To begin at the end

Serena Arora is a medical student in the Class of 2019 at McMaster University

 

I love puzzles.

I love looking at the picture on the box, seeing what the completed version will look like and then pouring out all the little pieces — knowing that, somehow, they all come together to create something.

In some ways, practicing medicine is like doing a puzzle. It’s complex, intersecting, and incredibly rewarding when done right. At the same time, medicine is fractured into a thousand different components.  As physicians, we look at our patients and we piece them apart into organs and body systems and tissues. We rip the details we think are important from the fabric of their narrative to focus on specific complaints. We take their words and distill them into our jargon, often so much so that their original story would be unrecognizable. Medicine is often an act of reductionism.

If medicine is a puzzle, then palliative care is like the picture on the box. It shows you that it is possible to fit the pieces together to create one beautiful entity. It seeks to stitch together symptoms, emotions, values, families, and beliefs... to bring together seemingly disparate components to create something new. Palliative medicine is listening to hearts and stories, systolic murmurs and dying whispers; taking blood and giving touch. Palliative care taught me the necessity of wholeness.

Putting together a puzzle requires context. Each piece relates to another, and without understanding those relationships, it would be incomplete. Our patients require the same of us. Health is situated in a certain context; our family, environment, socioeconomic status, culture, and social networks all factor into our wellbeing. When we leave gaps and lose pieces, our puzzle — our story — is incomplete. When my palliative care preceptors discussed goals of care, what they were really saying was, “Tell me about you. Share with me what your life looks like when it’s complete, in the context of everything that you are and all the things you feel are important to you. Help me find the missing pieces, so we can meet your needs and fill the gaps.” They ask patients to show them the picture on the box of the puzzle.

Each patient’s puzzle is created by adding pieces of life experience. With every success, hardship, loss, and accomplishment, more pieces are added. When we label someone as sick, some components of the puzzle become more complex. Sometimes, we set those pieces aside to work on them diligently for hours at the expense of the others. And when we separate the sickness from the rest of the story, we also separate the patient’s disease from their humanity. Our diagnoses can force our patients out of their comfort zones and into the world of healthcare, where they now have to play by our rules, use our language, and follow our directions. Their complaints are judged by our definitions of severity and our criteria.

Palliative care reorients these isolated pieces and puts the creation of the puzzle back in the hands of the patient. When we hand the patient the button for their pain medication, we hand back their control and their autonomy. When we stand on their doorsteps during a home visit, we give our patients a choice. A choice to let us in, to allow us to help, to set the limits of our involvement. In their palliative care story, they choose their own adventure — they decide the setting and the characters involved, and they write the ending. Palliative care is empowering. Despite the uncontrollable and unpredictable nature of death, palliative care reminds these patients that they are not helpless. They may not be able to choose when they die, but they can choose how they live for however long may remain. It empowers them to continue to finish their story, and to paint their own image of themselves in creating their legacy.

I love puzzles.

I love them, just like I love the complexities and intricacies of patients and their stories. Before my palliative care experience, I don’t think I even realized how much. Palliative care was my first clinical elective of my educational career. Less than a year into medical school, it seemed ironic that I was beginning my training with end of life care — to begin learning medicine at a point where, for so many, medicine was unable to cure their disease or prolong their life. The final chapters of my patients’ stories were where I started reading.

By starting with palliative care, I got to see the picture on the box of the puzzle before I even started putting the pieces together. I had the chance to remember that each aspect of my patients’ lives existed in the context of their larger narrative. I watched as my preceptors helped patients and their loved ones shape their legacy, completing their puzzles to create a lasting image. In palliative care, though our patients’ charts stated “allow natural death,” we performed a different kind of resuscitation. We circulated information so we had an open, connected support network. We managed shock and sadness. We helped revive nostalgia and breathe life into memories.

With every rotation, I carry that with me. As I delve into various specialties, I keep in my mind the image of medicine where the pieces fit together cohesively to practice care that is sensitive, holistic, and shaped by our patients. I try to centre the chapter of my patient’s story in the broader context of their life’s novel. I remember that we are treating people and not diagnoses. I remind myself that being in this profession means holding suffering in one hand and healing in the other. With every rotation, I carry with me the vision of the kind of medicine I want to practice and the kind of physician I want to be.

How lucky I was to begin at the end... and how lucky I am to be a piece of this puzzle.