness in the face of suffering? Though modern medicine can explain the physiology of how we decay and die in excruciating detail, it is certainly not equipped to answer the question of why we do. This observation alone should explain why questions of faith contend to occupy the center of a patient’s attention and not simply the periphery.
The next time you are in a small group or a prayer gathering, try to count how many times health-related concerns come up for prayer. Illness afflicts our minds, hearts, and souls as readily as our bodies. Healthcare workers are compelled to take hours of training in cultural sensitivity, mindfulness, and meditation; shouldn’t we be similarly compelled to attain and encourage proficiency in spiritual need assessment, willing to offer prayer when requested instead of retreating in indifference? Shouldn’t this be true in all the “helping professions”?
[Originally published at the Gospel Worldview Blog, written by very thoughtful college alumni. Read and contribute there!]
The morning was brisk and crisp and bright. I tugged the door tightly shut behind me. Already late, I fumbled for my keys and rushed down the short walkway to my car. I was not expecting to see the two bundles of fur that nearly blended into the gravel. They trembled in the early fall air, the ground sapping away any residual warmth from their shivering bodies.
I hesitated. There was no maternal figure or caretaker in sight, though I knew what the parents looked like. Both were white and one was spotted with orange while the other with black, similar to their two children clustered together at my feet. I had often heard the parents yowling late into the night, lingering around my back doorstep looking for food. I never fed them but my neighbor X had taken a recent liking to them, even giving them whimsical names that he doggedly tried to make stick as he fed them scraps that were often from meals I had cooked for him. They never answered to X but had consequently become more aggressive and confident in parading around my steps, even beginning to meow at me in languid expectation when I returned home exhausted from long days at work. This was not something I wanted to encourage and had steeled my soul over time to resist advances that others would have interpreted as charming or piteous. I knew the cats bore no special affection for me; they had no reason to, save the hunger in their eyes.
But I hesitated, conflicted in the middle of my early morning rush. The grown cats were nowhere to be seen, though they were likely watching my actions. I wanted to leave the kittens there; after all, I had no responsibility, ownership, or indebtedness to them. I did not think I could care for these kittens, as cute and helpless as they were, any better than the feral instincts of thousands if not millions of years of cat history. I already struggled enough to find time to care for myself, my neighbors, my patients… I knew that if I stopped for a moment, the gravity of caretaking that had become professionally instinctual would pull me, compel me, perhaps even obligate me to care. In the most efficient and realistic terms, I did not need to care.
But I hesitated. I remembered what had happened on the same doorstep a year ago shortly after I had first moved in. It was a similar morning, a similar rush, and a similar arrest to an otherwise ordinary routine. There had been a brutal storm the night before and though the sky had been clear, I had opened the same door to find a very drowned and very dead kitten lying there. I was again late and had sick patients to rush to care for and so I stepped over the dead body and drove to work. The hospital was so busy I barely remembered the dead kitten until I came home late that night, bone-tired and dreading dealing with yet another corpse. Thankfully there was none; my roommate had somehow taken care of the disposal. However, the image lingered with me and, unsurprisingly, immediately came to mind.
At that point I wanted to stop wasting time thinking and hesitating, so I quickly went back into the house and fetched a plastic box and lined it with an old pillow and dirty towels. I fished out a used plastic bag to use as makeshift gloves and gingerly lifted the kittens into the box, which I then laid out in a safer location in my backyard. Within minutes the kittens warmed up and immediately began mewling and searching for a mother. They could barely have been a week old, as their eyes were still mainly blind and led them to forage futilely within the box.
The whole scenario took less than ten minutes, but I was both irritated and satisfied with my improvisational efforts. I left for work. In the office, between seeing patients for back pain and drug addiction and diabetes, I asked my co-workers what they thought I should do. Almost unanimously, they agreed that I carried no responsibility, though a few thought that since I had now begun to care for these kittens, I couldn’t abandon them easily. Nobody really answered my most serious questions, the ones about whether or not I had an ethical obligation to care. Perhaps this was because I really wanted confirmation that I had no need to care and could be released from any moral culpability for whatever happened to these two kittens. Perhaps it was because I couldn’t shake the feeling that I already knew that such thinking was wishful at best and maybe even callous and deplorable at worst.
When I returned home, the kittens were gone. Someone or something had snatched them out of my shelter. I assumed it had been their parents and was grateful but a bit sad even though still sure I would see them around. I didn’t see them for a while. I began asking X if he had, and he had not known that there were kittens though he was not surprised. “They probably hid them away,” he said and the thought was comforting at the time, though I came to realize that I still did not trust the parents and was reminded of their children, all of the living and dead ones I had seen, every morning as I opened the door.
I remember watching X and his father argue over this. Their house and mine were separated by another row home that had been shuttered after its owner died a few years ago. We chatted and called out to each other over the overgrown backyard lot in between us. I watched as the feral parents lazily wandered through the tall grass and weeds. Earlier, X and his father had been talking about the new food stamps they had just qualified for. The conversation meandered to talking about the cats, and X’s father called them a nuisance that should have been neutered like the other ones in our shared backyard lot. I shared his perspective, though I watched X carefully as he listened quietly and defiantly, even slipping some food to the cats as we spoke. I knew there was a long history of tension between X and his father that partially stemmed from gaps in generation and culture. X was my age and equally as expansive, ambitious, and impulsive while his father was cautious, deliberate, and well-weathered. Though X knew how to entertain, it was his father who seemed to earn most of the keep in the family. Both of them were my good friends and neighbors, though at the time we all seemed to have different opinions on what to do with our local fauna, and as the three of us argued over their fate they mewled and hinting that their young children had been hidden away somewhere close by.
A few days later a work crew, supposedly hired by the bank that had repossessed the house between us, came through and cleaned house. The cats suddenly emerged, displaced from their hiding spots, and I watched as the kittens crawled through the grass blindly and weakly, barely able to crawl more than a few feet as they escaped the din. The parents hovered around as they could but were often sent running and ducking by the cursing workmen and curious neighborhood children. I watched from my doorstep, mostly silent.
The next day I was sitting in my room, which overlooks the lot, and overheard two neighborhood kids clamoring around the abandoned house. Something had caught their attention and they were noisy and purposeful. I don’t know what compelled me, but I dashed down the stairs and immediately confronted them.
“What are you doing?”
“Nothing.” They were siblings, perhaps six and twelve years old. The younger one wore his expressions far more plainly than his brother, who had long ago learned to hide his intent and purposes from strangers.
“You know that’s not your property. That’s trespassing.”
“We’re looking for worms. For fishing.” I looked at the younger brother, who averted his gaze as they lied.
“You can look in my backyard. That’s not your house.”
“We’re looking for our cats.” The older one became defiant and confident.
“Your cats? What do they look like? There are only kittens there, and you leave them alone.” I was surprised at the force and betrayal of emotion in my own words.
“They’re not your cats. They’re ours.”
“What do they look like?”
“Um… you know…” They clearly didn’t. I became more angry and upset, both because of the increasingly obvious lies they insisted on telling to my face as well as their obvious intent to find these kittens. I began blurting out my thoughts.
“You leave those kittens alone. They’re not yours, and they need their mother now. They’re also dirty, and you should leave them alone.”
We argued for a few more minutes and then they ran off, pretending to be distracted by something across the parking lot. I waited uneasily for a few minutes, thinking about what I should do to protect the very animals whose caregiving responsibilities I had already struggled to absolve myself from. I knew what these children would do. They would think they could care for the kittens on their own and would discover instead through their naïveté, impulsiveness, and inexperience that such young kittens actually cannot survive on cow’s milk alone or from inconsistent attention or from a human mother’s unforgiving wrath.
But I was not going to get involved. I was not going to trespass. I was going to shut my door, go to sleep, and figure things out in the daytime. I was going to give everyone and everything the benefit of a doubt and shield them from my cynicism about our ability to care and care well. I was going to observe and watch what happened.
And this is what happened: I never saw the kittens again. After a few days, I began asking X and some of the other neighborhood kids if they had seen them either, but there was nothing to describe. I watched the parents continue to stalk our backyards, but never with kittens in tow and no longer with purpose. I am no expert in feline emotions, but I wanted to imagine that there was a hint of sadness to their loss even as I knew it to be unlikely. They were only animals, scavengers whose existence was only made possible by our excess and whose misery was enabled by a sick combination of our pity and indifference. It is no wonder then that they acted as if this was nothing new, as if they had no reason to expect anything different from a backyard world perpetually littered with plastic wrappers and beer bottles and the inconsistencies of human affection and disgust.
After working 24 hours on call in the pediatric ICU, I was exhausted. I wanted to sleep, but friends had recently been reminding me of the health benefits of breakfast, so I dragged myself to a local diner for breakfast and sat at the counter next to a father and his little daughter. “We graduated from the booth to the counter,” he was explaining to the waitress, trying to hide his pride. The little girl looked shyly up, swiveling playfully on the rotating seat as she stretched up to rest her elbows on the countertop. I tried not to glance at them too much, but I was overwhelmed and fascinated by many simple things: the widening of her eyes at the stack of pancakes, the delighted silence as she chewed her way through the syrupy mess, the polite sips of tart orange juice from a well-worn cup.
The hospital tends to “stick” or creep into the outside world. That weekend I had been having nightmares, imagining what it would be like to suddenly find that my eight year old daughter was brain-dead, or my ten year old son was killed in a car accident, or my brother’s cold turned out to be leukemia.* Random and otherwise innocent sounds would make me think of beeping monitors and noisy breathing machines. It seemed difficult to completely extract myself from the hospital. Even when I went to the DMV, the inspector saw me in scrubs and asked, in an attempt to connect, “Do you work in the hospital? Have you seen dead people? … Are some of them children? That must be hard; I can’t imagine.” Continue reading “In Its Time”→
Summer had finally emerged and we were sitting out on my front steps, enjoying the afternoon heat and watching some of the other kids play out on the street. Some of the teenagers were casually tossing a football around, throwing it high and watching it bounce among the electrical wires, tree branches, and car windows before skittering along the pavement to be chased endlessly by the smaller children. Others were riding their bicycles for show, popping up the front wheel as they furiously pumped their pedals to maintain balance. It was idyllically urban, and I was thoroughly enjoying the leisurely scene after a month of long and hectic hours working at the hospital.
“Your parents must be rich, right?” It was an odd, abrupt question, and I pulled my eyes away from the street to take a moment and try to understand exactly what had just been asked. The twelve-year-old sitting next to me looked my way, waiting for a response. I stalled.
“Your parents, they must be rich right?” If there was any ambiguity in the question, he eliminated it. “For you to go to medical school. Your parents must be rich, right?”
It was not the first time we had talked about money. He lived down the block, and though we had come to be good neighbors and friends over the past year, he would say things that had a similarly peculiar way of making me fumble for words. Before, they had been questions or comments like, “Why would you want to live here?” or “I know a doctor makes bank; you must be making bank” One eight-year old quipped to me, “Nobody wants to move into the North side.” When I first heard it, I thought it was sad and troubling that a child could grow up knowing that his neighbors lived there out of obligation instead of choice. When I hear it now, I still think that.
But this question had a different flavor to it. “Why do you have to be rich to become a doctor?” I asked.
“Cause, school is expensive. So you need to have a lot of money to be able to get there, right?”
“Well… you have to borrow a lot, and then pay it back.” That answer didn’t sit well with me, so I tried to explain. “I mean, isn’t that why doctor’s make money? Cause they’re in debt, and they need to pay it back?” That answer wasn’t any better, so I shut up.
“Whatever. Doctors make bank.” He couldn’t be shaken from this thought. Neither could I.
There is a popular article circulating among my colleagues describing the deceptive income of physicians. It is a very detailed analysis of how the economic principle of opportunity cost means that the high debt burden, long training program, and loss of financially lucrative career alternatives make a medical degree something less than a cash cow. As each of these factors augment, the ability to maintain the quality of life that physicians (and perhaps twelve-year-olds in my neighborhood) have become accustomed to is now threatened. In fact, it is part of the reason that even within the physician field, medical students are driven towards high-wage, procedure-driven subspecialties: to make up for loss in real wage with higher-value training and marketability.
However, even that has not changed the unsettling sociodemographic that dominates higher medical education: children of upper-middle income brackets. My neighbor was right; according to the Association of American Medical Colleges:
Most medical students are children of parents with high levels of education. For example, roughly one-half of medical students’ fathers have a graduate degree compared with 12 percent of the weighted sample of men in the U.S. population. Similarly, roughly one-third of medical students’ mothers have a graduate degree compared with roughly 10 percent of U.S. women.
(Unsurprisingly, the disparity also carries itself along racial lines.) My father has a Ph.D and my mother a nursing degree, and both my siblings also went to college. This stands in sharp contrast to the neighborhood I live in now, where, according to the US Census Bureau, only 10% of the population has a Bachelor’s degree or higher, and the top 20% income bracket begins at $56,250 (which is almost exactly my salary as a resident).
That said, the first thing my parents said when visiting my neighborhood was, “This is so much like the place we grew up in!” They grew up in impoverished neighborhoods as children and even as graduate students that struggled to raise young children, as did many of their friends who similarly have graduate degrees and have sent their children to higher education as well. There was a time when something as simple as eating at McDonald’s was considered a luxury to our family, and I vaguely remember those days in my younger childhood.
I tried explaining this to my neighbor, that to answer his question, my parents did not grow up rich at all. He couldn’t believe it.
“You’re lying,” he said, over and over again. After a while, the words stung and I gave up trying to explain myself or my family. He had met my parents before, knew that they were humble and generous people, and didn’t make any other references to money or what he considered extravagant living except our education. He plans to go to college himself some day, and knowing the confidence and sharpness of his observations, I have no doubt about it.
But still, I sat there in the summer heat feeling decidedly uneasy, my leisurely sentiments having suddenly evaporated. I glanced at the thin and precise scars on his skin that were the hallmarks of a surgeon’s skill, and I wondered at exactly how our lives had come to be shaped by the practice of medicine… and how we, in one way or another, were the shape of its future.
What are your thoughts on the cost of higher education?