Family Medicine Vital Signs

By: Kristin Sandoval

Preceding my elective experience I was asked to write down a couple of learning goals to expound upon after as a reflective assessment of my experience. I approached this task as if it were a typical medical student requirement in that I chose topics that were of interest, but could also be researched and analyzed from an evidence-based or scientific approach. I thought to myself that the spiritual component of this elective would hold the least value because, while I am a spiritual person, I do not believe in the institution of a specific religion. Upon reflection of my experiences over the last two weeks, I think I would be doing myself and this elective a disservice were I to ignore the unexpected and profoundly significant impact that the spiritual care component had on my experience. Therefore, I discarded my initial intention in order to focus on the essential purpose of the integrative health medicine elective, which is, in my opinion, to gain awareness of a more comprehensive approach for the purpose of broadening the scope of how medicine is applied and contextualized.

Prior to this elective, I thought it would be unprofessional and even possibly disrespectful to cry in front of a patient when witnessing their grief. I had been afraid and dreaded the day I would be confronted with an experience where I could not keep total control over my emotions. On my first day on the spiritual care team I only just managed not to cry in front of a patient who was expressing an outpouring of fear regarding his mortality and loneliness. It was amazing to watch a total stranger express such vulnerability so openly; the pleading and desperation in his voice was heart-wrenching to hear. However, I felt ashamed and weak that I was crying because of the very fact that he was a stranger. I did not know this person, so why did his emotions touch me so deeply?

Then on the second day with the care team, I knew we were going to see a patient who had lost her baby on the Labor and Delivery ward. I expressed my concern about showing “too much” emotion. When we got to the room I realized that she still had her stillborn infant in her arms. The first thing that the chaplain said was, “She is so beautiful,” and my tears started to silently fall. I was thankful that she was sitting on the bed in such a way that her back was to me because I could not stop the tears from flowing. I was so afraid that if she saw me that she would start to cry, or that she would look at me like, “why are you crying? You haven’t lost anything.” Finally, the chaplain introduced me and when the patient turned to me she said, “Thank you.” We hugged and I told her that as a mother I could not fathom how she felt or what she was going through, but that she was so strong and I told her to believe in her strength. After, I felt so emotionally drained, but I was so thankful that I was surrounded by people who understood and supported me. I told them that I was so grateful that my experience had been with them and not in front of an attending. The next day I felt guilty that I shared such an intimate life-changing moment with a stranger and then stepped away and was going about my business as if it should not affect me.

After processing this experience for several days I realized a few very important things. The Hippocratic oath states, “I will remember that there is art to medicine, as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” A team dynamic based on a hierarchy, in which medical students are at the bottom and are evaluated by everyone else, is logical, but not supportive. Based on my medical education, more work still needs to be done to identify what the expectations are regarding emotional expression during rounds and whether they make for a compassionate and realistic experience with patients. Working with a chaplain provides exposure to difficult situations and a supportive, safe environment to work through the emotions that those experiences bring on. Chaplains, perhaps more than doctors, witness how a patient is coping with the impact of an illness or medical event. I think this is primarily because they allow for the opportunity for patients to share in a knowingly supportive and safe environment. Working with chaplains made me realize that, as a student, it is easy to become preoccupied with emulating the science and protocol of medicine, but it is equally important to have mentors that educate us on the art of medicine. They taught me that crying in front of a patient is not a sign of weakness; it is a sign of compassion and empathy and may even validate a patient’s emotions. When a patient is willing to let down their barriers and share their most vulnerable moments, thoughts, and feelings it is, in fact, respectful to sincerely acknowledge their vulnerability and trust in you by showing support through words and, when appropriate, emotions.

I set out on this experience to learn about the mind-body connection and how positive experiences or negative experiences, such as massage and pain respectively, influence that. However, I ended up connecting on a deeper level with a core component of medicine through my experience with spiritual care. I learned more comprehensively through experience and observation what it means to care adequately for the sick through compassion, empathy, and sincerity. The spiritual care team provided support and mentorship in understanding the art of medicine on a visceral level instead of an academic level. These are coping skills, lessons, and values that I can take forth and apply in my practice, and hopefully at some point in the future share with colleagues and students.

As an example of that, I have included a poem that I wrote, which helped me process my spiritual care experience:

“Do you see me naked and alone standing behind my wall of white and words.

I want to reach through my wall and touch you but I’m afraid.

I’m afraid you’ll pull away or take my hand and I won’t know what to say.

I am stepping into your world and I want to share your space,

If only for a moment.

I remove all the layers I am wearing,

And leave behind all of the things I carry with me.

As I do this, I realize that the weight of everything I have piled onto myself is immense.

The catharsis of letting each layer fall away, feeling my spirit lighten, is expressed by the tears I shed.

I have stripped myself of my excuses and my reasons not to feel.

I am naked vulnerable and alone,

But now I am present.

As I stand there exposed I am receptive and aware of my senses.

Opening my mind, my heart, and my spirit.

Now I am no longer alone.

The energy in the space we share feels like the raw wind across my skin alighting Sensations both welcoming and uncomfortable.

At times it feels like a mother’s touch, intimate and comforting;

And at other times like a harsh gale,

Abrasive and overwhelming.

And like the wind I accept its presence, feel it, and interact with it.

It flows around me,

But it is not within me.

As soon as I step out of your space the wind dies down.

I can remember all of the sensations and I can hold onto how the wind made me feel,

But I don’t have to take that energy with me.

Again I stand naked,

But now it feels different

Because I am no longer afraid of my vulnerability.

I can stand alone without feeling alone.

I can be what you need for a moment in time without sacrifice.”

Kristin Sandoval is currently a third-year medical student at the University of Utah School of Medicine. She holds a Masters of Arts in Interdisciplinary Studies from San Jose State University with a focus on critical issues and strategic progress pertaining to health care policy in the Department of Veterans Affairs. Kristin is passionate about humanities, patient-centered care, global health, and medical policy reform. She has a publication in J Trauma Acute Care Surgery and has presented research at WPA.