Outside The Circle

Detail from The Portrait of Giovanni Arnolfini and his Wife Giovanna Cenami by Jan Van Eyck

 

– 1 –

Lisa got to know him, and that was the mistake. At the time it did not feel like a mistake; it felt like normal human behaviour. Vivaan Bajpayee was 38, and he had been struck down in full flight, almost literally. One minute he was transferring through Heathrow from Amsterdam to catch a connecting flight to the US, the next he was writhing on the ground in front of hundreds of strangers, as the tumour within him expanded with blood. As it enlarged the tumour stretched the nerves of his liver capsule and caused intense pain. He was carried away to the nearest hospital, shocked, pale, sweating. His luggage, his laptop, his busy life, were all forgotten.

At the hospital they scanned him. The tumour was 15cm wide, its central portion bright – a sign of fresh bleeding within. Ominously, there was blood was also in the abdominal cavity. Lisa didn’t know the significance of this until she was told. It meant that the tumour had ruptured and cancer cells were now ‘swilling around’ (her consultant’s words) in his peritoneum. Cure was now impossible. Removing the primary tumour in the liver would not stop those escaped cells proliferating.

Lisa, the F1 (just qualified), got to know him. In the pauses between blood-lettings, during the updates, after the daily examinations, she formed a full picture. His wife came, and Lisa listened as the registrar explained everything to the couple. The consultant came later, and solidified the time scale. There is no operation. Chemotherapy for this kind of tumour is so-so, it extends life by a few months, on average… sometimes much less, it’s hard to know until the scans are done. But it cannot be cured.

Lisa said goodbye when it was time for Vivaan to go. Already he looked thinner. The consultant, in an aside after the last ward round, muttered “I’m not sure he’ll even get to chemo, to be honest.” Lisa thought Vivaan should know that. She had half a mind to tell him. But no: both Vivaan and his wife were looking to chemo as the last hope. To destroy the idea of it would be cruel. It pained Lisa. She felt she was keeping something from him, not being 100% honest.

Three weeks later Vivaan was readmitted. The tumour was hurting too much, and the couple could not cope with it at home. He had lost half his body weight. He had never received chemotherapy.

“What happened?” asked Lisa.

Wearily, Vivaan replied “I was too weak. The oncologist, the way she looked at me, it was pretty obvious even as I was wheeled in…”

“You were in a wheelchair?”

“Yes. I was tired.’

Lisa wished she had told him – ‘Look your best when you see the oncologist… walk in, if you can…’ Look strong.

Discharge papers were prepared. Lisa went in to say goodbye. She broke down.

Vivaan died at home a week later. Lisa knew, because she rang the GP to find out. She had to know.

Then Lisa took two days off.

 

– 2 –

Lisa thought about Vivaan constantly. His was her first ‘close death’. She talked about him at home with her partner; she talked about him in the pub; she dwelt on the contrast between Vivaan’s previous life, as a businessman, and his final form: caved-in, sallow, dull-eyed. The only conclusions she could reach was that life was not fair, that whatever your religion there could be no question of good coming from such tragedy, and that she wasn’t sure she could exist in proximity to such sadness. Vivaan’s death was a once in a decade event, in terms of tolerable intensity, in terms of the depth of the cut that it left in her soul. No way was she going to cope with this sort of thing on a daily or weekly basis.

When she was getting ready to go to work the day after she found out about Vivaan’s death, the energy drained out of her. She sat on the bed, sent a text to her registrar to say she was ill, and barely moved for the rest of morning. Next day was the same. That was a Friday, so she got the next two days off for free.

Her friend Caroline, a non-medic, said “Lisa, you’re burnt out already?”

Lisa shook her head. “No. The opposite. Burn-out’s when you don’t really care anymore. Perhaps if I keep seeing death like this I will burn out. Especially if I can’t do anything about it, if I’m just spectating.”

“That’s the job isn’t it? Not meaning to sound horrible or anything, but isn’t it inevitable that this will keep happening?”

“Depends which bit of medicine I go into.”

“You’ll see it everywhere, don’t you think?”

“So, I’m in the wrong job, is that what you’re saying?”

Caroline looked uncomfortable. She knew how long her friend had studied for this. She knew the nature of ‘vocation’, a word often overused by those who wondered why doctors complained about working too hard. Lisa stared out of the window into the street.

“I guess you’ll just learn how to deal with it.,” said Caroline. She knew is what the worst advice she had ever given. In fact, it wasn’t even advice.

 

– 3 –

The team knew why Lisa had taken time off, even before she confided in her (pretty decent) registrar, Goran. He nodded as Lisa gave her explanation, but didn’t seem to want to get into the gory emotional detail.

“It’s understandable,” he said. “We all need MHDs now and again.”

“MHD?”

“Mental health day.”

He was trying to be sympathetic, Lisa knew, but it made her feel bad. Her natural reaction, and the admittedly extreme consequence (taking time off) had put her into a box – the mentally fragile box. She walked away convinced that the registrars, and then the consultants, would talk about her. Not cut out for this and that… keep an eye on her… additional support… God! Lisa made a decision: to deal with this.

Her consultant, Dev Kumar, made time. Lisa entered his office at the agreed hour. He looked at her and waited for her to fill the silence. Did he know why she was here? Probably, thought Lisa.

“Dr Kumar, I wanted to apologise for the days off.

“It doesn’t matter. Vivaan Bajpayee was a very sad case. We were all affected.”

“But I was the only one who had to take time off.”

“It was your first time.”

“Same for Luke, the other F1. He didn’t take time off.”

“Everybody’s different.”

“But I’m worried… about the next time.”

“We’re unlikely to have such a difficult case for a while.”

“But we will. Maybe tomorrow. What do I do?”

“You grew to like him, didn’t you?”

“He was so nice. But it wasn’t so much that I liked him… I like most of our patients… it was the contrast. Between how he was, working, busy, young, and how he was changed.”

“I don’t want to sound cold Lisa, but that’s what disease does. It randomly picks out the undeserving. There is no point trying to work out why. We all have different spiritual backgrounds, mine is very different from yours… maybe you don’t believe in a God, I’m being careful not to go there, but whatever you believe, you soon realise as a doctor that nature is capricious. Random. It’s unfair. We receive people after they have been dealt their bad luck. It’s awful. But our job is to keep moving forward, to help them. Treat them.”

“Without dwelling on the tragedy.”

“I don’t find it possible to treat people effectively, to make decisions objectively, if I’m too involved. If I identify too strongly with a patient.”

“So, I need to learn to keep a distance?”

“While maintaining a caring attitude, yes. While remaining empathetic.”

Lisa hesitated. Her eyes roamed the functional space: no photos, no pictures. A dead box.

“I’m not sure… I’m not sure I can do that.”

Dev’s silence was meaningful: but you must Lisa, or you will be useless. Then he surprised her.

“Lisa. I’ll tell you how I did it. I was a bit like you, less err… intense, perhaps, but affected, like you. Going home saddened, thinking about patients over the weekend, suddenly deflated during social events by the thought of someone…” Lisa was nodding. Dev was talking her language. “And then I gradually realised, that… my feelings meant nothing.”

Lisa looked at him, shocked. “What do you mean?”

“This is just my way of thinking, mind you.”

“Please, go on Dr Kumar.”

“It was my method, of detachment. I told myself that whatever I was feeling, it meant barely anything to the patient who was struggling with a new diagnosis of terminal cancer, say, or who was worrying about what to tell their family or how they were going to spend their last days. Whatever their greatest challenge, my emotional response was irrelevant. Who cares if I go home and cry or lie on my bed, paralysed by grief…” Lisa shuffled uncomfortably. Dev continued, “Who cared? I was the patient’s doctor, one of many, another passing badge, face, voice, attitude… that would melt into history once they went home… once they died.”

Lisa looked down at her knees. He was making her feel trivial, like an insignificant functionary. Was it true? Did she mean next to nothing to Vivaan Bajpayee?

“You look upset,” said Dev.

“I am. I hadn’t thought about it like that. I get it. I’m just another face…”

“No, not just another face. You were his doctor. That means something. If you did not perform well, as his doctor, and as a human, his remaining time would have been the poorer for it. You were highly significant to him, but you became significant purely through your professional position. You would not have met him unless you were a doctor in this hospital at that particular time. Your proximity to his suffering was due to your job. And when he went home, when he died, your job was unchanged. Your job was to help the next unfortunate patient. Because they will always be arriving at the door of your soul.”

Lisa sighed. “No more days off then?”

“Everyone is different. If you need a break, you need it. Talk to me or someone you trust. The odd patient will burrow deep into your psyche, and your memory. That cannot be bad, but it cannot stop you bring an effective doctor.”

 

– 4 –

It was four months later, by which time Lisa had moved on to another team. She saw it coming. A young male patient, with a young family this time. An incurable lung tumour. Not quite so close to death, as there were chemotherapy and immunotherapy options. But the shock was just as bad, and the man’s wife was unable to accept the situation for quite a while. She cried, she asked the same question several times over, and Lisa, who watched the senior doctors on the team do most of the talking, was appalled by the emotional trauma being experienced.

Quietly, without drawing attention to herself, Lisa shared the trauma and anticipatory grief. But she recalled Dev’s words, and in witnessing the wife’s all-consuming distress Lisa realised – this is not my family, this is not my grief… I am an observer here. No, more than that, I am instrumental in his care. But I am outside that tight circle of intimacy. And I will carry this sadness without letting it soak through me.

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