It started years ago, late one summer night. I sat in the office across the hallway from the neonatal intensive care unit, waiting for a blood gas to materialize on the glow of the computer screen. Through the blinds, I could see the dull orange of the parking lot, the light reflecting off the scattered cars, as clouds of insects swarmed the lights; over the desk, a fluorescent light bulb hummed.
I started without a plan, without ambition. I don’t remember which story I started with, but I remember the moment it started, how the words unraveled, and now, all these years later, I am still writing.
Later, after hundreds of hours, I would wonder why. Why pour hours into struggling to find the right words? Why toil to find the current of truth beneath a veneer of objective detail? It always struck me that I could use my time in better ways. I could read journal articles, wade through work emails, paint the guest bedroom, or mow the lawn, but instead, I kept coming back to the blinking cursor, to find the thread of the story and wrestle with the stories that held sway over me.
Six years later, after an emersion in the world of literary agents and publishers, I held the book in my hand. When All Becomes New is a collection of true patient stories from neonatal intensive care. As I flip through the prologue, I realize I am still trying to rationalize my endeavor, still trying to formulate an answer for why I poured years of my life into this project.
I re-read the words, “As the incidence of physician burnout soars, the attempt to capture truth and humanity in story can help us to notice, to draw near, to bear witness. Stories can moor us when feelings of despair and guilt and futility crest. It is these stories written down in notebooks, on blogs, stowed away on laptops, contained in the books on the bookshelf, which can help us to navigate the waters.”(1) And I know this is why.
Notice
Have you ever walked past a painting or photograph on the wall for the hundredth time only to realize you have never really seen it? Never noticed the nuances of color, the subtle shades, and the entirety of the image? Perhaps this is true for the maple in your back yard, the rise of the sun in late fall over the tree line, or after the accumulation of time, your spouse’s eyes.
In his book Four Seasons in Rome, Anthony Doerr writes, “The easier an experience, or the more entrenched, or the more familiar, the fainter our sensation of it becomes. This is true of chocolate and marriages and hometowns and narrative structures.”(2) In healthcare, we could add patient care to that list. What was once shocking, exciting, and unsettling becomes commonplace as familiarity sets in; noticing becomes more difficult as the sharp edges fade away.
In some instances, the act of close observation is easier than in others. Traveling, for example, opens me to the people and world around me. In Beijing, Poland, or Turkey, my senses are on alert and the mundane is transfixed into the unfamiliar. Just ordering lunch or walking down the street becomes a medley of jarred senses: the hard syllables of an unfamiliar language, the differing architectural lines of the buildings lining the street, and smells that find no match in my olfactory synapses.
At home, the drudgery of the daily routine can seemingly drip lidocaine on my senses. Writing counteracts this — the struggle to describe what the operating room looks and feels like, the intermittent misting of the endotracheal tube or the downy hair of a preterm baby, forces me to reckon with my inadequacies of language and structure, my mind’s craving to skim across the surface of the encounter.
As Doerr tells us, “A good journal entry — like a good song, or sketch, or photography — ought to break up the habitual and lift away the film that forms over the eye, the finger, the tongue, the heart.”(2) The process can be unsettling; the ground feels soggy and the visage misty. Some truths can only be uncovered through narrative.
Draw Near
I used to think it was critical for physicians to remain emotionally detached. I thought I was supposed to compartmentalize my emotions and thoughts, the way a boat is divided into watertight compartments that can be closed off in case of a breach. My training instilled these values in me; the only things that mattered were the objective facts: choose the right pressors, the right antibiotics, the right ventilatory settings.
I remember the general surgery intern carrying the weight of the hospital overnight, the pages coming in faster than she could answer them — a pressured deluge of crisis. I remember my own experience of coding a baby in the ER then walking into the next exam room a few minutes later to see the next patient. But the walls are not watertight. Invariably they form fissures and buckle under the weight, resulting in substance abuse, failed marriages, burnout, early retirement, and suicide.
The hours of writing and reflection drew me into the depth of our shared humanity and vulnerability. A paradox emerged. I found that drawing near connects us in ways that protect both the patient and the physician.
One day, after everything went wrong and the baby’s blood pressure plummeted and her heartbeat faded to nothing, I offered her mother a hug. There was nothing else to do. She was alone, weeping, and my heart broke for her. Surprisingly, that hug, meant to extend compassion, also allowed me to accept compassion and forgiveness for something I could not control.
Observation and attention enable us, as physicians and leaders, to gain and give perspective, to cultivate empathy toward our patients and those we serve and lead. As author Rana Awdish writes, “close observation is a form of devotion.”(3)
Bear Witness
As humans, we have an intense need to bear witness and to share those stories with the world. Photographs, magazine articles, books, movies, and radio journalism stories pour into the world daily. We tell of war zones, cancer diagnoses, rescued dogs, and forest fires.
In healthcare, we bear witness daily. Over the years, my own litany of stories accumulated beneath the outer shell of clinical care. They shifted and swayed in my mind. The stories had become part of who I was and how I saw the world, and I felt compelled to share them.
That is why I wrote about the Army sniper’s son. It happened so fast, within hours. He was born early, but a week into his hospitalization, he had weaned off the ventilator and was tolerating enteral feedings — until one morning when his abdomen became dark and distended. Bedside surgery revealed an entirety of discolored, friable, necrotic bowel. Hours later, we slipped the breathing tube from between his pale lips as his young parents and five soldiers in full dress uniform looked on.
Ford Madox Ford says, “You may well ask why I write. And yet, my reasons are quite many. For it is not unusual in human beings who have witnessed the sack of a city or the falling to pieces of a people to desire to set down what they have witnessed for the benefit of the unknown heirs or of generations infinitely remote; or, if you please, just to get the sight out of their heads.”(4)
There were other people in the room that morning: a respiratory therapist, a medical resident, a nurse, and a chaplain. We never talked about it, just blinked back the tears and moved on to the next task. But words on the page can connect us where our spoken words fail, and they are always there for us, revealing a larger truth and shared experience. I always held tight to the solace that the good outcomes outweighed the bad, like an accounting equation. But the equation never worked; it was always lopsided.
I thought perhaps I was alone in this sentiment until I found the words of critical care physician Rana Awdish, “…that even when the good outcomes did outnumber the bad, they wouldn’t make even the slightest dent in the darkness that bled from the bad ones. That shame is unique in its wholeness, an impenetrable black orb that deflects light.”(5)
When the writing hours grew frustrating and progress seemed elusive, I kept thinking of how the words might impact someone else the way other writers have impacted me. It seemed a lofty goal, but not long after the book was released, nurses told me how deeply they connected with the emotions I described. Without words, we bear witness together but harbor the consequences in isolation.
Stronger
The “soft” non-objective arts — writing, music, or painting — allow us to notice and draw near and bear witness. They can help us remember that despite the dark outside the windows, the midnight stillness of the hospital around us, we are never truly alone. They can help us take down the flimsy compartments and feel in ways that foster empathy for our patients, our colleagues, and ourselves.
When we recognize ourselves in another’s greatest joys, darkest moments, grief, embarrassment, fear, and elation, we become resilient in our shared connection. Ultimately, these endeavors can pave the way toward stronger clinical care and stronger leadership.
References
Rattray, B. When All Becomes New: A Doctor’s Stories Of Life, Love, And Loss. Eugene, Oregon: Resource;2021.
Doerr, A. Four Seasons in Rome: On Twins, Insomnia, and the Biggest Funeral in the History of the World. New York, NY: Scribner;2007.
Awdish, R. The Subway. Chest. 2021;159:435–436.
Ford, FM. The Good Soldier. London, England: Vintage Classics;2010.
Awdish, R. In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. New York, NY: Picador;2017.