The hidden cost of medicine

Students of medicine trust that their lives as physicians will be revealed gradually, like a photograph coming to light. We hope that time and exposure will develop our clinical acumen, sharpen our focus, and help us maintain our composure. We’ve seen the wounds our mentors have rent and reunited. We’ve watched pains ease with remedies and rhetoric. We wonder at them, the ones who came before us, and ask ourselves which pearls they’ve sifted out, and kept, and which they’ve cast aside. Naturally, we believe that the art and the science of healing elevates and liberates our patients and ourselves. Surely, we think, the fruit of our labor is hanging somewhere in the sun, down a challenging road, and our struggle to learn (and learn, and learn) is how we’ll eventually pluck it. This is the truth, but it’s not the whole truth. The shadows of a photograph, the grit of an oyster, the bruise of a fruit, are all a part of our medicinal education that I never might have appreciated had my grandfather not fallen ill, and died.

His story is not an uncommon one. A war vet, and gorgeous, he saw more than his fair share of guts and God-knows-what in the strife between foreign nations. He was the son that came home, somehow. He married, and they had five children who grew up as bold as their father. Those kids left their third-world beaches, their titles, their cooks, and their cleaners to enjoy the promise of first-world welfare and isolation. All hopes were cast onto us, the next generation. The kids, our parents, would not leave ’Ma and ’Pa in the sweltering tropics. So, when fortune (though modest) afforded the flights, my grandparents came to Canada.

Here, they had a little house so blessedly close to mine at the shabby end of Nanaimo. Lola cooked adobo and rice, crocheted, and cared for cacti. Grandpa gave us little ones lessons in cursive and treehouse construction. He gave us the honor of scorekeeper, always, and taught us to carry our 1s.

As the years ticked by we all grew taller (he penciled the doorframe with our heights—“keep still, keep still…”). By the time we stopped growing, Lola had left, and the tender tendrils of creeping dementia had already started what couldn’t be stopped. Some days he would tell me to take his watch, his cane, his ring, in exchange for the rice without poison. Some days he would bellow and fly out the door, fall, bleed, and then tell the police we had pushed him. He told his children bawdy stories that did not concern their mother, God rest her. He dreamed, while waking, of foxholes and trains, the booming bombings, the march to Oblivion. Worst of all were his moments of lucid clarity…glimpses of my beloved teacher, flickering for an instant or more, then shuddering and going out, leaving us all more alone than alive.

At the end we all gathered, three generations of love and commitment. We kept vigil in that fluorescent room. I thought forward to all the times I would see this scene in the years to come. But this is the first, I thought. This was the only time that I would be that grieving grandchild, whispering into his maybe-deaf ears, whispering, whispering, just in case. The care aides swept in and out like stagehands in a play, arranging and rearranging him like a prop between our mournful scenes, then rushing away. My parents, aunts, and uncles were left with mouths agape, aborted questions catching in their throats. There were no pamphlets, no What to Expect when Your Father Is Dying. No How to Prepare Your Youngest for How Grandpa Looks. The nurse seemed annoyed at our numbers, our accents, our questions, our fears. There was nobody else, so I set to work, interpreting the bland, quiet, brutal action.

“The drug is called morphine.”

“Vitals are vital signs: heart rate, breathing rate, temperature, blood pressure…”

“I’m sorry; they have to move him again. To keep away bedsores.”

“They’re trying to keep him comfortable—yes, they’re keeping him… sleeping.”

We nibbled cookies and sipped weak tea from the cart they rolled in with the folding chairs, and we waited for something to happen. The steady rhythm of his breathing was precious, and awful. We strained our ears between sentences and clipped our answers short for fear of mis-sing a change in the pattern or depth. The only thing my family knew was that the sound of him wouldn’t, and couldn’t, last.

But I knew what the cookie-cart meant when I entered that dank little room. I saw the patch on his chest, the one with the ragged edges and blue-black shading, for what it truly was. The lump in the hollow of his clavicle, the molehills in his groin when the care aide turned him… I understood, in a rudimentary way, how a stroke could leave him unable to swallow, unable to wake, and how his history of staring spells had meant that this end was a long time coming. I wondered what was worse: the fog of uncertainty that clung to my family, or the bracing insight that clung to me? Neither could change what would happen, and narrating the fine details of an old man’s death would have been no more help to them than hearing “forget it” would have been to me. His strong heart and able lungs still clung to life, despite the crumbling mind, the sickly brain, and the cancer running rampant. I recalled lectures on dehydration, sepsis, hepatic encephalitis, palliative care… I couldn’t help it. I couldn’t help them, not really, and I couldn’t help him. The pain of that is crushing. 

The shadow in this picture, the grit that maybe begets the pearl, and the bruise that threatens to swallow the fruit is the terrible insight that medical knowledge gave me, but not my family. The things that we, as students, will learn and have learned, will give us the power to help and to heal. In return, those things will reveal, without pardon, the times we are truly, utterly helpless. We worry day to day about the things we don’t know, but rarely consider the pain of knowing. When we accept our new careers we sacrifice our ignorance, and any bliss it might have brought as life hurtles on and on. It’s the fine print of this contract we’ve already signed. The truth is that we will see the stigmata of death and disease in shopping malls, lecture halls, on the hands of strangers and the faces of people we love most dearly. There will be no unseeing. To practise medicine is not only to understand the minutiae of life and death, but also to learn how to balance the weight, to carry the terrible burden, of that understanding. And then, even still, when those lessons are mastered, we must go a step further; we must become deft at unloading, unpacking. We must arrange that knowledge somehow, some way, so that families sitting or pacing or weeping can pick up the pieces, carry them, and carry on, as we do. If we understand that as the true cost of medicine, all that remains is the question of whether we’re ready, and willing, to take on the price.

Acknowledgments
Competition organizers would like to thank the Rachel Bagnall Arts in Medicine grant for its generous support of this initiative; the Arts in Medicine club and Dr Carol Ann Courneya for their support; and the Vancouver Pen Shop, the Regional Assembly of Text, and a few private donors for their donations of prizes.

Ms Caddy would like to thank her family, and especially her late grandfather, Deo (1922–2014), for the years of laughter, love, and learning she has been so fortunate to enjoy.

hidden

The winning submission was selected by a panel of judges with literary experience and an interest in fostering the relationship between the written arts and medicine. The judges were chosen by members of the Arts in Medicine club.

hidden

Ms Caddy is a medical student from Nanaimo, BC, enrolled in the University of British Columbia’s Southern Medical Program, class of 2016. Having forgone a creative writing degree to pursue biology, she attended Malaspina University-College (now Vancouver Island University) before earning her BSc in biology at the University of Victoria.