Doctors and Death
Sunday January 4th All Things Considered

Joanne Silberner reports on how doctors learn to put death at arms length. Before doctors become doctors they deal with the same isues surrounding death as everyone else...the sense of loss, frustration, and grief. But to become doctors -- that is, good doctors -- they need to get comfortable enough with the end of life so that when patients die, including patients they may have known for years, they can leave it behind them in a way that relatives and friends cannot.

You can read the transcript:

JACKI LYDEN, HOST: When we experience the loss of a loved one, we often look to those who treated them, their doctors, for comfort and explanation. We want answers, and often don't stop to think that our doctors' medical training may not have prepared them for handling the issues surrounding death. But some doctors are working to better cope with the fact that their power to stave off death is limited. And when patients do die -- patients they may have known for years -- they're learning how to leave it behind them in a way that relatives and friends cannot. NPR's Joanne Silberner has this report.

JOANNE SILBERNER, NPR REPORTER: At George Washington University Medical School, one of the required courses covers how to deal with death.

DEVIN CLINE (ph), SECOND YEAR MEDICAL STUDENT: Good morning, Miss Smith.

UNIDENTIFIED DOCTOR, PLAYING ROLE OF PATIENT: Good morning.

DEVIN CLINE: I've Devin Cline, a second-year student.

DOCTOR: Hi. Nice to meet you. As you know, you had an ultrasound on your pelvis which has unfortunately shown a large mass.

JOANNE SILBERNER: Twenty-three-year-old medical student, Devin Cline, is role-playing, practicing with a doctor who is playing the role of a patient.

DOCTOR: A mass?

DEVIN CLINE: Yes, a mass.

DOCTOR: So -- that means cancer.

DEVIN CLINE: No, it does not necessarily mean cancer. A mass...

JOANNE SILBERNER: The idea is to get students comfortable talking with patients about serious, possibly deadly conditions.

DEVIN CLINE: There is a difference from the normal density in the tissue.

DOCTOR: I mean, you know, I've read that Gilda Radner, her books and every -- I mean, a tumor down there is usually -- it's a cancer, it's ovarian cancer. And you die from it, right?

DEVIN CLINE: Unfortunately, it may a cancerous tumor. Or it may be something benign as well. Just a change in the growth pattern. So, uh...

JOANNE SILBERNER: Cline is still searching for words. But when it comes time for him to talk to a real patient, he'll have a better idea of what he wants to say, so he'll be free to listen more carefully to his patients. He says he's had only limited exposure to death. When he was in elementary school, his best friend's father died. Then in medical school, he had to deal with cadavers. The student were taught to respect the dead bodies: not to wear baseball caps in the autopsy lab, not to fool around. But still, it took some adjusting.

DEVIN CLINE: People make jokes about death and things outside of the room. And I think it's a human type reaction to the situation, because it kinda hits close to home, these -- you know, you're walking into the room and there are 30 dead people sitting there. So it's the way people deal with it.

JOANNE SILBERNER: Cline is being taught that he doesn't have to be callous to be able to cope, and that it's not always a doctor's failure when a patient dies. Death is part of life. But even with the role playing, he's not looking forward to putting what he's learned into effect.

DEVIN CLINE: When it comes to times where I'm in the hospital, on the wards, talking to a real patient, it won't be as easy. I'll need to sit back, and it will be upsetting. You know, the person will probably cry -- I'd probably cry. It would be a much longer process, a much more difficult process, for both of us. Psychiatrist Robert J. Lifton (ph) has studied how people react to death. He says what doctors need to learn is to become a little numb to it. It all begins with the first-year anatomy course, where the students are confronted with cadavers.

ROBERT J. LIFTON, PSYCHIATRIST: One is told this is the beginning of gross anatomy study. But it's also an initiation rite which tells one that one is entering into the realm of death, that one has something like a shamanistic position between life and death as a doctor.

JOANNE SILBERNER: With some power over whether a patient lives or dies. To harness that power, Lifton says, doctors need to master the universal fear of death. Medical schools never used to teach about dying or spirituality. Now about a quarter have some sort of course. But most doctors still learn by watching older doctors, and through the experience of having patients die. They learn not to dwell on what might go wrong in an operation and not to experience the full sense of pain and loss of a death. But, Lifton says, doctors have to be careful not to numb themselves too much.

ROBERT J. LIFTON: The unfortunate direction would be to, in a sense, run away from the situation -- either being there physically, but not responding, not offering any sort of help or assurance because one is not confronting the death that's taking place -- or literally being not there.

JOANNE SILBERNER: Staying away from the bedside, abandoning the patient to nurses or orderlies, which he says frequently happens. The loser is the dying patient. The ideal is a partial numbing, where the doctor can close off feelings of intense grief but still have enough emotion and empathy to help the patient and family. Partial numbing is something 42-year-old Stacy Month (ph) been working on her entire career.

STACY MONTH, HEAD PEDIATRIC HEMATOLOGY AND ONCOLOGY DIVISION, OAKLAND KAISER HOSPITAL, OAKLAND, CALIFORNIA: Can I check you out? Does everything work?

DOMINIQUE TATE, PATIENT: Yes, ma'am.

STACY MONTH: Let me see. Your legs work?

DOMINIQUE TATE: Yes.

STACY MONTH: Yeah. Does your nose work?

DOMINIQUE TATE: Yeah.

STACY MONTH: Do your ears work?

DOMINIQUE TATE: Yeah.

STACY MONTH: Very good. Terrific.

JOANNE SILBERNER: Month cares for children with potentially fatal cancers and blood diseases. She heads the pediatric hematology and oncology division at Oakland Kaiser Hospital in California. Her patient, 5-year-old Dominique Tate (ph), has been battling lymphoma for a year. She's going home today, having finished what everyone hopes will be the last of her hospital stays for chemotherapy.

STACY MONTH: Well, are you gonna celebrate? Are you gonna have a party?

DOMINIQUE TATE: I don't know.

STACY MONTH: You should. Are you happy? You told me you were happy...

JOANNE SILBERNER: Dominique's cancer is in remission. But two other patients Dr. Month will see in the clinic today -- one 10, the other 13 -- each have a blood abnormality that's very likely to lead to a deadly lymphoma. Month started medical school 20 years ago when there weren't any classes like the one Devin Cline had. She had to learn on the job.

STACY MONTH: I remember the first patient I had who died. And I sort of couldn't leave their bedside, I was just so struck by the process and feeling like I had to take it all in and really experience what was going on with the family, with the child -- and was certainly very upset by it.

JOANNE SILBERNER: She cried after that death. But what made it bearable is that the parents sent the medical staff a letter of thanks. Today Dr. Month goes to her patients' funerals when she can. She says it gives her a chance to work through her emotions. And she still cries, in private, when her patients die. I should say at this point that Dr. Month and I went to college together. She was easily the funniest person in class, joking around a lot and acting in comedy reviews. Now she's more somber. She doesn't laugh as much. She admits that 13 years of caring for dying children has taken a toll.

STACY MONTH: It's hard to retain that sort of -- a joy of life and sense of humor and all that when you're dealing with this on a day-to- day basis. So I think I'm saying oh yeah, you know, I can handle it, or I'm trying. But you're right, there is a heaviness that we all feel -- all the doctors, nurses, social workers, psychologists feel. And sometimes we think, wow, how do we do this?

JOANNE SILBERNER: They do it in a number of ways. Month makes a conscious effort not to dwell on her patients when she's not at work. At work, she focuses as much on her patients' families as on her patients, reminder herself if it's tough for her, it's tougher for the families. She and all the other people in her division counsel families extensively. So even when all their medicines fail to save the child, they know they've helped someone.

STACY MONTH: The only way to get through it is not to say oh, these are my failures, these are the patients that died, this is where, you know, it was a failure. It was a terrible tragedy. But if you say this was the situation given everyone, and this family, you know, they're the ones -- you're right, that are gonna live on. And if they can live on and be successful, productive members of society and not have severe depression the rest of their lives, and you know, all that thing -- then that's a contribution that our team is making.

JOANNE SILBERNER: Something else has made Month's job easier. Twenty- five years ago, most cancers and serious blood disorders in children were fatal. The cure rate for a condition like leukemia, for example, was barely 10 percent. Now it's about 80 percent.

STACY MONTH: It's so helpful to see that: to go to a clinic and see someone that was cured from their disease.

JOANNE SILBERNER: She said she'd rather work with children with cancer than with adults with cancer. It would be too easy to relate to the adults, to think it could be her. And in fact, while it may seem that doctors who learn how to deal with death in a professional way have an easier time of it, when they or their loved ones face the end -- well, that's not necessarily so, says psychiatrist Robert Lifton.

ROBERT J. LIFTON: In the case of at least some doctors, they enter medicine partly or largely because of their own fear of death. And while there may be some advantage in the knowledge of disease process that he can, or she can, convey to others, family members -- I'm not at all sure that a doctor does any better with his or her own dying.

JOANNE SILBERNER: The ones who make the effort to learn to deal with death, it seems, can help their patients, but not necessarily themselves. Joanne Silberner, NPR News, Washington.


Dateline: Joanne Silberner, Washington, DC; Jacki Lyden, Washington, DC

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