Hands tell stories. The tell the stories of our lives. The knobby knuckles and contorted joint angles on an elderly woman tell the story of one who suffers from rheumatoid arthritis and spends much of her day in pain. The rounded clubbing of the fingers tells the story of a man who has smoked all his life. A concert violinist has developed fine callouses on the tips of her fingers. The scars on the back of a young man’s hands tell the story someone who struggles to extricate himself from the grip of heroin abuse. A handshake with a construction worker reveals rough skin thickened by years of hard, physical work, whereas the same greeting with an office worker is smooth and soft. In ways that are unique, the shape, texture, scars, and calluses conform and adapt to tell the story of who we are and reveal hidden details of what we do.
Growing up I remember my dad was always very careful with his hands. As an ophthalmic surgeon, his livelihood and (more importantly) the vision of his patients depended on the integrity, dexterity, and proprioception of his fingers. For him, mistakes were measured in millimeters. Any cut or irritation on the hand could make operating much more difficult.
As an emergency physician, the condition of my hands is far less vital of a concern. I do need some degree of fine motor control to be able to place a central line, sew a laceration and manipulate the ultrasound transduce to find the common bile duct. But the abrasions and residual paint on my hands often tell the story of recent projects. And as running has given way to weight training, I have developed characteristic calluses at the base of my fingers from the knurling on the bar.
So much of life is lived with our hands and therefore our work is reflected in the calluses we develop. Physiologically, these calluses are thickened portions of the epidermis that form in response to repeated irritation. They develop most commonly on the hands and the feet as these are the surfaces that have the most contact with our environment. But practically they serve as a protective barrier to the rough, and textured world around us. Calluses allow us to face the difficulties of life and persevere through them in order to do something important.
Before our kids were born, my wife used to teach middle school. We agreed that neither of us could do the other's job. As an ED physician, if one of my patients becomes unruly and combative, I can sedate them. But if I were to use that same technique in the classroom, my teaching career would come to an abrupt end. In the same way, I routinely care for patients who have been shot, stabbed, assaulted, or have a myriad of other significant medical or traumatic problems. As one who is more sensitive, my wife would melt into puddle of emotion in a corner of the ED. She feels things much more intensely than me.
You can say that we have two very different temperaments that are well suited to the jobs that we do. That is certainly the case. I recently ran across a photo of me and my wife at my white coat ceremony destined to become an emergency physician. I had drive and enthusiasm. And, in my assessment I had the ability to withstand tragedy unmoved (at least so I thought). As I look at the picture now, I see a younger version of myself excited about opportunity but innocent and naïve. After years of working in the Emergency Department, I have developed calluses - to the suffering, tragedy, and pain that patients experience.
As we navigate our day in the clinics or on the wards, we need to develop a certain amount of callousness to the suffering and tragedy that we face for a number of reasons. In order to effectively care for our patients, we can't melt into a mess of emotional uselessness. Additionally, we need to retain the ability to distance ourselves from their suffering so that we can remain objective in assessing the patient, risk stratifying between differential diagnostic considerations, recommending the proper course of treatment, and knowing when our efforts have become futile.
However, if we emotionally distance ourselves from our patients too much, we risk becoming little more than a medical automaton. It is vital that we retain a certain amount of softness and emotional connection so that we can provide what the patient needs most - the reassurance that everything will be OK. And, even if it isn't, that we will be there with them - to walk with them in their suffering.
Much like the calluses on my hands, the calluses that we develop clinically serve as a protective mechanism. But they can also be an excuse to snuff out any flicker of emotion and lock our feelings away into some deep vault. This is a bad place to be. Just as in the gym, the same work that creates the calluses, also creates the growth. To grow as a person and as a physician, we need to embrace this dichotomy of callousness.
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