Crazy Thoughts

For a reading workshop during our MS1 symposium, we read “The Use of Force” by Dr. William Carlos Williams, who was a physician that was more well-known as a poet. The short story was first published in 1938 and describes an encounter between a pediatrician and a little girl with diphtheria. The child is not cooperative during the interaction, and he ends up prying her mouth open forcefully to get a look at her throat. During our discussion of the story, which included a group of first-year med students led by a psychiatrist, I believe that we all agreed that we didn’t like the way the physician treated his patient, and that we were glad the encounter was a fictional story. We then had a conversation about different motivations when working with patients and whether there were more appropriate ways to deal with ingratitude. However, something about the character’s narration of his inner emotions resonated with me, which made me pretty uncomfortable. It’s not that I’d ever been gripped by fury and violence when interacting with a patient before, but there was a specific incident in my memory that had emerged when I read the story.

During the summer of 2014, I was a volunteer at a children’s development center in Taipei, Taiwan, working with children with cerebral palsy and other neurological disorders. Every day, I played with the kids, helped them when they had difficulty eating lunch, and guided them through various physical therapy activities. I was specifically assigned to a very sweet 4-year-old girl, Jackie. Our main goal at the center was to maintain or improve the kids’ mobility and cognitive abilities. As an example, every morning I would grip Jackie’s arms and walk her from the toilet to the sink, making sure that she put one foot in front of the other instead of seizing up or getting her legs tangled. The whole process took about 20 minutes – I quickly learned how incredibly patient every teacher there had to be during my few weeks there.

One day, I was getting ready to change Jackie’s diaper before their post-lunch nap. I usually had her lie down on the mat, but I had seen other teachers sit the kids down for short periods of time. One of the teachers suggested to me that I could cross her legs, so that she could practice balancing and sitting up for the amount of time it took me to cross the room and get her a fresh diaper.

After I was sure that Jackie was sitting up on her own, I went over to the area where all the kids’ backpacks were kept. There, I knelt to reach into the back of the cubby and grabbed one of her diapers. Timmy, a boy with Angelman Syndrome, had just walked in holding his nanny’s hand. He had dark, curly hair, and was wearing an orange bandana around his neck. He was always very fashionable and smiled at everyone. But he also had cuts and bruises all over his legs, and the teachers were always scolding him for recklessly careening across the play area. He turned to me with that joyful smile on his face, and I smiled back.

Then I turned, ready to head back to Jackie with diaper in hand. Suddenly, I realized that she had toppled to one side, still in the same spot that I had sat her down. Her legs were still crossed, but they were now in the air, and her head was resting on the ground. All around her, the teachers were busy changing the other kids’ diapers, and no one had noticed that she had fallen. She wasn’t crying or yelling. I have no idea what she was feeling inside – perhaps she was frustrated to be in such a predicament, or perhaps she was patiently waiting for me to come back.

Either way, I had a sudden, horrible, mad urge to laugh. And I have no way of explaining why. There was nothing about the situation that I found funny, and I immediately rushed across the room to pick her up. Luckily, she was unscathed and I changed her diaper with no further incident. But still, right before I flew into action, there was that singular moment where I almost – but did not – burst out laughing. Was I sleep-deprived? Was I desperate and frustrated, and somehow, the combination of emotions and exhaustion had produced this very inappropriate reaction in my brain? Retrospectively, I’m not so sure. I do know that I’m very glad it didn’t happen, and that to everyone else nothing appeared out of the ordinary.

Still, I want to address this completely irrational impulse I had in the moment. It’s the only time I’ve been so disturbed by a feeling that I can describe surely as wrong, and yet nothing really happened. It brings me back to the story that we had read. The physician in Dr. Williams’ short story did end up violently prying open the patient’s mouth, in a sense succumbing to the eagerness for aggression that had been cumulating during his visit. Meanwhile, in ordinary everyday life, I’m sure that physicians do sometimes experience emotions or feelings that are not optimal or even appropriate, whether it be tears welling up when talking to a patient, or feeling frustration toward a patient for their lack of understanding, or fear of failing a patient while reassuring them. Sometimes they might be confused or even repelled by what they are thinking to themselves. But they don’t show what’s happening internally, and perhaps compartmentalize those thoughts to be able to continue acting as a physician.

I guess my question is, when a feeling that seems inappropriate occurs and we “compartmentalize” it, where does it go? It’s very likely that we will never again address the fact that we had that feeling, and instead, act like it never happened. Is it okay for me to not ever acknowledge that I had almost laughed at Jackie, the girl who trusted me to take care of her, when she had fallen, and to speak about my time with her fondly?

We stress the need for empathy in doctors constantly, because it is of course a core characteristic that anyone going into med school needs to have. We are also taught that to make mistakes when treating a patient is inevitable – which is why we should learn to ask for help and learn from what we did wrong. We talked in our ethics class about how in surgery, moral mistakes (mistakes of judgement) are perhaps more grievous than technical errors. But I wish there were more discussion about what should be done in the case where a mistake never manifests itself physically and is rather a mental one – an error of the psychological kind. While our moral restraint ensures that these thoughts stay internal, I still believe that we should encourage discussion so that our moral compasses stay on the right track.

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Crazy Thoughts

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