Monday, October 16th, 2017

Cognitive Dissonance

Jason Han, MD

The fellow and I knew that we had to deliver some bad news.

“Unfortunately, there is a lot of air around your lungs that are preventing air from getting inside of them. We are going to need to place a chest tube today, which will help correct that.”

“Okay, a chest tube. But is it painful? You guys are going to do this to me while I’m awake? Here?”

He had a point. This procedure was admittedly invasive and painful. We would need to dissect in between his ribs and guide a large tube into the ribcage to remove the air around his lungs. As an intern, I had only observed this being done in the operating room before.

“Yes,” the fellow answered. “We do this at the bedside all the time without general anesthesia. It’s quick.”

I followed his lead and nodded. “We can give you some local numbing meds to make you comfortable.”

Once the patient agreed to the procedure, we covered him with sterile drapes and laid out the instruments on a back table. Within minutes, his room was transformed into a make-shift OR. I injected lidocaine at the site and pressed the scalpel into his skin. The “bedside procedure” had officially begun.

Technically, nothing was different about what we were about to do than what I have seen in the OR. Yet, I could not help but notice a fundamental difference in having a patient awake and conversational in front of us. What’s more, he was able to feel pain. When we made certain movements, he immediately groaned and told us.

“Ow, I can feel that!”

“Sorry, let’s give you some more numbing medication there. You’re doing great, please try to stay still.”

At one point he was in so much pain that he was unable to hold back his screams.

“Ow! This is unbearable! Are you almost done?”

Undoubtedly, the procedure was affecting the patient. But when this patient began to vocally express how our actions were causing him pain, this began to affect me deeply and viscerally as well. I looked up at his face, distorted in agony, and I could not help but recognize his humanity.

Before I realized what was happening to me, my vision began to narrow as I broke out into profuse sweat. My breathing became labored and shallow. At one point, I feared losing consciousness and had to excuse myself to sit down outside of the room. By the time I recovered, the procedure was over.


This was the first time in residency where I became aware of the psychological challenges that accompany my path ahead. I always recognized that some aspects of surgery would be difficult to process, but I had not experienced the true weight of causing pain in another person until that day. The responsibility. Anxiety. And to some extent, guilt.

Logically, I understand that these procedures are necessary and Hippocratic. No matter how invasive or painful, they are undoubtedly carried out in an overarching mission to heal and help my patients.

Yet, this experience has taught me that, a part of me will undoubtedly find some aspects of this job to be traumatic, and have a difficult time coping with the pain I cause along the way. The act of applying sharp instruments to another person’s body, causing bleeding and eliciting pain, is psychologically burdensome. Its invasiveness leaves neither party unscathed.

Sometimes it manifests in the subconscious. Most nights I fall asleep as soon as my head hits the pillow. However, over the past few weeks, despite being sleep deprived I have been frequently waking up from vivid dreams, often alert and drenched in sweat. I look around an empty bed where only a moment ago I imagined seeing and hearing a patient in agony.

I initially believed that I was uniquely experiencing these signs of work-related anxiety. I felt embarrassed about nearly passing out during a procedure. Sometimes, in the field of surgery, letting the work get to you can be interpreted as being unfit or weak.

But to my surprise, my colleagues endorsed the same exact phenomena.

“I have nightmares like those all the time. And last week, I had to lay down for ten minutes after getting light-headed during a spinal tap.”

“I grind my teeth every night. My teeth are pretty much down to nothing.”

These shared experiences suggest there is perhaps a cognitive dissonance that is inherently difficult to reconcile in surgery. How could it be easy for the brain process something that is concomitantly life-saving, yet traumatic? Noble, yet violent?

My answer to this for the time being is that these nightmares among other visceral phenomena that we experience are the manifestations of our humanity, our connectedness to our patients. We ache because we see ourselves in them, and can feel their pain.

It is not because we are unfit or weak, but rather because we are empathetic. There is no shame in feeling discomfort, a deep gnawing unease, when a part of our job inflicts pain in our patients. These feelings motivate us to become better, more efficient, and more considerate each day.

Bluntly suppressing them is not the answer. Surely, my fellow residents and I will inevitably grow hardened against the traumatic aspects of our work over the next decade to an extent, feeling little hesitation or anxiety in the face of blood, emergency and pain.

Yet, a part of me hopes that I will perhaps never fully overcome the cognitive dissonance in my job, because perhaps that anxiety that wakes me up at night, the feeling of weakness that overtakes me from time to time when I see another person in pain, is an indomitable reminder of my humanity, the reason why I chose to pursue this path in the first place.

About Jason Han, MD

Jason Han is currently a first year Integrated Cardiothoracic Surgery Resident at the University of Pennsylvania. He graduated from the Perelman School of Medicine in 2017. He is drawn to stories in medicine that reveal deeper insights into our humanity, psychology, and values. You can follow him on Twitter @JasonHanMD.

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