Dr. Sri Sushma Nagasuri Fellowship trainee, Palliative Care CMC-Vellore
My professor once said to me that, ‘it is not answering to the blank sheets of paper that I should be worried about, but answering to the eager expectant eyes of patients once I graduate that should bother me’.
Following my under graduation, I began my career in palliative care. A wonderful psychologist, whom my husband and I respected very much, said to me that I am very young to be in palliative care. It did not make sense to me then. Medicine as a career choice naturally involves empathy, pain, and understanding of deeper human emotions to help connect with patients. If I am young for palliative care, so should I be young for any other branch of medicine and so will be, all my colleagues.
However, always wanting to be a doctor, I was certain about the secret ingredients to becoming a good doctor. The checklist was simple and straightforward-
- Good communication skills
- Ethics and transparency
- To be able to relieve pain
- Patience at all times
I remember my first day at work when I took the relatively bigger and darker seat in the cabin reserved for the doctor. The chair instantly made me realize the responsibility to every patient and family who would be entering the cabin from then on. It felt strange – heavy and good, at the same time. Soon, I began to interact with patients. Unlike the college of my under graduation, patients here were from more diverse backgrounds and ethnicities, speaking different languages. This limited my communication skills and I began to realize that good communication skills are not about proficiency in language alone. Having to see terminally ill in most cases, I also had the challenging task of breaking bad news about death which was not so far away to patients, both old and young, which I found extremely difficult. At times, I could not hold my own tears before revealing the information and had to be consoled by the patient relatives themselves! Good communication skills – uncheck.
Another important quality that I wanted to maintain was transparency and ethics with all the four principles – autonomy, maleficence, beneficence, and justice. I had assumed that this would be quite simple. However, several situations challenged me. Sometimes, the patient wanted more information related to diagnosis while the relatives intensely pressured me to withhold information to protect the patient. Sometimes, it would be medically ethical to perform a certain procedure but the patient and family (who against medical advice) would want discharge despite my attempts to convince otherwise. Ethics and transparency – uncheck
I had diligently gone through the standard books on palliative care by Dr. Twycross. They were relatively small in the world of large books of medicine. I initially felt knowledgeable and adequate. However, the challenges that were posed by patients were clearly out of the textbook. It was only the experience and the wisdom of the nursing staff, social workers and psychologists that was of help when it came to managing difficult bedsores, bad odor as well as addressing the financial, psychological, social and spiritual needs of the family. Knowledgeable – uncheck.
The pain in terminally ill is often intense, unbearable and inhumane to even allow the experience of it. I simply knew that I could rely on Morphine that was the most powerful medicine; we in palliative care had access to. Unfortunately, often than thought, the pain can be resistant to the highest doses of morphine and other cocktails of medications. In such cases, all I could offer were a few smoothening words and a hand to hold. To be able to relieve pain – uncheck.
As a budding medical professional, with various good and bad experiences in my pocket, I had made a resolve to be patient to all my patients. That, I would keep my calm at all time and answer to all their questions no matter how long it would take. After all, patients attending palliative care do not have much time and all I can definitely offer some time of mine. Unfortunately, at times, though few, some patients attending palliative care can be as annoying as patients attending other clinics who create a scene to be seen before their appointment time or demand special attention. This then required some behavioral therapy! Patience at all times – uncheck.
As a novice, I now realized that I am both young and innocent like the psychologist first remarked. But with time, as I travel this path under the guidance of my teachers, I pray that I find the wisdom that I am seeking to be equipped to take the seat. I know that the price of this is not ordinary. I may develop a thicker skin in the process but make sure that I continue to have broad shoulders. The seat in my cabin will continue to remind me of my purpose. And dear medical student, there is one hot seat waiting for you, as well.