Stepping lightly over boxes of medical experience

A multi-vehicle trauma! This is what it is all about, Ithought, as I followed my senior resident to the stairs. While my age placedmy training against a St. Elsewhere’s backdrop, my excitement was moreconsistent with the modern, high-energy ER soundtrack. The emergency roomitself inspired excitement, and as a third year medical student I had not yetdeveloped the healthy fear that affected more senior, and more answerable,members of our surgical team. As we approached the cubicle I noted that thepatient was small, maybe two years old. Red froth bubbled from his mouth asthe emergency room staff frantically removed his cervical collar. I heard theword ‘tracheotomy’, and someone said “hold him down!” as his arms reached intothe air. I grabbed his hand and held tight, grateful that I had found a missionthat I could handle.

To my surprise, the hand gripped back. And suddenly… timestopped. Small fingers wrapped around my finger, and at once I was sittingwith a small boy, stillness around us. I looked beyond the red froth, to see hisclear, blue eyes gazing forward. No longer aware of the work to be done, I beganto understand a tragic story. Through pieces of conversation I realized thatthe boy’s mother and father lay dead on gurneys in cubicles behind me, victimsof a drunken driver. In a flash I could see all of what our experience onearth offered: life and death, hope and despair, beauty and horror.

After 15 years, I still feel heaviness in my heart as Iremember that night. I have not attempted to describe the scene before, but Ihave sometimes felt the moment’s essence, as a secret part of what has sincebecome ‘me’.

I have many secrets. I remember the 5-year-old girl who Imet in the oncology clinic, with newly diagnosed leukemia. I silently winced inpain at the smile on her small face, an innocent unaware of the needle-sticksahead of her. She sat with her mother, whose expression betrayed the knowledgethat her daughter would be forced from the world where she belonged; a child’sworld of security and happiness. I remember the seven-year-old child who diedof sepsis in our recovery room after hours of attempted resuscitation, and Iremember the horror that filled the room as we accepted the futility of ourefforts. And I wonder, how have these secret images affected me? Am I a betterdoctor, or parent, or friend, or do I now carry a seriousness that has drivensome of my personality inside, and beyond reach? Will I be a better psychiatrist? Am I more tuned in to pain, or has my exposure given me a resigned, grimacceptance of suffering?

For much of my life, my approach to learning was that alllearning was good learning. My goal was to face life’s experiences as asponge, seeing as much as I could see, and experiencing as much of life aspossible. My assumption was that humans had the capacity to keep the wheat anddiscard the chaff; to assimilate the positive and to disregard the negativeaspects of experience. The end result would be a ‘complete’ personality, freeof bias, unfettered by misconception, and nourished by the ultimate sustenanceof personality, information.

At some point my early opinions about learning becametempered with caution. I began to see that in regards to learning, experience,and personality, at least in my own case, I am what I eat. As much as I wantedto believe that I was capable of learning only the desirable aspects ofexperience, I saw that my personality was affected in ways that I hadn’t predicted. I remember briefly facing these questions as a college student, when I wondered,in 1970’s fashion, if there was in fact any evidence that people were ‘smarter’after formal education. I thought more about the topic during a period of mylife when I actively meditated, as I became aware of the constant parade ofthoughts that drifted through my consciousness, despite my best efforts tolimit them. This view of personality as an unorganized collection ofexperience is more Eastern, more consistent with what I have read of thedeveloping ego, and more consistent with my experience as a parent ofteenagers. Some things, once learned, cannot be unlearned. Some badexperiences are unconsciously assimilated and eventually inhibit function, muchlike adware on a Windows 98 computer. Memories accumulate like boxes of artifactsin a darkened basement. In my own case, half-opened boxes litter the floor,and some emit frightening noises.

As I work toward becoming a psychiatrist, I would like todevelop an understanding of the biases that shape my attitudes; biases thathave the potential to interfere with neutral observation and reflection. It iseasy to identify the obvious examples of personal experience that interferewith the neutrality that I desire. For example, I can easily recognize thebarriers that stand in the way of my feeling compassion for the playgroundbully. And the death of one of my best college friends during the attacks ofSeptember 11 undoubtedly affects my opinions of America’s role in the world. Butwhile in psychiatry we learn to identify personal and historical events thathave shaped our attitudes, I wonder if work and training experiences areincorporated in potentially prejudicial ways as well, perhaps beyond questionbecause of their endorsement by common medical experience. I would like toidentify the ways that my experiences in medicine and psychiatry change my viewof the world, in order to have foresight into bias that will develop in thefuture. Of course, unique character traits result from experience in allprofessions; as I sit in the auditorium prior to my daughter’s band concert, theprincipal, oblivious to the ages of the assembled parents, reminds us to remainquiet and respectful during the concert. But with admitted narcissism, I seethe experiences faced by physicians as particularly memorable.

The experiences faced in psychiatry training, while lessovertly dramatic than the world of CPR and tracheotomies, force one toincorporate a different type of emotional experience. In my short training, Ihave been moved by the isolation of schizophrenia, by the emptiness and despairof depression, and by the ravages of families wrought by addictions. It isoften difficult to come to terms with reactions to psychiatric experiencebecause of the lack of formal resolution. Psychiatric diseases for the mostpart are not cured, and yet are not fatal by themselves; so there is no exclamationpoint to treatment successes and failures, and less opportunity to place experienceon the opposite side of the line that protects our present world view from thetragedies of the past. There is also a learned frustration that develops as weaccept that the will of our patients does not always coincide with our desireto help. And again I wonder, what have I begun to ‘understand’ about mentalillness? Can I make a difference? What is the meaning of life in the face ofsuch suffering?

At these moments, I try to find gratitude for theopportunity to seek psychodynamic understanding. The beautiful, horribleexperiences of life weave tapestries, unique to each of us and to each of ourpatients, with fibers visible only to those willing to see them. And in thetapestries lie the questions, and the answers to the questions, and the answersto all of the questions to come. To study the fabric of these tapestries is tostudy the essence, and the meaning, of life itself. It may be asking too muchto weave our own tapestries by design, but one can be aware of the admonition ofAldous Huxley, that experience teaches only the teachable.

And once again, we are back to the original question. Isall learning beneficial, and are all experiences enriching? Is it true thatwhat does not kill us makes us stronger? Perhaps the answer is moot, since nomatter our preferences, experience finds us. Maybe I can make an occasionaldecision as to what to remember, or face life’s challenges and disappointmentswith the respect required to ease cynicism. Perhaps I can embrace the feelingsand the meanings of life events, rather than attempt to diminish theirawareness. Perhaps all I can ask for is to find experiences with my eyes open,and to place my boxes in a well-lit room, where I won’t trip over them.