Friday, April 9, 2021

Choosing Palliative Care as a Medical Specialty

by Sylvia Lane (@sylv_lane)

There are few things more introspective than deciding on a specialty in medicine. The decision forces you to analyze what interests and values you hold but also who you are as a person. How do you solve problems? How do you work with others? What brings you joy? As a third-year medical student, I was able to try on many specialties. Rotating through various fields allowed me to soak up knowledge from almost every type of healthcare professional. But this experience comes with a heavy burden of choosing a future career path.

From the beginning, I knew that I was not like most of my fellow medical students. Of course, we all share a special bond dealing with the shared stress of progressing through medical education. But I never felt like my perception of medicine was the same as theirs. I always felt sidelined in discussions, scoffed at as the bleeding-heart empath. As I stepped into my third year of medical school, I was filled with enthusiasm to find people who felt like me. People who view medicine in the way that I do. They must exist, right?

Unfortunately, this was far from my experience. Though each clerkship was a valuable learning opportunity, I continually found something to be missing. Every physician I met was focused on medicine as a cure, while I regularly found myself asking about the impact on the patient’s quality of life and relationships. What will this surgery mean for the patient and their loved ones? How does this treatment impact the patient’s life goals? For me, being a doctor was never about finding a cure. To me, medicine spans not only a patient’s symptoms, diseases, and therapies, but also their family, employment, hobbies, and future. Separating the symptoms from the patient as a human seems impossible to me.

I came to realize that palliative care was the field I had been looking for. I scoured the internet for all the resources I could find. With bright eyes I started to tell everyone: I found my specialty! However, it was not met with the enthusiasm I was expecting. Every time my friends spoke about their specialty of choice, they were received with positivity, warmth, and excitement. But when I started saying, “I want to do palliative care,” I got a different response. Even through their masked faces, I could see shock and discomfort. Most people responded with one word, “oh,” as they completely changed the subject. I was thrilled to find a specialty that seemed exciting to me, but these encounters made me feel like I was somehow wrong.

For weeks, I questioned my choice. Was I missing something? Every person I spoke to seemed to be distressed by my decision. Some teachers I respected told me I was wasting my potential or would ultimately change my mind. Discouraged by the sentiments of those around, I turned to Twitter for support from my medical community near and far. The replies I got were nothing like the responses I had received in person. More than 500 people responded with excitement, positivity, and support. Deciding to pursue a career in palliative care had felt good, but in that exact moment I knew it was right. Finding a community of people like me gave me the courage and strength to stay true to myself. And for that, I will be a better physician.

For more Pallimed posts about (and/or written by) medical students, residents and other learners, click here
For more Pallimed posts by Sylvia Lane, click here. This is her first post, but someday there may be more!
For some ideas on fostering student interest in palliative care see this Pallimed post.

Sylvia Lane is a fourth year medical student at the University of Vermont. Between clinical rotations she spends her time perfecting her baking skills, watching new films, and learning how not to kill all her houseplants.

Friday, April 9, 2021 by Pallimed Editor ·

Tuesday, April 6, 2021

What Is Grief, If Not Love Persevering?: A Palliative Perspective On WandaVision

by SarahScott B. Dietz (@SDietzMD)

WARNING: THIS POST CONTAINS SIGNIFICANT SPOILERS FOR WANDAVISION.

In January, WandaVision released on Disney+, promising a weekly serial centered around two romatincally involved and familiar Marvel characters, Wanda Maximoff (aka Scarlet Witch) and Vision. The advertisements showed a black and white, vintage look to the show, and gave few clues as to exactly how it would tie in with the rest of the Marvel Cinematic Universe. Fans were intrigued for many reasons, chief among them being that the last time we saw Vision, he was dead. (CW-Superhero violence/death)

I dove into WandaVision like many fellow geeks: remote in hand, rewinding to scrutinize frames for clues as to what the "Big Story" was, and trying to solve the mystery before they revealed all. My Nick At Nite viewings of My Three Sons and Patty Duke provided ample cultural references for those first few episodes, and my Marvel lore was at least adequate. But where was it all headed?

Somewhere around the third or fourth episode, it hit me like a vibranium baseball bat. WandaVision is a study on grief, loss, and mourning, in layers and layers. I took to Twitter, as one does, noting that colleagues in palliative medicine might want to keep an eye on the show. A friend replied, asking why I would think so.

“It’s Wanda, it’s a giant grief bubble for her. She’s doing this out of grief,” I replied.

"I see it now,” he said, “It’s like superhero complicated grief.”

Complicated grief is what happens when the symptoms of loss and mourning do not begin to subside over time, instead worsening and becoming more intense. People struggling with complicated grief become caught up in their emotional turmoil, and the normal healing process is stalled. They dwell in a world colored by their loss, and may seek out items, locations, or sensations that make them feel proximity to the person they have lost.1

Superhero complicated grief is, in other words, a perfect explanation for trapping an entire town of innocent people in order to build a perfect happy sitcom life with your deceased beloved.

While Wanda is the focus of the story, every character in this series is processing grief stemming from the events in Avengers: Infinity War and Avengers: Endgame, most specifically the “Snap” in which Thanos exterminated half of all life in the universe. Fifty percent of the population disintegrates in place, in front of their helpless loved ones, only to reappear in exactly the same place five years later. In the hospital in Episode 4, we get a window into the chaos, tension, and anxiety in the moments as people return after five years. Is the man shoving his way through the hallway desperate to call his wife because he is just returning, or is he hoping to hear her voice again for the first time in half a decade? A key character, Monica Rambeau is shown reappearing in the same room where she was with her mother 5 years earlier. Only now her mother is not there in the hosptial bed, and Monica finds out that her mother died in the 5 years she had been 'gone.'

In Episode 6, Hayward, a main antagonist, growls at Monica that it was so easy for the ones who vanished, they have no idea how hard it was, how much pain those left behind suffered. Even his pain and, yes, grief, is manifest in that short outburst. (The next bit about Monica not having the stomach to sit with her dying mother, though, that’s just an inexcusable snark.)

Monica’s loss is also heightened by having been disintegrated by the "Snap", and the isolation that she feels as a result. While Monica's mother may have died surrounded by loved ones, Monica was unable to be near her mother, to hold her hand or comfort her in her last moments. Monica has to find her own closure without the benefit of those final good-byes. For too many families, that scenario may hit close to home this year, as COVID-related visitation restrictions have limited our ability to be present with each other, even in times of great need.

In the midst of all the grief processing and mourning on screen, I appreciated the reference to Vision’s advance directives. I found it satisfying that going against his stated wishes not to be re-animated or used as a weapon was presented as proof of serious transgression. It does make me wonder what the contents of an Avenger’s advance directive would look like. Do they have a standard order form? Does it include circumstances in which resurrection would be acceptable?

WandaVision’s executive producer and head writer, Jac Shaeffer, has shared that they set out to build Wanda’s story arc on the stages of grief: denial, anger, bargaining, depression, and finally acceptance. (2) In retrospect, it’s easy to see that progression. Early in the season, Wanda is perky, the problems are light, and she is cheerfully in denial. We see her sink deep into depression, her kids worried about her. Is there anyone who has gone through the grieving process who did not sympathize on some level with the exploding Wanda, energy radiating out away from her in a messy, undirected eruption of frustration and angry sadness?

In the midst of a brutal tour of Wanda’s memories and many losses, it is Vision who crystalizes the essence of our journey: “What is grief, if not love persevering?” To lose someone we have lost does not erase the love we have felt for them, it simply moves the object of our love out of reach. Grief is the space left behind, and it is the work of loving someone who is gone.



One of the most moving moments of the show for me was in the very end, when Wanda and Vision were saying goodbye to their boys, and to each other. There was a genuine sweetness to it, tenderness in a scene that could easily be overwrought. It was the superhero version of a farewell I have seen in my practice, occurring in deeply religious families. It is a mix of emotion found in someone with a deeply held belief that they will surely see their beloved again, someday — certain faith that this will happen, blended with uncertainty of what exactly it might look like, and when. Sadness for the parting, even as they trust it will not be forever.

I am grateful for WandaVision and the conversations it has sparked about grief, loss, and trauma. Marvel being Marvel, we know that even though we have said our farewells this time, we will be able to see these characters again. I can only hope that it will be in a form that is as thought-provoking and enjoyable as WandaVision has been.

For more Pallimed posts about grief.
For more Pallimed posts about culture and media.
For more Pallimed posts by Dr. Dietz click here.

SarahScott B. Dietz, MD practices palliative medicine in western Pennsylvania. She is a life-long geek of many fandoms, and lately has been learning both gardening and how to TikTok.

Reference

1 Shear MK. “Grief and mourning gone awry: pathway and course of complicated grief.” Dialogues Clin Neurosci. 2012 Jun;14(2):119-28.

Tuesday, April 6, 2021 by Pallimed Editor ·

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