To say that the current COVID-19 pandemic is stressful is an understatement. We have all felt the worry of exposure and the impact such an exposure might have on our family and friends. We have worried about aged parents and grandparents. Many of us have lived the stress of having to help children adjust to a new world of home school and limited outlets for social and emotional development. Some may have felt the stress of schooling our kids at home. Many of our dearest friends, colleagues and health care partners have been on the front lines, facing long difficult hours taking care of some of the sickest patients they have ever encountered. Some among us have felt incredible stress when we couldn’t help more.
As a surgeon I care for patients with cancer and the stress the impact of the pandemic was different. I have spent fewer hours in the hospital in the past month than in any of the preceding months since graduating medical school again. Although I was fortunate to never stop operating completely, the pace was a stroll compared to business as usual. And all the reasons why that needed to be were not just reasonable, they were intuitive. We needed to preserve resources – human and material – to best prepare the overall healthcare system for this pandemic. Taking up my professional residence in a busy academic medical center I had the privilege (and the time!) to participate in discussions of the ethics of cancer care during a pandemic. And intellectually it was crystal clear that in order to maintain core principles of bioethics – justice, beneficence, non-maleficence – we needed to put protocols in place that fairly distributed available resources to patients that needed them most.
As a researcher I study decision-making and, in particular, the role of distress in decision-making for cancer. I study this because distress following a cancer diagnosis is common. Combining the diagnosis of cancer and the fear and worry we all felt in response to pandemic conditions was uncharted territory. Despite my academic interest in this space I was completely ill-prepared for what it would feel like to not be able to offer my patients the care they wanted. While I am focused in my academic pursuits on the impact of distress on the process of decision-making, I completely took for granted that in the day to day care of my patients, the delivery of my surgical care that is common and standard, is my greatest tool to reduce distress in my patients.
The first of discussions I had with patients when I had to postpone their surgery or offer them an alternative plan that was definitely safe, but was not usual, did not go as well as I had planned, especially given the amount I have thought about distress and patient-provider communication. I entered those conversations armed with my sort of overly academic view that our approach was fair and appropriate given the circumstance. But in holding to these views so tightly I failed to bring empathy to the conversation. At one point when a patient had become obviously distressed by what I was proposing I even started down a philosophical discussion about resource poor health care systems and why the decisions being made were good and right, even if they couldn’t see it that way. Being stuck squarely between my own research interests, the unusual restraints of the healthcare system and meeting the needs of my patients induced remarkable distress (pardon the irony). My stress was from being both committed to the health and well-being of those suffering with COVID and the friends and colleagues taking care of them but to also place myself into the experience of each of my patients, who were simultaneously feeling all the same stressors of the COVID pandemic as I was and a diagnosis of a cancer, for which treatment was all the sudden less certain. Delivering healthcare in the face of scarcity is juxtaposed from how healthcare usually works in America. While I think it is too soon to be completely into the reflective stage of this pandemic, I do think the lessons in empathy and in more flexible approaches to the delivery of care that I have experienced, are rampant. I look forward to looking back on this time knowing that we, as a healthcare system, may be at least a little better for the lessons we have collectively learned through some very dark days.