On Doing Battle

Author’s Note:  No patient names or identifying characteristics were included in this story.

My life as a fourth-year medical student was a world away from what the previous year had been. After having spent a year as an observer, I was expected to function more like a junior physician. Everyone I worked with seemed to understand this implicitly. Residents began asking me what the treatment plans for my patients should be instead of dictating what the plans would be. Nurses who’d only ever told me about “the patient” started to ask me what I wanted to do for “my patient”. Families turned to me as their first point of contact with the medical team. I slowly started feeling responsible for my patients.

That year, I took care of a girl named Abigail. By then, I had developed a habit of making up nicknames for the children I took care of as a way of communicating my affection. Abby’s last name was Sargent, so I called her “Sarge”.  She looked at me strange the first time I used it, but she grew to enjoy it. At 14, Sarge was old enough to be obsessed with text messaging but not quite old enough to have reached those insufferable teenage years. She was gentle and a bit shy, the kind of girl who would respond to a joke with a smile and a soft chuckle rather than a full-throated laugh.

Sarge was also thin – too thin. She was ill with an eating disorder, meaning her brain had distorted her relationships with food and with her body. Despite how skinny she was, Sarge believed that she was overweight. Whenever she tried to eat, a voice in her head—The Voice, as she called it—would remind her that food was bad and so was she. Though she was so thin that the T-shirts she wore draped from her shoulders like curtains, she was utterly afraid of becoming overweight.

It wasn’t just that she disliked eating—she was convinced that eating would make her fat and therefore that food was bad for her. A professor of mine who specialized in eating disorders explained it this way: patients like Sarge feel the same way about eating a plate of pasta with a glass of milk that another person might feel about eating a plate of spiders and washing it down with a glass of poison. No matter how badly she hated having to be in the hospital, no matter how guilty she felt about watching her parents cry at how thin she’d become, no matter how deeply she knew that not eating was ultimately dangerous, every mealtime was horrifying for her. The Voice had completely hijacked her thoughts.

Sarge had been admitted to the hospital after losing enough weight to threaten her life. Under my care, she was to undergo the standard treatment for patients like her: feeding her enough calories to return her to a healthy weight. The treatment protocol was straightforward. A nutritionist calculated the number of calories Sarge needed to eat daily. Every day, the foodservice staff would bring Sarge three meals and two snacks corresponding to the number of calories she’d been prescribed.

The catch was that Sarge couldn’t refuse the food. If she felt she couldn’t eat, she’d have to drink a milkshake to take in the calories she was assigned for each meal. If she refused the milkshake, a feeding tube would be inserted through her nose, down her throat, and into her stomach, and a machine would pump the milkshake directly into her stomach. Afterwards, the feeding tube would be removed. The tube had to be removed after each meal to keep her from using it as a crutch to avoid having to eat. If she gained weight by feeding tube alone and didn’t conquer her fear of eating, she would go home, avoid eating, lose the weight she’d gained, and end up back in the hospital.

Sarge was in agony. She hated food but having the feeding tube put in was painful; she was afraid to have it inserted. At each mealtime she felt trapped. I felt like I was punishing her, but I knew that she had to take in nutrition one way or another. She had become so malnourished that her body didn’t have the nutrients needed to perform basic functions—her heart could stop at any time.

Every morning after I checked Sarge’s vital signs, I’d sit on the edge of her bed to chat. Sometimes we’d do crossword puzzles together and she’d teach me about the Disney Channel’s newest shows. Other times, we’d talk about her disease. She once told me through tears that she knew The Voice wanted to hurt her but that she didn’t know how to beat it. The sight of this little girl weeping powerlessly in the face of her disease broke something inside me. Her pain became my own. I promised her that she could beat The Voice and resolved do everything I could to help her. I poured whatever energy I had into her treatment, believing that her breakthrough was near.

I made an effort to be with her during her meals, kneeling next to her to remind her that she was stronger than The Voice. At each meal, watching her stare at a turkey sandwich and fries or a cheese quesadilla as if facing her mortal enemy, I believed deeply that this time would be the time that she finally finished her plate. When she didn’t, I’d be disappointed, but I’d tell myself that it’d happen next time. If I ever couldn’t be with her during a meal, I’d swing by her room to check on her afterwards. If she’d been able to finish it, I’d congratulate her. If not, I’d remind her that she was brave for trying.

After weeks of morning chats and crossword puzzles and mealtimes together, my rotation was coming to a close. I was leaving the unit; Sarge wasn’t. Despite both of our best efforts, she hadn’t gained enough weight to go home safely. On my last day, I knelt beside her bed to tell her that I was being reassigned and wouldn’t be taking care of her anymore. I told her I was proud of how far she’d come and that I knew she was going to beat The Voice. I gave her a long hug—my arms wrapped around her shoulders, her little arms wrapped around my waist—and left her room for the final time.

As I walked down the hallway, my I felt my face getting hot. A burning pressure was building behind my eyes. I blinked quickly a few times, trying to suppress the oncoming emotion. I couldn’t. I walked quickly to the nearest bathroom and locked myself in it. I sat on the toilet, hands folded together, elbows on my knees. Looking downwards, I watched the tears as they fell from my eyes and splashed on the tile in front of me. My chest heaved. I sobbed quietly to myself.

My emotions surprised me. After all, I had learned the lessons of life and death. And Sarge wasn’t even dead—she just hadn’t gotten better. After more than a year in the hospital, I’d certainly learned that some people got better and some didn’t. And yet here I was, weeping as if I’d forgotten everything I’d learned.

I was angry. Not with Sarge, and not quite with myself. I was angry at her illness. I had come to work every day believing that she could turn the corner at any moment, but that moment never came. I had wanted to make her better so badly and yet I was leaving her in almost the same state that I’d found her. I had gone to battle on her behalf and I’d lost. I too felt powerless in the face of her disease.

When I was a third-year student, a naive observer, I’d cried at Mavis’ death. But the tears I cried for Sarge came from a different place. Sitting in that bathroom, I better understood the difference between being a spectator and a caretaker. Mavis’ fate had taken me by surprise. It was the first time I’d lost a patient and it shocked me. But I hadn’t felt responsible for her. I was watching someone else care for her. I had cried for Mavis because I felt sad for her. I was crying for Sarge because I felt defeated. I had believed that I could make her better, and I was crushed to know that I hadn’t.

Despite learning that her eating disorder could take months to resolve, I had allowed myself to believe that I could make her better if I just tried harder. At times, I’ve been advised to manage my expectations. “Do your best,” I’ve been told, “and live with what happens”. There is some wisdom in detachment. If every working day is fraught with emotion, I’ll burn out before long. This advice is also a reminder to remain humble. I believed so strongly that I could make Sarge better in part because I assumed that I had more control over her outcome than I really did.

Looking back, I finally understand why my obstetrics resident had cried that day. She wasn’t upset over a mistake she’d made—she hadn’t made one. She wasn’t overcome by a general sadness, the way one might cry at hearing a tragic story. I think she cried because she had truly believed that she’d deliver that baby successfully and was devastated to know that she hadn’t. Statistically speaking, she must have known that she would lose some babies over the course of her career. Yet she never walked into a delivery room believing that she would lose that baby. The heart of being a physician lies in this apparent contradiction.

Many of my patients won’t get well. Many will die. To approach each patient believing that they can be made better—even those for whom I know that “better” will never mean “cured”— is to guarantee myself disappointment. And yet I find that I have to believe. Not just because my patients will want to know that I do. Not just because their families will look to lean on my belief when they’ve lost hope. I have to believe because I can only do my best for my patients when I am convinced that they can get better. A warrior can only give his all to a battle when he believes victory is within reach. The emotional cost of disappointment is the price of becoming the physician I hope to be.