The Mask

  • Elizabeth Hiroko Ristagno
    Address correspondence to Elizabeth Hiroko Ristagno, MD, Department of Pediatrics, University of Louisville School of Medicine, Office of Medical Education, 571 S Floyd, Ste 412, Louisville, KY 40202-3830.
    Department of Pediatrics, University of Louisville School of Medicine, Louisville, Ky
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      Obviously she was loved; the line of her memorial service stretched out the door, and colorful flower arrangements covered the floor and tables. I nervously entered the funeral home and took my place in the queue as I wondered whether I should be there. I had agonized over the decision: was it appropriate for me to go to my patient's memorial service? After all, I was “just” a resident. Was the family angry at us, the health care professionals, for not being able to help their daughter? In medical school, I had not been taught the proper etiquette for such heart-wrenching situations. I glanced at the touching photos, portraits, and videos depicting the young girl, but quickly turned away as my eyes filled with tears. For composure, I focused on each person around me and tried to identify his or her role in her life. I felt uneasy, a stranger who knew her only during the last month of her short 9 years.
      I had performed rounds on her every day in the intensive care unit with a subspecialty consultative team, carefully reviewed her laboratory results, examined her, and talked with her family. Often I had returned to her room before I left the hospital in the evening to check on her and chatted with her mother and father. Each time, I had methodically donned my gown, gloves, and mask, but the second her mother's eyes found mine, I saw her disappointment. She knew my using isolation gear meant we had still failed to reach a diagnosis. Every day, I had reinforced the need for isolation, and even though my words expressed hope, my mask hid the sadness I felt for their little girl and for them.
      Her father was intimidating. He had asked for the pharmacological mechanism of every medicine she was prescribed. He was armed with a notepad of questions and a second notepad chronicling each day's events. Each morning he ran through the list of differential diagnoses and quizzed me on laboratory results that were pending. He was an experienced parent of a patient; nothing escaped him.
      The girl's baffling illness had been punctuated by numerous hospitalizations at several different tertiary hospitals. Those exhaustive and repeated workups had never revealed a diagnosis for her compromised immunosystem. Her clinical course was rocky until she took a sudden turn for the worse. She developed secondary invasive fungal and bacterial infections. During a discussion of a risky and potentially fatal therapy the night before she died, her father held back tears as he realized her fate. The drained and defeated face of her father that evening haunts my memories.
      Now I will face him for the last time.
      When I had sought their advice, my attending physicians had encouraged me to go to the memorial service. They had shared several stories of patients' funerals and expressed the importance of their attendance to the family and themselves. But while standing in line with other mourners, I still wondered whether my brief involvement in her health care justified my presence at her memorial service. Was it an intrusive effort that served my own needs rather than her family's need for comforting? As I slowly approached her parents, my mind raced. What could I say? What was there to say?
      Time ran out quickly. I found myself hugging her father and handing him a card. I held my hand across my face as an imaginary mask and said, “Do you recognize me now?” It was a lame attempt at humor as my eyes started tearing. He genuinely laughed and I turned my attention to her mother. She reached out to hug me. My mind went blank and between my trembling sobs I blurted out the first words that came to my mind: “I am so sorry . . . we couldn't save her.” Her mother cried with me, nodded, and whispered back “I know, you did all you could. Thank you so much for coming.” At that moment, all doubt disappeared. I knew I had made the right choice.
      Residency teaches taking histories, performing physical examination, learning diagnostic skills, thinking critically, and practicing evidence-based medicine. But who teaches you to be a compassionate physician? Neither medical school nor residency teaches you when it is appropriate to hug family members, cry with them, or attend a memorial service or funeral. These occasions are awkward, and many residents and physicians choose not to get too involved. They leave their mask on to prevent emotional connection with the patient and family. Many of us fear uncontrolled or outward displays of grief with patients and families, assuming that it adds to their burden and lessens our effectiveness. In this instance, I discovered that my genuine expression of grief and regret to this family was the only healing I could offer. My journey through the memorial service line taught me that communicating compassion and sharing in grief can be effective medicine—not only for the family, but especially for me, the physician.