This is what I remember: It is late June or early July of 1992. I am a new doctor in the emergency department at San Francisco General Hospital, standing in a chaos of crash carts and swarming, shouting men and women in green scrubs. The trauma room is rectangular, windowless, and whitewashed in bright, artificial light. Life support equipment occupies one long wall and chrome cabinets line another.
I am female, white, and young. The patient is male, brown, and younger still. I have just moved across the country to start my residency training in primary care internal medicine. He has suffered multiple critical wounds from a gun or knife. We are both new to this hotbed of urban urgencies and emergencies—a relentless montage of bleeding, breaking, nodding, gasping, screaming, and dying humans.
At one end of the room is the bed, at the other, two opposing doors aligned so a person could race with a gurney in a straight shot across the room’s width. He is in the bed, of course, and I am standing in that race path, closer to the door that connects to the trauma wing hallway than to the other that leads to radiology and the rest of the hospital.
In those early days of being a doctor, I am surprised to find myself the healthy, clothed person in the doctor-patient relationship. I ask people questions that would be considered rude in other circumstances and touch them in places their closest friends never will. To this patient, as to the others before and after him that day, I look like everyone else in the blur of professional faces. But I wonder whether, as he rolled in, I finished up some less critical task, a task I might easily have abandoned, stalling so a doctor who knew what she was doing could get to him first.
So there I am, just standing and watching, fully cognizant that the patient and I are the only people in that busy, crowded space not moving in purposeful ways. Around us, doctors, nurses, residents, and medical students assess the patient’s airway, breathing, and circulation, do the head-to-toe survey, and locate and quantify his visible injuries and other less obvious sites of damage, the vital organs and easily-nicked arteries along the trajectory traveled by the blade or bullets. They put in IVs, order fluids, x-rays, and CAT scans, set up for a central line, page the senior trauma surgeon, and call up to the operating room and intensive care unit, setting other crews of competent people into action.
I have been taught each of these steps and so have some idea of what needs to be done, but “some” suddenly seems dangerously inadequate and abstract. I have no experience with serious traumatic injuries and little idea of how to actually do what needs doing. I don’t know how to decide what gets done when, who should do what, how to figure out what has already been done or begun, or how to jump usefully into the fray. I also don’t know how to get the answers to any of those questions in this moment when the patient needs everyone’s full attention. And I am far more afraid of doing something harmful than doing nothing at all. After all, the bottom line about what is going on in this trauma room is that the patient is, to use a vernacular in which I’ll become fluent later that summer, trying to die.
“You,” someone yells. “Prep the chest wall.”
Relieved, I position myself on the patient’s left at torso level. There are tables of supplies on either side of me, and countless people clustered along each of the bed’s four sides. I recognize the tall form and short ponytail of a woman who had been a year ahead of me in medical school. I know she’s training in general surgery because one of her close friends just married one of mine. I don’t remember seeing her at the wedding. I consider that maybe surgical residents, on call every two or three nights, don’t go to weddings, though my friend married a surgeon so that can’t be true.
A bottle of antiseptic appears in my hands. I find gauze, rip open the packets, and soak them. I have read about chest tubes and once saw one inserted, so I know where to clean. Equally reassuring, I know from other procedures that the antiseptic effect will be maximized if I apply three layers, allowing each one time to dry before adding the next. I don’t consider that the method of application might vary contextually. I have studied hard and learned well, but my only emergency medicine experience was at a community hospital where most patients walked in with coughs, infections, broken limbs, or chest pain.
I begin spreading the tawny liquid at the patient’s armpit, below the thick dark hair he probably didn’t have just a few years earlier, moving the gauze in long, circular sweeps and overlapping the wet lines so no skin is left vulnerable to infection. An injury has torn his lung, and the air it can no longer hold is filling the usually very thin pleural space between the lung and inner chest wall, further compressing the damaged lung and making it harder and harder for him to get the oxygen he needs. Once the outer chest wall has been cleaned, the surgeon will insert a thick tube into that space, draining the misplaced air and allowing his lung to properly inflate. I appreciate the urgency of the situation so am moving quickly, but I’m also focused on doing it well and getting it right.
As I wave my hand near his chest wall to accelerate drying, I look around, noting that the bed and floor are littered with medical detritus: plastic and paper wrappers and sheaths, as well as pieces of the patient’s cut and ripped-off clothes, the remnants of which dangle from his body amid catheters, leads, and blood. I am surprised by how little blood there is, and how much of it appears to be iatrogenic—the result of his medical care rather than his injuries.
Just then, near my right ear, a female voice says very loudly, “What are you doing?”
It’s the surgeon, my former roommate’s new husband’s friend.
“Give me that.” She rips the antiseptic bottle from my hand, pulls off the cap, pours the liquid onto the patient’s chest, and drops the bottle. Color soaks the sheets and drips onto the floor as she reaches for what she needs from the open chest tube insertion tray on the table behind us.
“Hold him still,” she barks, and I do.
Blood appears instantly along the neat line she makes with her scalpel. She moves her gloved fingers and a clamp into the space she has created, lifting and separating the skin and subcutaneous tissue from the structures beneath. The patient’s insides are strikingly pale. A red trail of blood flows out from the wound and down his side, creating a small pool on the sheet below.
She works quickly. An instrument goes in, she leans forward, and there’s a visible give as the metal shaft enters the pleural space. She puts her long finger into the aperture she’s just made, inserting it as far as the knuckle, then moves it around.
I remember him bucking, which seems questionable in retrospect, though not impossible. It’s conceivable that they needed him awake to indicate what hurt and where so they could accurately assess the extent of his injuries. But if the injuries were as grave as I seem to recall, and if the plan was trauma room to scanner to operating room, then wouldn’t he have been sedated and intubated? Or were they saving that for later? And while almost everyone is an unreliable narrator after so many years, it seems only fair to also point out my use of the words “they” and “if the plan.” In the emergency department that day, I didn’t feel much like a doctor. Whereas on the medical ward I would have said “my patient” and “my plan,” in the trauma room there was me and there was everyone else. In truth, the trauma I recall most vividly from that day is my own.
PubMed is the search engine for the National Library of Medicine’s comprehensive biomedical and life sciences journal article database where doctors go to look up almost everything. Put in the words “violence” and “violent,” and dozens of key phrases pop up. Many refer to subtypes of violence, such as domestic, youth, gun, sexual, and workplace, or to violent things, people, and events, including video games, patients, and crimes. Others focus on screening, prevention, and management strategies. But no key phrase addresses the violence doctors inflict on patients. Even those that seem as if they might, such as “healthcare violence,” yield articles about patient-to-healthcare-personnel violence, with branches for different countries, hospital locations such as emergency department or psychiatric service, and weapons used. Combining these key words with “doctor” or “doctor–patient relationship” doesn’t help. Searching “violence by doctors” yields articles on violence toward or against doctors.
I don’t mean to equate medicine’s violence with these other types in nature, degree, or morality. But at this moment in American history when violence figures daily in the news, when it’s clear that the need for violence is often in the eyes of the beholder and certain people are more likely to be its victims than others, and when police and prosecutors, policymakers and the public are all examining how they contribute, consciously and unintentionally, to our society’s explicit and structural violence, I wonder how it can be that in my profession we are not considering our own violence from new and varied perspectives as well.
It’s not that we’re avoiding current events altogether, but we look at violence as we look at everything: from a position of power and privilege on turf (conceptual as well as concrete) that we control. We are talking more about race and racism and about how violence impacts the lives of our patients, trainees, and colleagues, yet we aren’t looking at the inherent and potentially unnecessary violence of our own work, and in particular at those instances when we say we have no choice, claiming there’s no other means to our unquestionably laudable ends and that people who question our violence in those moments, when lives or organs hang in the balance, clearly do not understand what we’re up against. In medicine, as in law, policing, politics, and education, we continue to labor under the delusion that our challenges are unique, our coping mechanisms justified, our fundamental assumptions accurate, and our moral imperative sacrosanct. As a result, as violence has become a national topic, we have talked about the ways in which the violence of the world beyond medicine impacts medicine but not about the ways medical violence impacts the world.
When my PubMed search came up empty, I e-mailed a renowned academic, a person who is as well versed in the medical literature as anyone I’ve ever met, to ask whether I was missing some key search phrase or literature. Her reply made clear that no one is studying violence from this particular angle, at least not directly, and it’s worth mentioning that her speculations about the researchers who might know about violence by doctors all work on the topics of problem patients and problem doctors. While these groups matter, I am at least as interested in violence by those of us who are not problems, we who are by all measures just doing our jobs and doing them well.
Although I can’t conjure the trauma room surgeon’s face with any precision, I do remember that as I painted our patient’s chest wall using the same deliberate technique I now use before injecting a patient’s knee or shoulder, the surgeon looked at me with disgust, not disappointment—professionally, in other words, rather than as a friend or acquaintance. Disappointment, it seems to me, signals expectation, which often implies caring, while disgust reduces the other to an unworthy object. Her glance, as much as the trauma room events themselves, seared this moment into my otherwise uneven memory of that long-ago summer, which is interesting when you consider that she has almost certainly forgotten the events I’m describing here. It’s likely worth noting that the glance itself met one of the Oxford English Dictionary’s definitions of violence: “strength of emotion or an unpleasant or destructive natural force: ‘the violence of her own feelings.’” Often we think of violence as primarily physical and of the injuries it inflicts as necessarily visible. While what we doctors did to our patient that day was largely physical, an assault on a body with the goal of saving that same body, the surgeon’s quick and largely inconsequential glance at me had a similarly righteous and unpleasant natural force. In that room, she had greater power than I, and although my behavior was aberrant, that same approach taken by me in different circumstances was, and remains, not just acceptable but desirable.
In so many of the public discussions of violence in recent years, the shootings and deaths get the attention they deserve, but the “unpleasant or destructive” words, actions, and policies that provide the cultural scaffolding for those visible displays of violence do not. The harms of words are more insidious but perhaps no less destructive. As Claudia Rankine writes in Citizen:
That time and that time and that time the outside blistered the inside of you, words outmaneuvered years, had you in a chokehold, every part roughed up, the eyes dripping.
That’s the bruise the ice in the heart was meant to ice.
To arrive like this every day for it to be like this to have so many memories and no other memory than these for as long as they can be remembered to remember this.
The word violence comes from the Middle English, via Old French and from the Latin vehement, indicating something that has a “marked or powerful effect.” Tearing a body open certainly qualifies, whatever the circumstances, but so too sometimes does our treatment of other people, especially when that treatment becomes so common over so many years that some people don’t see it or count it, while others can’t escape it. Just as society has hierarchies of persons and power, so too does medicine. The trauma of doctor training has its own literature as, increasingly, does the trauma of being a patient. But neither addresses the heaped personal and structural insults to which Rankine alludes in reference to race, and few question its origins, necessity, or the profundity of its impacts on human lives.
For days and weeks and years after that day in the trauma room, I couldn’t discuss what had happened with anyone. I felt ashamed by my incompetence and discomfort, and by something else I couldn’t then name. In medical school, there had been those who couldn’t wait to do the things doctors do—and they weren’t by any means all future surgeons, though I suspect most, if not all future surgeons fell into this category. Without hesitation, and with what seemed to me uncanny instincts about what was required and how to do it, they made themselves useful. They fit right into medical culture, and I did not. Terrified of hurting patients, I awaited guidance and permission. Eventually, in order to survive, I submerged my innate responses and bent my behavior to the dominant norms.
But there was another reason I kept the trauma room events to myself. As disturbing to me as my own failings was the fact that a woman I had known as nice could violate another person’s body so casually and with such brute force. I could not think of how to politely phrase a question about what made that possible for her, or how to ask it with genuine curiosity. I also recognized that a portion of my discomfort had to do with gender, and that thinking that was not entirely fair to either her or to the entire class of people we call men, even if the reason I thought it was based on abundant social, biological, and historical truths about who is most likely to be violent.
A quarter century later, here are the questions to which I still don’t have answers: How can you just rip into the body of a sentient and suffering fellow human being, even for the best of reasons? Does it ever haunt you, how you must hurt people in order to help them, doing things to them that would otherwise qualify as torture? Do you put those thoughts out of your head in order to do what needs doing, or do you not have those thoughts? And if you don’t have such thoughts, and I do, is there something wrong with one of us, and if so, which one?
The problem with this reasoning is obvious. Of course, the surgeon did the right thing that day by getting the chest tube in quickly before the patient could no longer breathe. Of course, there are situations in which people have to do hard, violent things to others, and we need people able to commit medicine’s necessary violence to save limbs and organs and lives. Of course, I too learned to inflict the sorts of violence, far more minor but real, required by my chosen specialties of internal medicine and geriatrics.
We are all guilty of violence at some moments in our lives. And still.
If in all other situations, cutting a stranger’s body, causing it pain and making it bleed, qualifies as a crime, shouldn’t we (doctors, certainly, but also police and soldiers) be discussing that during professional training, and after, in what might be called real life? And, acknowledging the inherent complexity and uncertainty of such situations and the lack of a single, right answer, should we not also be considering what it takes to do such violence, how to develop that ability in healthy, compassionate ways, and how to know when to exercise it and when to try alternate approaches, as well as when to walk away, if only temporarily, so as to gain perspective? And shouldn’t we additionally consider that inflicting violence of all kinds as people scream and thrash, physically and existentially, comes with psychic costs to both the inflictors and the inflictees that need to be addressed, and that if addressed, might enable the people on both ends of the stethoscope—or any other actually or potentially violent equation—to function and feel better? Finally, shouldn’t we in medicine (and we as human beings moving through our daily lives) more routinely ask ourselves, for everyone’s sake, is this violence and if so, is it absolutely necessary?
A 2002 World Health Organization report notes that violence lacks a singular meaning since both acceptable behavior and harm are subjective, culturally influenced, and fluid. Then it offers this definition: the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.
Strictly speaking, by this definition, violence is inherent and ubiquitous in medicine. In most doctor–patient encounters, the physician holds the power. We have license to use some types of physical force. Many medical decisions, discussions, procedures, and prescriptions carry a high likelihood of harm or trauma, as does our deprivation-filled, hierarchical, and psychologically demanding training process. So violence is a constant threat and frequent reality in medicine, the sometimes nearly inaudible, other times thunderous refrain playing in a never-ending loop as we move through our days.
But what this definition is missing is the issue of intent, not as it appears in the WHO language to mean knowingly using force or power in a way that could or would cause harm, but as in the person’s primary goal in its exertion. In medicine, force or power are generally exerted with the goal of improving a patient’s health or saving a life, not with the intention of harming or killing, though those things happen regularly as well. As a child with a ruptured appendix, when I nearly died in an elevator on the way to the operating room, people jammed needles into me, moving parts of my body, yelling, and thrusting a tight oxygen mask over my face. As a teen, when I dislocated my shoulder playing volleyball, a tall, muscled orthopedist yanked at the arm in order to put it back where it belonged, using a maneuver that felt medieval and, if only very briefly, shockingly painful. The first medical violence saved my life; the second restored function in my dominant arm.
Yet there are many other instances where I’m left wondering about where and how we determine what violence is necessary or acceptable. Was there as much urgency in that trauma room as the surgeon’s actions implied, or does being in the trauma room offer license to do things in the most expeditious way possible, providing a pass of sorts to doctors who are stressed and afraid of performing badly or failing their patient or who have too much to do and need to get through this procedure or that admission, and this call night or that clinic, so they can move on to the next one? We count only a small fraction of medicine’s harms, prioritizing those suffered by patients over those to staff and systems, and counting almost exclusively the harms that visibly impact the body or its function while ignoring the scars of violent words and actions on psyches and relationships.
I’m thinking here too of the harm done by harms inadequately
acknowledged. A friend whose husband has cancer sends me e-mails in which she describes his treatment. It was meant to induce remission of his disease. In a perhaps less likely but ideal scenario, it also would cure him. Three months in, she wrote of his chemo: “it halts—reverses, more like—his recovery progress from the surgery. He’s skinny skinny—it feels like an inadequate word to describe his physical condition.”
And two months later, she explains that he stopped the chemo early: “It was just so grueling. Since he stopped, he’s been gaining some strength and weight and eating with somewhat less suffering.”
It’s those last three words that haunt me. Yes, the chemo might save him. In the meantime, it had not just a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation, it was undeniably causing all those things except his death, and in so doing, pushing him toward that terminal precipice as well. Equally telling, the violence had been such that my friend and her husband couldn’t even imagine the end of suffering; the most they could hope for was somewhat less of it.
Anyone who has been through medical training, and most people who have been in medical settings for other reasons, particularly as a patient or as a person who loves a patient, has witnessed violence. Often it is necessary but sometimes it is not, or it is questionable, or more of a potential than actual entity. I should explain that I’m using the word potential here as we do in anatomy, to signify a space that exists but isn’t always apparent between two adjacent structures until it fills with inflammatory fluid or blood as a result of injury or disease. Thus, our society has always had certain sorts of violence and the potential to be discussing it, but we weren’t, and even now, when it can be felt everywhere in our divided body politic, it’s still entirely possible for certain sorts of people—a middle-aged white female doctor like me, for example—to go through days and weeks and see it only if I choose to.
In the minute-to-minute practice of medicine, in life, there is so much that might be questioned or questionable except that we have all been conditioned not to question it and to assume its necessity. In a recent lecture, the poet-professor Camille Dungy was asked how to access a Phillip B. Williams poem written so the words formed circles which may have represented halos or bullets or handcuffs, and she replied that “You have to untrain yourself how to not access it.” In both medicine and in society, it seems we haven’t done enough to negate the negative or to adequately explore the line between necessary and unnecessary when it comes to violence. I also suspect that if we were to find that line, it would be less like the line where the computer screen I’m staring at now stops and the air beside it begins, and more like the line between water and land in a tidal zone, where what is expected varies with seasons, weather, time of day, and who is looking—a local, a tourist, a fisherman, a naturalist, or a poet.
It is also true that unnecessary violence occurs sometimes in the company of necessary violence. Sarah Manguso captures that mixed scenario in her memoir The Two Kinds of Decay when describing the insertion of a special catheter called a central line into a large vein near her heart. As a healthy college student, she had developed a life-threatening autoimmune disease that went on for so long that her arm veins were “blown,” a word she rightly points out is “a clinical term,” and one I’ve used many times myself. (I can vividly, almost sensually, recall enjoying the feel of the medical patois in my mouth and the flavor of the implied violence it so accurately captured.) The procedure did not go well:
So the lidocaine began to wear off, and the doctor kept telling the interns and the surgery residents exactly what the trouble was, and he became frustrated when he couldn’t get the tube into me, and tried another, thinner tube, and sweated onto me, and stunk up the entire room with his frustration.
He tried again and again to jam the tube into my vein. Every now and then he had to stop and apply pressure, as I was bleeding. At one point I thought I felt a jet of blood spurt into my chest cavity, and that’s when I lost my composure.
Months later, after his hair had gone from steel gray to white, my father told me it had looked like a horror movie.
Manguso’s father reacted normally, with horror. By contrast, the surgeon appears entirely focused on his task. I imagine the residents’ reactions fell somewhere in between those of the family and those of the surgeon, not that numbers of exposures should necessarily affect how we respond to the distress of others, though they seem to. In fact, it seems that violence functions a bit like smell and opiates in this regard, stimulating a phenomenon called tachyphylaxis in which a person’s response diminishes rapidly with repeated exposure. We stop noticing the perfume, or need more narcotic, or no longer normally register another person’s suffering. Some people argue that the last of those insensitivities is a good thing in doctors, an essential adaptation to an environment replete with danger and misery. That may be true in part, but studies also show a near universal decline in empathy during medical training, and it may be that some of what we classify as healthy adaptation is in fact toxic acculturation. We stop perceiving patients as people and see them instead as tasks, impediments, or problems—other and less than. When a plurality or even a visible minority of people in one setting or profession have become insensitive to the essential humanity of others, the culture itself is unwell.
Fast forward nearly two years from the trauma room incident in the first week of my internship. Move across San Francisco to the University Hospital and take the elevator up eleven floors. It is early evening in San Francisco on the sort of cool, clear fall day when you can turn a corner and see a long, horizontal line where the flat expanse of gray Pacific Ocean meets the pink glow of the creeping dusk and understand why for so long humans thought the world was flat. But instead of walking out the hospital’s sliding double doors into a night of exercise and dinner, friends and sleep, I am a second-year medical resident in the days before duty-hour restrictions, on my way to see the sole patient on my service whom I don’t particularly like.
His room is midway down the hall not far from the nurses’ station. It is dimly lit, less because of the time of day than because he prefers it that way. He is full of demands and insistences. I rarely dislike patients, yet I’m struggling to find something in this endlessly dissatisfied man from which to create even a thin laminate of affection or respect, and I sincerely hope I will be able to make it through the procedure he needs without saying as much to my team.
Of course, the patient is only part of the problem for me this evening. Our team is on call. For the next twenty-four hours, we are responsible for all admissions to the medical service, our significantly sick current patients, and those of the several other teams who get to go home. Also at play are one solid but not stellar intern, another biding her year of medical training before she can sink with relief into the milder rhythms of a psychiatry residency, and three medical students, including a third-year I am working hard to help but who is certain to fail his core medicine rotation.
We will not leave the hospital until we have done everything that needs doing for both our new admissions and all the other sick patients on our service, work that generally takes an additional nine to eleven hours after we hand off on-call responsibilities to the next day’s team. At this point in my training, I have been on call every third or fourth night for the better part of four years. I do not expect to have much of a life and have put aside not only thoughts of the world outside the hospital, but also images of the garden burger I like to order for dinner at this hospital, the lumpy mattress in the medical resident call room, and the one not completely revolting water fountain a few floors down. Strangely, I don’t feel tired; working despite chronic exhaustion has become as natural as breathing, even if it is not without its impact on my physical, intellectual, and emotional functioning. My efforts on behalf of patients and my endurance during this arduous adolescence of medical training often fill me with the smug warmth of righteous self-satisfaction. Nevertheless, this particular call day is testing me. To use proper residency lingo, we are getting slammed. This is better than “getting killed” or “getting slaughtered,” but our growing tallies of admissions, or “hits,” and large burden of other patient tasks, or “hurts,” mean we might yet achieve that status.
I am now thirty years old, still white, still female. The patient in question is older than I am by ten or fifteen years, also white, but male. He has AIDS, as so many of our patients do—a San Francisco hospital in 1994—but he is not one of our new admissions. Those acutely ill patients are elsewhere in the hospital: in a handful of other rooms along this same hallway, in the intensive care unit two floors below us, and in the emergency department on street level awaiting the availability, via discharge, transfer to another service, or death, of a free bed upstairs.
He has a fever again, or maybe still. I can’t remember. We have already sampled the usual sources: sent his urine and blood to the lab, x-rayed his lungs, surveyed his skin and looked in his ears and mouth, pressed on his belly, and tested his nervous system. Since we cannot adequately explain or treat his fever, protocols require that we now pull from his spinal cord a few tubes of the hopefully clear, but perhaps straw-, orange-, or red-colored fluid that bathes his brain to test it for bacteria, fungi, and mycobacteria.
My subpar medical student and I collect the lumbar puncture supplies, have the patient sit up so we can identify the correct level of his spine for needle entry, position him on his left side in the fetal position facing the pulled shades, and clean and disinfect his skin. Before we entered the room, I ran through all these and the subsequent steps with the student and now I stand back and let him take charge. Except for the patient’s demeanor, this is a perfect student case because the patient is relatively young and has terrific bony landmarks.
The student is slow but, to my surprise, appears to be doing everything just right. I hover while pretending not to and he looks up at me frequently for confirmation. We silently confer about entry place and direction, and he inserts a local anesthetic and then the thick lumbar puncture needle, pushing first through the skin and next toward the slim space between vertebrae. The needle goes in smoothly. It may be that all three of us release breaths we didn’t realize we were holding. Then the needle stops. From the way it stops, I know it’s hit bone. But we discussed this. My student looks at me, I nod, he makes a slight adjustment and tries again. And again, and again.
I wish I could tell you that at this point the patient said something warranted but phrased in an obnoxious way, such as, “Obviously you don’t know what you’re doing. I want the girl to try now,” but I don’t think he did. More likely I was the one to speak. Maybe I said, “Good, I’ll take it from here, thank you,” to let the medical student know I was stepping in without tipping off the patient that the student had failed.
I assess the patient’s position and adjust the needle until it’s just right: angled slightly toward the patient’s head and aimed at his belly button. I am good at lumbar punctures. In over two years of residency, I have never missed one—until now. I pull back slightly, shift the needle upward a fraction of a centimeter, and push it forward. When you find the right spot, the resistance feels rubbery. If you push a little harder, the needle pops through and then you pull the stylet out of the needle and the syringe begins to fill with fluid. But I hit only bone, solid and impenetrable.
I smile apologetically at my poor student, reminded of a day just before I got my driver’s license when my mother took me out for what we were sure would be my last practice session. I couldn’t even start the car. I tried and tried. Nothing. Exasperated, she insisted we change places. The car wouldn’t start for her either. We had to call a tow truck.
I try the lumbar puncture again. Each time I move the needle, our patient tenses. He asks if I know what I’m doing and doesn’t believe my answer. He complains about everything. I march along the seemingly endless hard surface of his spine with the needle, feeling for the slightest change in resistance indicating that I have reached the relatively soft space between bones. His already curled body is coiled with tension. Goosebumps cover his skin. Now and then, he gasps. At the needle’s tip, I encounter bone, and bone, and bone. Each time the metal hits the highly sensitive periosteum, he protests.
I look at my medical student. He can’t take a coherent history or do a competent physical exam but he has well-developed muscles and can hold our patient, thinner than he is, sick and twice his age, in place. His engaged muscles look like the drawings in an anatomy textbook. Sweat has formed dark stains on the armpits of his blue scrubs, but if he is disturbed by what we are doing, I can’t tell by looking at him. More obviously present in his eyes is the unwavering desire to please me. On academic thin ice, he will do whatever I ask.
“Try to relax,” I say to the patient in as gentle a voice as I can manage. But what I’m thinking is: I’ve never had a problem doing this procedure, even in patients whose landmarks were obscured by obesity or whose ancient spines were distorted by arthritis, but of course with this patient, who is unpleasant and often dramatic under the best of circumstances, I can’t get in.
I am usually vigilant about premedication, pain control, bringing bedpans, and whatever else patients require to feel as comfortable as they can in a hospital. This evening, I don’t care. I suppress a desire, an almost physical urge, to stab the patient more and harder. I need this procedure over and done with. My pager keeps alarming. My interns need supervision. I have no idea where the other student is and hope she isn’t still with the new patient I asked her to help admit three hours ago. There are patients with my name on their charts all over the hospital. I would rather be doing anything other than dealing with this particular patient. I am very hungry and I have to pee and my desire to flee his room is like an itch I cannot reach.
I decide it’s time to heed my own advice. I take a deep breath. I reassess the situation. Then I pull the needle all the way out and start again from the beginning. I speak little and move quickly, intent on success. The patient’s breath becomes audible as the needle slides in. He groans as I feel the pop. The medical student hands me tubes and we collect the pale fluid we need.
The patient remains in fetal position, his back to me, trembling slightly. We lowered his thin gown to his waist for the procedure and the air in the room is cool, but I know his shaking isn’t just a matter of temperature. He may be crying.
“Okay,” I say. “Okay. It’s over.” I cover him. The room is quiet, though beyond its closed door we can hear voices and a beeping machine. He looks frail beneath the sheet. Looking at him, I realize that for a doctor, for me, there may be a fate far worse than failing at medicine’s necessary violence. I have just hurt someone I am meant to help.
When I put my hand on his shoulder in a lame, late gesture of comfort, he flinches. The answer to what’s making him sick may be in his spinal fluid and the sooner the fluid gets to the lab, the sooner we’ll be able to give him the medication he needs to get better. He knows that as well as I do, but we also both know that’s not the reason for his submission. I have used my power, position, and physical strength to defeat him, and I have never felt so ashamed.
In almost all situations, context matters and stress erodes empathy. Both influence not only what happens but what we see and how we understand it. The Encyclopedia of Psychology defines violence as “an extreme form of aggression”
with “many causes, including frustration . . . and a tendency to see other people’s actions as hostile even when they’re not. Certain situations also increase the risk of aggression . . .” When I was a resident, the hospital was my home. There are 168 hours in a week; most months, I worked 100 hours a week. That sort of immersion is known to ease and speed acculturation. When combined with restricted access to basic life functions, including drinking, eating, urinating, sitting, and sleeping, it begins to resemble indoctrination. We saw our colleagues far more than our families or friends. The norms around us became our norms, especially when we felt most stressed or frustrated, scared, angry, overwhelmed, or exhausted. By my second and third years of residency, I was very competent, and not infrequently proficient, at my job. In all contexts, I felt like a doctor. It’s only now that it occurs to me that when I felt like a doctor, I felt important, powerful, and (mostly) benevolent, and so I noted the violence less, or I accepted it more easily; it became just part of the work. Only as I emerged from training and began resuming more normal life activities was I again able to see medicine’s violence and the threat of its violence in all their unquestioned ubiquity.
But that isn’t quite right either. I keep thinking of the concept of conscience and remembering situations in which I submitted to cultural norms even when I suspected or knew they were wrong. Throughout my residency and occasionally since, my patients have sometimes needed procedures only a different sort of specialist could do. In many of those instances, I would still be drawing up local anesthetic and ordering or administering pre-medication while the other doctor forged ahead as the patient moaned or held the side rail in a grip so tight their knuckles blanched. When it was over, I would clean up and console the patient and apologize as if I were a more caring doctor than the one who had inflicted their pain, even though I could have stopped the procedure or insisted on pain medications, and I had not, at least not sufficiently. Instead, I had deferred to what the other doctor and I both accepted as the cultural priority, an imperative which might not have had greater power had I not allowed it to.
Violence is easy for people without empathy or a conscience, but even among non-sociopaths, some are more inclined to it than others. In medicine, we tend to see surgeons as more violent and their subculture as harsher. While there is evidence for the accuracy of such generalizations, they can blur the more important truth that most of us have done little to question or reform the violence we so often encounter in hospitals and clinics (in our neighborhoods, cities, countries, and world). It was me after all, that day of the lumbar puncture, whose violent behavior lacked empathy. I saw my patient as hostile when it’s more likely that he lacked the skills to express his suffering in other ways. He was, after all, a gay man when being a gay man was far more dangerous and hard than it is today, and he was alone and sick and dying. His unpleasantness might have been consequence, not cause. And me? I was just having a rough day at work. What’s more, it was a day that overall left me feeling skilled, useful, and pleased with my life and work, a pleasure that came in part from the ways my position and abilities as a doctor provided me with “power, threatened or actual,” both in the hospital and in the world.
“Empathy,” writes Rebecca Solnit in The Faraway Nearby, “is first of all an act of imagination, a storyteller’s art, and then a way of traveling from here to there.” In all interpersonal relationships, and so in all medical care, the here is me and the there is you. We physicians have produced an extensive literature about empathy (put that into PubMed and you get 19,150 results). There are scales to measure it and interventions to try to increase it and still it plunges downward as people become doctors. I see this year after year when teaching reflective writing to doctors and doctors-in-training. With medical students, shock and horror at witnessed medical violence bubbles up in their stories, sometimes inadvertently, often insistently. They identify with the patient. When I teach the same material to practicing physicians, it is evident that by residency, and certainly thereafter, the horror largely vanishes, replaced by other topics, such as mortality, suffering, affection, impotence, or disillusionment, in which the violence is at most the main event’s unacknowledged backdrop.
At the same time, there are countless articles by doctors about doing things they instantly or later regret, and about standing by, or laughing, or helping while other doctors say or do reprehensible things. These stories often lead to shame so profound that people don’t talk about the events for decades. One article of this sort that caused controversy a few years ago involved a male doctor’s admission that during medical school he had played along with another male physician’s indefensible behavior while the latter’s hand was inside an unconscious post-partum patient’s vagina. Notably, the article’s content was not the primary reason it got so much attention both in the medical blogosphere and in publications ranging from Cosmopolitan to the New York Times. The fuss erupted because, as a condition for publication, the medical journal had insisted that the author remain anonymous. Its editor-in-chief stated that this unprecedented action was taken to “prevent the identification of others in the story, most importantly the patients involved,” but because years had elapsed, names had been changed, and because unconscious women having life-threatening bleeds following delivery of a baby tend to remember things other than the name of the medical student standing by during the day’s traumatic events, many found it hard to believe that the patient was the journal’s primary concern.
There are so many ways in which a culture of violence is built and reinforced, and so many ways, direct and indirect, that we all become part of the aggression and its consequences.
Here is a summary of what went on in that trauma room in the summer of 1992: The patient needed a chest tube. The surgeon did what needed doing the way it needed to be done: quickly and accurately. I neither understood nor adequately accomplished my own small task. We kept the patient alive long enough to make it to surgery and then walked away, acting like it was just another day at the office because that’s exactly what it was.
These are facts.
But so, too, are these: metal, plastic, and fingers were shoved into most of the patient’s orifices and through his flesh to create new holes in his endangered body. When he cried out or tried to complain or resist, he was forced into submission. At no time in the process did any one of the many people not doing something critical at that moment tell him what was happening or why, in case he could understand. At no time thereafter did anyone pull the team together to discuss what we saw, and what we did, and what we might have done differently or better.
In situations like that—settings and circumstances where at least some people deem the violence necessary—there are so many facts. And so many opportunities to do, and be, better.