Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Healing the Rift Within: Confessions of a Palliative Care Physician

Janice Mulder, BSc (Pharm), MD

[Citation: Mulder J. Healing the rift within: Confessions of a palliative care physician. Innovations in End-of-Life Care. 2002;4(6), www.edc.org/lastacts]

Over the last six years, my work as a palliative care physician has challenged me in many ways. As I walk past the door of someone who is wasted and too weak to get out bed , I wonder what is it that I have to offer. How much easier it would be to simply walk by rationalizing that this person is comfortable and has no need for my expertise as a physician. As a physician, I was trained to investigate the problem, make the diagnosis and prescribe the treatment. What happens when I can't fix the problem and there is nothing I can do to make it go away? How do you help someone deal with a lifetime of disappointments and find words when there are no words?

My personal journey in medicine has not been any easy one. I trained to be a family physician, but decided after working for a couple of years that I wanted to be home with my children while they were young. I took off eight years. My foray back started through my interest in philosophy and medical ethics. I was able to arrange a one-year residency in palliative medicine. Once I was back on the ward, I realized that my first love and my gift were at the bedside. I am a clinician at heart.

I was taught that doctors were not supposed to feel. We needed to keep a good objective distance between our patients and ourselves. I had often left one emotion-laden encounter to be called to another without any time to pause. As a human being, it was impossible for me not to feel the pain and suffering that I encountered in my daily work. The problem was that since I wasn't supposed to feel, if I admitted that I was having problems, I would be labeled as a weak physician and someone who couldn't cope. A part of me fears criticism even as I write this reflection.

I came to realize that if I wanted to work as a palliative care physician I would need to look back over my year of intense exposure to suffering and learn from that experience. Over the course of three months, I wrote about my patient encounters. With the help of a nurse colleague, Dr. David Gregory, I wrote an article¹ about my experience with compassion fatigue. During this process David was able to point out to me that there were many times that I had helped facilitate healing in my patients and their families.

This act of writing and reflection made me aware that in those situations where healing had occurred, I had been able to use both my person-self and my physician-self. As I looked back, I realized that I had entered medicine a person and left as a doctor. It became apparent that this rift within myself, the inner wound that occurred during my medical training, caused a large part of my distress. I needed to heal that rift and claim my work as a whole physician. It has taken me time to discover how I need to practice palliative medicine and to stand firm in my own conviction. The following story of an elderly patient and how we worked together illustrates my growing understanding of what it is to be a "whole" physician. I anticipate that my understanding will continue to evolve.

Liz was a woman in her 80's. She had lung cancer and pain that was very difficult to treat. We were both aware that there was more to her pain than the physical component. Her husband had died when he was very young and she was left to raise three small children on her own. Over the years, they had disowned her and she had not had any communication with any of them for many years. As she slowly shared her story with me, I wondered, how does one heal the pain of a lifetime? She was very slow to trust and did not let people into her inner world very easily. She was willing to share the superficial layers, but would not go any deeper. She was too afraid.

One day as I sat listening to her, I wondered what it was that she was supposed to teach me. I know that paths cross for reasons and I have started to pay more attention to reciprocity. The relationship becomes mutual when patients realize that they have something to offer the physician as a fellow human being, and when physicians allow themselves to learn from patients. After this encounter, I wrote Liz a poem, trying to reflect back to her what it was that I heard her say. She was touched by the poem; it had spoken to her heart. She had been heard.

She slowly revealed more of herself with me. The turning point of our relationship came the day when she shared with me that "I was the only one stupid enough to think that all I had to do was to love them." I could feel the hair on my neck stand up. I realized that I, too, had held this belief in my own life. Should I say anything? Should I maintain my professional distance? I reflected for a moment and said, "Liz, I too believe that." She looked at me with incredulous eyes. Here I was the doctor, and I, too, struggled with similar issues. We met person to person that day. I no longer had to be the doctor who had all the answers. We were companions on the road of life.

Over the next number of weeks, we shared stories and slowly, she seemed to heal some of her inner wounds. When I asked her what had helped to make the difference she informed me that she, too, loved helping people. I was stunned by her reply as I realized that it was my vulnerability, honesty, and willingness to be real with her that had been so helpful to her during her hospital stay, more so perhaps than the painkillers and the more traditional medical responses to suffering. We were both helping each other.

It was hard when she died. She had reminded me of my mother and her death challenged me to look again at my relationship with my own mother. I realized that the gift that she gave me was her trust and her willingness to be vulnerable. We had both grown.

So, what is it that I offer my patients and their families? My expertise as a physician is crucial in my ability to help make people physically comfortable, and I am currently expanding my own definition of what it means to be a responsive physician. Pain and suffering are often exacerbated by psycho-spiritual distress. There are times when my patients turn to me as their physician for help in this area, so I realize it is a legitimate and crucial domain in which to build my expertise. I have had to come to my own understanding of the meaning of life and death. I have been challenged to reach beyond my ability to prescribe drugs, to be willing to be fully present with my patients and their families, and to use myself as an instrument as I have journeyed with them. A high degree of self-awareness is needed so that I can sort out what is mine and what belongs to my patients.

When one forms authentic relationships the caring that one gives is returned.

It is a two-way street. My work in palliative medicine has facilitated my own inner healing. There was a time that I wasn't sure I would return to medicine. I was filled with a sense of awe when I realized that I was healed in the place where some of the wounding had occurred.

Over the years, I have come to appreciate how important it is that I take time to reflect on my work, debrief when necessary, and take time to look after myself. Time for exercise, relaxation, and fun are all necessary to counterbalance the pain and suffering that I encounter on a daily basis.

Inasmuch as it takes time and emotional energy to connect with people, it is also the most rewarding part of my work. These close encounters do not occur all the time, in fact, they are rare, but when the opportunity arises I realize it is important that I try to meet my patients and their families at the level of our common humanity. The genuine caring and love that they feel does make a difference, all the difference in the world.

References

1. Mulder J, Gregory D. Transforming experience into wisdom: Healing amidst suffering. Journal of Palliative Care. 2000;16:(2):25-29.[Return to Personal Reflections]

2. Mulder, J. Healing: The Power of Love in Medicine. Presented at Canadian Palliative Care Association National Conference, Victoria , BC, October 2001. [Return to Personal Reflections]