Sally is now able to go back into the hospital, attending meetings and making presentations in conference rooms. The work has helped her to move past the memory of watching her husband suffer and die.
I feel strongly that it is our responsibility to protect the natural world. When we heal the land, we heal ourselves. The land adjacent to the cancer center was unused and ignored and full of weeds and trash. Reclaiming and nourishing the land inspired and healed me. This was a way for me to transform the memories of Stefano’s pain and suffering into something meaningful and beautiful for others traveling a similar path.
When you are sick, you feel that you don’t have control over your circumstances. We wanted to give choices in the healing gardens: You can follow this path or choose that one. You can sit in the sun or in the shade. You can be next to water, or you can rest under a tree. You can gather together in open spaces, or you can retreat into a quiet nook by yourself. We wanted the garden to give folks a sense of empowerment.
I know from my experience with Stefano’s illness that patients undergoing chemotherapy have heightened sensitivities, so we avoided very strong smelling plants and also anything too jarring or too bold. We wanted a place where patients would feel comfortable and safe.
There were so many hurdles to overcome: the complexity of the site itself, the protected wetland zoning restrictions, hospital requirements, accessibility issues for patients, and the gigantic task of raising the donations to pay for the construction of the gardens. But Mary and I made an indominable team and we were totally committed. With the amazing support of the Cancer Center and the community, close to two acres were transformed into the Healing Gardens over a four-year period.
The garden has proved to be a refuge for hospital employees as well as for patients and their families.
Employees walk through the garden and sit at the tables under the umbrellas eating lunch together. One man told me that he came to the garden every day while his wife was hospitalized. Another patient described her routine of always visiting the garden prior to treatment. I see nurses powerwalking during their breaks. Parents and children run around and play. Many wonderful folks including patients have become Healing Gardener volunteers who tend the garden. More and more people are enjoying and becoming involved. Witnessing the garden being nurtured and loved has given new meaning to my life, for which I am forever grateful.
Photo and caption courtesy of Mary Magrinat
Exposure to nature has been shown to reduce stress, decrease pain medication usage, decrease blood pressure, and induce relaxation in patients. According to one study, patients who recover from gallbladder surgery do better with a window view than with a view of a brick wall. Visitors to gardens benefit from tree-lined paths that invite strolling and are accessible to wheelchairs, seating areas that invite conversation, and the proximity of birds, squirrels, and other wildlife. Studies have also shown that stressed hospital employees use the gardens as much as patients and their families do and also derive substantial benefit. Other articles support the importance of walking in and being exposed to nature for our mental and physical health. Exposure to nature decreases depression and even changes brain activity, compared to exposure to urban environments.
Just as I found solace during Victoria’s illness while wandering the grounds and gardens at City of Hope, others find peace in hospital healing gardens. Many health systems have begun reintroducing nature into the sterile hospital environment.
Too often, we are cut off from our surroundings, working and living in sterile buildings under artificial lighting. There are no windows to the outside in operating rooms. Day and night become interchangeable under a bright array of halogen lamps. There are no seasons within the constant temperature- and humidity-controlled environment. There have been many days when I emerged to discover that night had fallen or that it had rained and I hadn’t even known it. One day, I was surprised when I walked out into a snowstorm.
We have extracted ourselves from the natural world in an effort to create and maintain a controllable environment. Just as we believe we can overcome diseases and our own biology, we have pulled away from the rhythms of nature and the cues that come from the patterns that surround us and of which we are an integral part, often in an effort to deny their importance. There is beauty in these cycles. They are grounding and bring understanding, comfort, and a sense of peace and continuity. By observing them we gain perspective on our place in the world and internalize the reality that, no matter how important, the individual life is a small part of a greater whole. Flowers and plants bloom, die back, but then regrow. We are no different. Death is a natural part of all our lives, and the reintegration of nature into our world reminds us of its importance.
The other day I visited a patient of mine, Ron Evans, an airline pilot newly diagnosed with metastatic lung cancer, which was spreading aggressively. It had invaded his thoracic spine, causing his vertebrae to collapse. Despite two operations to remove the cancer and decompress his spinal cord, he had become paralyzed from the chest down. We were trying to control his disease, but he and his family now recognized that in the end, it was going to take his life. His main concern had become relief from wracking pain.
I was afraid to see him, fearful that Ron and his family would blame me for his loss of function, angry that I had been unable to stave off his illness, although in reality I knew we had done everything possible to preserve, or restore, his function and independence. This feeling of failure was my problem, not his. I was feeling the weight of self-doubt that always comes with complications and poor outcomes as I entered his hospital room.
To my surprise, Ron, and his wife, family, and friends, gathered around Ron’s hospital bed, greeted me warmly. They were glad to see me and bore me no ill will. Ron was grateful for all I had done and tried to do for him and was thankful that I had come to spend time with him. It was enough that I cared about him, that he was not alone. His only request was for better relief of his pain. I called my anesthesiologist partner, Paul Harkins, for advice about stronger medications if the increased dosing of sustained-release morphine proved insufficient, and consulted with the palliative care specialists, who could also help with this. Ron was still hopeful that he could be out of pain. He knew he would never walk again. He knew his cancer was not curable and that he was likely to die soon. He and his family were coming to terms with this and expressed gratitude for the care and guidance we were providing.
After my visit, I walked out of the hospital and made my way toward the healing garden. As I followed the steps down, I read the plaques set into the stone wall, the names etched into opaque aqua glass, commemorating those who had died and were remembered, including my sister Victoria Stern Whelan. I passed the trees planted in her and other patients’ honor. I stopped, felt the sun on my face, took a deep breath, and listened to the birds singing as they cavorted in puddles on this beautiful spring day. I walked the pathway, admiring the installations, the boulder field, the marsh grasses, the budding trees, and the colorful flowers. Sitting down on a bench overlooking the garden, I tried to take it all in. Here was a place of peace and comfort, a place where healing could begin. I thought of my sister and took another deep breath and cried.
*From Swan by Mary Oliver, published by Beacon Press, Boston. Copyright © 2010 by Mary Oliver, used herewith by permission of the Charlotte Sheedy Literary Agency, Inc.
CHAPTER TEN
from
emotional armor
to emotional agility
Empathy is the gateway to the emotional experience of others. How much it nourishes or depletes us depends on the gate swinging back to replenish us through self-empathy and self-compassion.
—HELEN RIESS, MD
The year before Victoria became ill and died, my colleague Matt Manning’s father developed metastatic kidney cancer and died after a long illness (this was discussed in detail in Chapter Eight). During this time, his father had a devastating stroke. I spoke with Matt on mul
tiple occasions about his father’s condition and acted as Matt’s interpreter with the neurosurgeon, whom he found arrogant and distant. In our conversations, I also tried to explain the impact of the stroke, as well as Mr. Manning’s long-term prognosis from extensive damage to the dominant hemisphere of his brain.
Matt was a valuable resource for me when Victoria became ill. We talked at length about leukemia, of which I knew little. He was able to coach me through her bone marrow transplant, including the pretransplant conditioning, with its near-lethal doses of radiation. He remained a supportive and knowledgeable friend when Victoria relapsed and when she died, I turned to him for solace. I also wanted to understand how he was able to bounce back from his father’s death and how he managed to keep functioning as a kind and empathetic doctor without crumbling.
Two months after my sister’s death, Matt and I talked late into a fall evening, sitting on the porch at my home and looking out onto Lake Euphemia as the sun set, listening to the resident swans quarreling with the invading flock of Canada geese. We spoke about his father’s illness and how Matt might not have made the same decisions for himself. We also spoke about what Matt calls “emotional armor,” a protective shield that allows him to practice medicine yet remain relatively unscathed.
Physicians develop an emotional armor, where you have to make difficult decisions but not feel their impact directly. When we are dealing with patients, we are trained to be objective, to avoid intensity of emotions and anguish. When things are going badly, it is not in our best interest to be overwhelmed by feelings. We have to remain sharp and have good reflexes and sound judgment.
The very first patient a doctor ever works with in the first year of medical school is a cadaver. There’s a reason behind that training. It makes it possible for us to look at the human body as simply a system of organs. Right from the start, we are trained that way, before we ever really see or interact with our first patient. We are desensitized so that we can withstand the painful things we will encounter with respect to our patients and their suffering.
When I am in the office and I know that somebody is experiencing devastating problems because of what has happened with their reaction to treatments, I can look at those situations objectively. I can sympathize with how they feel, but I am not truly experiencing what they feel.
The emotional armor we develop is a bit like anesthesia. It is an intentional numbing that allows us to undertake stressful, challenging tasks and complete them. Each physician has his or her own amount of self-preservation, but I think that even my most empathetic colleagues have learned to create barriers.
As a doctor, I can walk through my clinic that might be filled with difficult, anguishing situations, but I am wearing my armor suit. I can navigate through and remain an effective physician. When it is your own family member, the armor doesn’t work. It’s gone. Suddenly you’re overwhelmed with feelings and aware of the consequences of each decision.
When something happens to a family member or a close friend, it is as though a match has been dropped inside my suit of armor. For the first time, I am feeling the burning pain of what is happening in the world.
Most unsettling to Matt are situations where he feels the anguish of a patient or family member so intimately that he cannot protect himself.
One evening, I saw a woman in her mid-thirties who came into the hospital with a headache. She was diagnosed with a large lung cancer and dozens of metastatic deposits in her brain, and she had never been a smoker. It came as a complete shock to her. The oncologist and I both went into her room and started sharing with her what we were finding and what it meant for her, objectively laying things out in a kind but dispassionate way.
We’d had this talk with other patients a lot over the years, and as we were getting to the point of talking to her about her prognosis, which was just going to be months, the hospital door flew open and three excited little girls ran into the room carrying cards and signs, and they jumped onto her bed. They were carrying get-well signs for their mom, and she turned to them and just completely turned her attention away from us. She smiled and beamed at her kids, thanking them.
The oncologist and I excused ourselves and stepped out in the hallway. I have three daughters at home, and the woman in the bed was very similar to my wife. That was a situation in which I was actually feeling the impact of what I was doing. The emotional armor, which normally protects me from pain, was pierced.
While I had never heard the term “emotional armor” before, this captured an essential component of the struggle between engagement/empathy and overexposure that physicians experience. Matt couldn’t avoid the emotionally wrenching experience of meeting the dying woman’s children as they jumped excitedly on her bed. He saw his wife and his own family. The distance disappeared. All he could do was to excuse himself, an interloper, from the room and leave the woman to enjoy her closeness with her children.
But how, I wondered, could Matt continue to expose himself to such raw emotion? Didn’t this exact a heavy toll? A lot of people’s exposure to oncology is through tragedies in their own families, he said, and they assume that oncologists are going from one tragedy to the next.
The truth is that most of oncology is taking care of a patient who has had a curative surgical procedure, and I am stepping in to provide an adjuvant therapy to prevent a recurrence of a cancer. After I am finished with their treatment each day, they go off to work or resume their day. A lot of the things that we treat are not terribly challenging or emotionally heart-wrenching.
That being said, there’s the other 20 percent of patients who are not going to do well. The treatments are simply designed to improve their quality of life, such as to reduce the pain in a spot where the cancer has invaded into a bone. Even though that is a tragic situation for that patient and their family, what they express to me is appreciation. In the clinic, they are immensely grateful to our staff, because what we are doing often is exactly what they need. Most days, it is not emotionally wrenching to be an oncologist.
This is also true in my world as a neurosurgeon. While I take care of patients who are dying, the majority are not. A typical neurosurgical patient is one who is suffering from excruciating pain because of a ruptured intervertebral disc in either the neck or the low back. Most recover without surgery and benefit from physical therapy and sometimes injections. Surgery, when necessary, is often extremely gratifying for surgeon and patient alike, as the end result is relief from searing pain and restoration of function. While risk is a feature of any surgical procedure, these interventions and episodes of care are rarely life-threatening and usually relatively uneventful.
Moments of great intensity do occur regularly. How we handle them helps to define our relationships with our patients and with ourselves. Do we connect emotionally, or do we defend ourselves, protected by our armor? I remember moments that offered the potential for connection with a patient or family—moments where I fell short. Those have stuck with me over many years. I regard them as failures. Most physicians remember their failures far longer than they do their successes.
One such failure occurred early in my career, while I was a chief resident. I helped my attending, Donald Ross, a compassionate and technically adept neurosurgeon, remove a brain tumor from deep within the brain of a man in his early thirties. The surgery took many hours. It went well, but we knew the patient’s prognosis was extremely poor: initial pathology suggested a glioblastoma, a malignant brain tumor with a terrible life expectancy. Donald invited me to speak with the family in the consultation room after the surgery, while he stood by. Entering the cramped room, I encountered, for the first time, his wife, parents, and three small children, who nervously awaited our report.
I was scared and couldn’t bring myself to tell them the truth, that this tumor was incurable, that the patient would die relatively soon. Instead, I parsed my words. They were technically correct, but avoidant. I didn’t know it at the time, but I had donned emotional armor to shield
myself from the feelings that flooded me when I stepped into the consultation room. Overwhelmed, I found their situation unbearably sad and had no idea how to face them. I also had a young wife and a small child. The patient and I were almost the same age. What he and his family needed were honesty and compassion. Instead, I avoided connecting, leaving someone else to fill in the gaps. Of course, there is no telling whether the next doctor would be any less avoidant of the dismal reality they were now confronting, but to this day, I carry a sense of failure: I avoided my own pain but fell short as a physician.
For all the formal training I received in the technical aspects of neurosurgery, I had none in its human aspects. These include communication skills such as discussing prognosis with a patient, delivering bad news, counseling patients on which treatments to take. To the extent that I learned such things, it was through observation of the attending and senior resident surgeons. No one ever discussed the emotional impact of a case, or the sadness we felt with the death of a patient. I never spoke with Dr. Ross about how I felt regarding the patient’s family; looking back I believe he would have been receptive if only I had found the courage.
Grief Connects Us Page 21