A Medical Student Perspective on Loss and Self-Awareness

“There are these two young fish swimming along and they meet an older fish swimming the other way, who nods at them and says, ‘Morning, boys. How’s the water?’ And the two young fish swim on for a bit, and eventually one of them looks at the other and goes, ‘What is water?”

– David Foster Wallace, Kenyon College Commencement 2005, “This is Water.”

The journey from medical school to residency goes fast: there scarcely seems time enough to do it all. Although we practice again and again so we can better discern what troubles our patients, we do not do the same for ourselves. In fact, until I lost my friend this year, I suffered from a condition common among medical students: a lack of understanding of my own inner voice.

David Foster Wallace (1962-2008) was a novelist and essayist. He is best known for the novel, Infinite Jest, which explores themes of family, addiction, and the role of entertainment in modern American life. Much of his fiction has semi-autobiographical themes and his fish story is a simple, poetic reminder that we ourselves create meaning from experience. Wallace died by suicide in 2008 after a twenty-year battle with depression.

Let David Foster Wallace’s parable remind us that the most important realities are the ones hardest to identify and talk about. We should devote time and experience to self-awareness and reflection, until it becomes fluid and reflexive, just like the examination techniques we are taught and practice for long hours. With a strong base of self-knowledge and robust self-care practices, we can be better prepared to handle the challenges that inevitably come with our profession. These include loss, in all its forms: loss of a loved one, loss of a patient under your care, missed birthdays and milestones with loved ones, loneliness, and despair.

I lost my friend to suicide two hours after I completed the USMLE Exam and fifteen minutes before we had a scheduled call together to discuss some upcoming plans. He was 24, and one of my closest friends in medical school.

I immediately began searching for answers. I lay in bed, unable to sleep, but unwilling to rise and blink myself to reality. I ruminated over where he had been emotionally in his last moments and how was it that no one could reach him. I found myself searching my memory for evidence of his unhappiness, for fear or despair. I found nothing.

But would I know the signs if I saw them? How deep ran his feeling of apathy on the heels of the pandemic? I did not know. Inevitably, my struggle to piece together the loss of my friend was not solely about him, but about my awareness of myself.  Who was I to speculate on what he may have been feeling the day we went running together, or the day after OBGYN exams, or in his last hour, or when I, myself, stumbled over what despair felt like? When I struggled to name the tight feeling in my chest when I looked at photos of him?

In the days and weeks following this tragedy, I became acutely aware of my feelings in a way that I hadn’t before. I noticed my inner state as I moved from anger to grief, and slowly started to heal. But it doesn’t need to be this way. You can practice self-awareness just as you do physical examinations.

I refer again to David Foster Wallace, who said, “The capital-T Truth is about life before death. It is about the real value of a real education, which has almost nothing to do with knowledge, and everything to do with simple awareness; awareness of what is so real and essential, so hidden in plain sight all around us, all the time, that we have to keep reminding ourselves over and over: ‘This is water. This is water.’”

He reminds us that education should be as much an apprenticeship to awareness of the self and empathy towards others as a pursuit of knowledge. We should honor self-care practices at all times; not just in the wake of a tragedy. In the day-to-day life of a physician, it is so easy to get caught up in caring for others that we forget to care for ourselves and ask basic questions like, “What am I feeling right now? What do I need in this moment?”

Similarly, as students we should ask ourselves, “What do we need, here in medical school?” Encouragement, empathy, moments of solitude, time with friends or family, a chance to go home, a chance to share our uncertainties about the future. We should allow ourselves the time to know our needs, know what resources for support are available from our medical schools, from our peers, and from our mentors. We should know where to go and what phone number to call if we are not okay. We should take a collective breath and ask if we are listening – to each other and to ourselves.

We must resist the old dogma that makes medical students so highly self-critical, that we cannot be anything less than perfect. I am almost certain my friend suffered this misperception. During a long day caring for a patient deep in their own troubles, with deadlines to manage or a night of study ahead, take some time to check in and ask yourself how you are feeling.  Ask yourself, “How am I showing up in this moment, and am I being kind to myself?”

When I think of the kindness my friend showed others, I am reminded that every day a little bit of encouragement, empathy or validation can deeply affect us, can penetrate the murkiness, generate resilience, and encourage us to laugh. Every interaction ripples outward. Every loss, too. It is with fondness for his memory that though the stakes are so high and the time so rushed, I never pass up the opportunity to give a word of encouragement to others or to myself. We should also acknowledge that every day, there is much we get right. There is much we do for one another. The early days of the pandemic made this clear. The kindness of my classmates toward me after I lost my friend did so, too. My classmates joined his memorial service in exceptional numbers, joined me in idle moments after lectures, and asked how they could help with a fundraiser we coordinated for a non-profit that maintains a crisis hotline.

Since this event, I resolved to maintain a daily journaling practice, at times no easy task at the end of a long day. Self-awareness is a muscle to be exercised and strengthened. I received a gift, a blank journal of “200 writing prompts”, which allows 150 words on simple topics like, “What do you look forward to every week?”. I encourage you to try different tools and see what works for you. One of my colleagues colors in the little squares of a wall calendar according to his moods. The important thing is affording protected moments for reflection.

Medical students, know what you need. Shed the old claim of infallibility. When I shed it and truly examined the experience of loss, I was able, with new awareness, to move through it. Become comfortable talking about loss, about grief, and your apprehensions about the future. Study your emotional landscape and the world around you just as you do your textbooks.

I promise it is never too early to ask yourself what your needs are, nor to begin building a reflective practice toolkit. These accomplish two things: you build a foundation for the challenges medicine is sure to throw your way, and you gain understanding of what other people need, too. You can never be in another person’s experience, but your own feelings can be a good compass to determine ways to ask your peers, friends or patients what they need. Combine this with intermittent self-reminders of why you chose this exceptionally rewarding, challenging field, and our community will be better for it.

You can read This is Water here.

Fiona authors a narrative medicine column with exercises designed to encourage reflective practice. Find it here.