When You Smile at Misfortune

I stand, like 1 of 12 soldiers, lined up in a long hallway with 6 doors on each side. A bell rings signaling the beginning of the exercise, and each soldier shuffles dutifully toward a folder clipped to the door in front. It is an exercise we have all been through before, but the nervous energy still emanates from each of us. We knock on our doors, almost in unison, and enter with feigned confidence. My third-year observed standardized clinical encounter (OSCE) begins relatively smoothly. My first standardized patient is an elderly woman with pneumonia. Her pneumonia severity index is high, indicating that she warrants admission to the hospital. However, she is adamant in refusing to go to the emergency room. Although she insists that she will be fine, I stick to my conviction. She eventually acquiesces, but she makes her disappointment obvious to me. I am certain this is the correct clinical decision, but I wonder if I have been too firm. Was I meant to allow her to make her own informed decision? I have no time to linger on that because I am on to the next patient. Behind the next door down the hall, I find an iPad with a slice of a CT scan of the abdomen displayed. Bubbling out from the head of the pancreas is a circular structure, made more conspicuous by an arrow pointing directly to it. The patient has already had a biopsy of the pancreas that revealed adenocarcinoma; my task is to inform her of the results. I have little time to organize my thoughts. When I step into the room, clutching the iPad to my chest, an older woman sits in a corner looking down, hands folded in her lap. A younger woman is seated beside her, glaring up at me. After introducing myself, I ask how they are related. “Her daughter,” the young woman says flatly. Apparently I am running 15 minutes behind schedule, which is the cause for the glare and frosty introduction. I lean casually against the exam table, suddenly aware of the ceiling camera staring down at me. I attempt to inquire about how the patient is currently feeling, but her daughter cuts me off. “We’re here to find out the results of the biopsy,” she says with an eye roll. I ask them to tell me what they have already been told by their other physicians. I gaze intently at the patient, but she refuses to maintain eye contact for more than a few moments. It is the daughter I will have to reckon with. “We know that there’s a mass in her pancreas and that a biopsy was necessary to find out what it is,” the daughter states. It seems they have been left oblivious to the possibility of cancer. “That is correct,” I say. “The biopsy was done because there was concern that the mass could be cancer. The only way to tell for sure was to get a sample to look at under the microscope.” I think perhaps I buried the word within too many other words. But then the daughter stands up and throws her hands in the air. She heard it. “Cancer?” she yells, taking a step toward me. “No one said anything about cancer!” “Yes, cancer,” I say, but as I say it, I can feel the corners of my lips fighting against a smile. A smile. Precisely as I am saying the word cancer. It is a momentary twitch, and my face quickly resettles to a neutral expression. I wondered if perhaps they had missed it. But no; it has been subtle yet unmistakable. I fail to regain composure for the remainder of the OSCEs. My mind keeps wandering back to that moment. Was it the overdramatic acting that I had found comical? Perhaps, although that had never tripped me up before. Then my mind drifts to the moment, less than 48 hours prior, when my family had revealed my father’s cancer diagnosis to me. I had gone home for the weekend suspecting nothing, though 2 weeks prior my mother had inquired about the differential of a mediastinal mass “for a friend.” When my mother finally did deliver the news, she did so plainly. Adenoid cystic carcinoma of the trachea, a diagnosis I had never heard of before. She and my sister had known for at least a week at that point. It was hard not to feel a bit blindsided, exactly as my patient’s daughter had. Perhaps there was something surreal about playing the role of the informant so shortly after being the informed. Maybe the moment had held, for me, a bit of irony. Surely I was not entirely devoid of empathy.... Was I? If I could fail to exhibit sympathy even in a hypothetical patient’s moment of misfortune, would I ever be able to exhibit true empathy in an actual patient’s moment of misfortune? But in the days that followed, I witnessed variations of my blunder on display throughout the hospital—an intern’s nervous laughter as she explained the potential risks of a paracentesis, a wife’s sad smile as her husband was rolled back to the operating room. It is more likely emotional overload rather than apathy or insensitivity that prompts these contradictory expressions of emotion. An involuntary attempt to achieve a type of emotional homeostasis. In the weeks that followed my father’s diagnosis, and over the course of an oncology fellowship, I discovered that there may be no such thing as an appropriate response to misfortune. I have often found that if given space enough or time enough, laughter ruptures into tears, tears melt into laughter. Laughter ignites into anger. Anger dissolves into indifference. And sometimes, our insides and our outsides just do not match

Aesthetics · Art · Disappointment · General surgery · Empathy and Medical Education · Ethics and Legal Issues in Pediatric Healthcare · Family and Patient Care in Intensive Care Units · Medicine · Psychology · Social Psychology