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Resident Reflection: Holding the Line against Apathy

headshot for CompassionGuest post from Ahilan Sivaganesan, MD
Neurosurgery Resident Physician, Vanderbilt University Medical Center

The vast majority of physicians enter medicine with an inborn sense of compassion. Junior residents, however, are the logistical workhorses of teaching hospitals — their north star is efficiency and they are measured largely on their capacity to “get things done.” The consequence is often a slide towards unwitting apathy. I, like all residents, have witnessed this reality first-hand. By reflecting on my experiences, I hope to discover insights we can all use to take matters into our own hands.

Clinical Anecdote

The message reached my pager at 3:30 p.m. on a frigid, unforgiving December day: “31 year old male, motor vehicle crash, no movement arms/legs.” Bringing myself to within an inch of the man’s face I bellowed: “Sir, open your eyes!” No response. As clinically indicated, I then made a fist with my right hand and performed a sternal rub, digging my knuckles into his sternum with gritted teeth. Still no response. Then suddenly, the man spontaneously opened his eyes, looked frantically around the room, and then closed his eyes again.

Exasperated, I wondered, “What’s going on here?” Suddenly it hit me. I reviewed the patient’s scans and my fear was confirmed. Cervical spine injury and brainstem hemorrhage had rendered the patient “locked in.” Although fully alert, he was paralyzed from the neck down. Roving eyes were the only proof that a man still lived inside his lifeless body. He would be a prisoner unto himself. Fighting my instinct to stop and take stock of this tragedy with the man’s family, I rushed away to make preparations for surgery. Commiseration would have to wait.

The memory of this patient remains a splinter in my mind. The devastation — of a man’s life, of a family’s future — had passed by me that day as a mental footnote. I had fulfilled my obligations as a neurosurgery resident, but was there space for my full humanity?

A Resident’s View

“Doctor, Mrs. Anderson is in serious pain after surgery. She has morphine ordered, but it’s not cutting it.”

“Doctor, Mr. Johnson is asking to stay another day. He’s been discharged, but he doesn’t have a ride.”

resDuring medical school, I would have pounced on these scenarios as opportunities for genuine doctoring. As a resident, however, they have become issues that need to be “handled” — new tasks for my to-do list. A patient’s inadequately controlled pain, then, is not the gnawing discomfort of a 40-year old mother of two, but rather a new un-checked box on my to-do list. A grandfather stranded in the hospital, with no transportation, means I have to keep an extra patient on our list.

How do I combat this plague of unwitting apathy? I start with mindfulness. Before entering any patient’s room I take a deep breath, mentally set aside all other looming tasks, and resolve to treat the interaction as an opportunity for true connection. It is a matter of being deliberate. I try to leave every interaction having learned at least one unique, personal fact — a reminder that a patient is not just a vessel for surgical pathology. What if the ubiquitous “patient list,” which all residents carry, were to incorporate these humanizing facts? Suddenly, bed 10 is no longer a “50yo M, post-op day 5 from aneurysm clipping,” he is a “50yo M with a son in Afghanistan who is post-op day 5 from aneurysm clipping.” Solutions such as this, which imbue our workflows with the fruits of rich patient interaction, may buffet a slide toward apathy. A system of credits, wherein patients can register their gratitude for caring residents, may also make a difference.

Ultimately, we must discern the various elements of a vibrant doctor-patient connection, and then weave triggers for those elements into residents’ daily activities. I will always remember walking into that spine-injured patient’s room the day after his surgery and noticing his college graduation photo pinned to the ICU monitor. Looking back and forth from his mangled face to the photo, I slowly realized that they were the same person. From that moment, that image — of a healthy, proud young man — was what came to mind whenever I thought of him. I began to see him the way his loved ones saw him, and I’m sure I provided more compassionate care because of it.

Is that not the standard to which we must aspire — to treat patients as if they were our loved ones? There is much a resident can be cynical about in healthcare. Much is out of our control. But how we relate to patients is a personal choice, and physicians can take simple steps to sustain the inborn compassion that drove them to medicine in the first place.


  • Sharmyn says:

    Wonderful perspective-Thank you Dr. Sivaganesan. You are a great man and much appreciated for all you do. As a pituitary tumor patient advocate I know personally many, many great neurosurgeons across the country and I’ve work closely for the past 15 years with my neurosurgeon, Dr. Daniel Kelly. I’ve been blessed through the years to see, the good, the bad and the unbelievable, behind the senses of a day and life of some of the greatest doctors in their field. But when I was in my hospital bed after my pituitary surgery for Cushing’s disease, I had so many doctors-in-training in and out of my room, and none of them seem particularly excited to be there but they were pleasant. I referred to them as the Ducks, because they would all follow behind Dr. Kelly. Later as I got more involved helping patients I learned the Residents, worked long hours and with very little time for anything but, like you said, the list of things to do… Well in the past 15 years I have seen these great men and women go from Ducks, to highly experience neurosurgeons. And most importantly they are great people and their dedication to help patients is greatly appreciated by, so many patients and their loved ones. Thank you for your dedication and compassion Dr. Sivaganesan.

  • Saurabh says:

    Thanks for sharing, Ahilan. These are very important thoughts to hear, especially for those of us in training.

    I’m a fourth year medical student applying to neurosurgery. The upcoming application process is of course full of its own uncertainty, but I’ve picked up a new uncertainty as I emerge from the “medical student” cocoon: how will I maintain the empathy and desire for true connection with my patients within the hustle and bustle of residency? Moreover, how will I do it within neurosurgery?

    I identify strongly with this piece. The junior residents I’ve worked with, tasked with “running the show” on the floors and for patients heading to the OR, are, at times, mind-numbingly busy. It appears to be one of those things that you just can’t truly understand until you experience it, until all that responsibility is yours. In medical school, we are gifted with “free time” — during these moments, we can get to know our patients and enthusiastically complete the sorts of tasks that Ahilan would have jumped on during his time as a medical student. Transporting a patient is both a chance to talk to a patient and answer questions, but also to understand the workings of the hospital a little better. But this task is far different in the relatively leisurely context of medical school compared to residency, as Ahilan so aptly describes it.

    To add a little more detail to the picture, the junior resident is responsible for dealing with issues as they arise on the floor, while seeing new consults and reporting all of this to senior residents and attendings who want to hear competency when they pick up the phone. Whereas in medical school, dealing with a patient with inadequately controlled pain could have been a lengthy learning experience, complete with combing through his chart, bringing a pen and paper, and discussing it down to the level of the social context of his pain, that same patient in residency is now a tile within a mosaic of new transfers, new admissions, new post-ops, and new actively dying patients.

    So it is necessarily difficult to maintain humanism. It’s heartening to hear that it can be done though. I think the point about mindfulness is an especially important one. Mindfulness overcomes the mind-numbing. We must actively reflect: what brought us here in the first place? What are our patients — and, importantly in the neuro ICU, their families — going through? I’ve learned that some of these thoughts are borne of a naiveté that is characteristic of the medical student, but these are the qualities that inspired us to pursue medicine. It’s important to maintain some of that at our very core.

    Thanks again for this post. It reassures me that apathy is not an inevitability.Thanks for sharing, Ahilan. These are very important thoughts to hear, especially for those of us in training.

    I’m a fourth year medical student applying to neurosurgery. The upcoming application process is of course

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