In this narrative medicine essay, a neurosurgeon works through his grief over ending his surgical career due to intractable pain from an elbow injury by appreciating what he can do instead of focusing on what he lost.
Source : JAMA Published online March 16, 2023
Author : Joseph D. Stern, MDLying awake in bed, I stretch out my arm mimicking routine movements I make while operating: this elicits sharp pain. Frustrated, I watch as my “normal” life and routines slip away. The other day I tried to pull off my trouser leg with my right hand; the pain made me stop, and I had to switch arms.
“It’s like a death,” my friend Gus declared of my elbow injury. He had just retired as an oncologist. At the top of his game, at a time of his own choosing. A few weeks earlier, he had been feted by his practice and our health system with a retirement party.
I wasn't feeling quite as lucky; a few months ago, I was a neurosurgeon, seemingly at the top of my game, feeling in control of my destiny. Then, I had had to stop doing surgery. I simply could no longer do it. My dominant elbow began screaming in pain. For 3 years, I had felt pain but chose to push through it. I took frequent breaks from work for a week or 2 at a time, and the pain would always go away. This time, it wouldn’t.
I tried extended time off. Then my partner assisted me in surgery—he performed the parts I felt I could no longer do without making the pain worse. This didn’t help, so I backed off from surgery altogether. Still, things didn’t improve. A month later, I had surgery myself.
Now, I am relearning how to do things I always took for granted: straightening my arm, making a fist, grasping, pulling. The physical therapist is encouraging and helpful, but it seems the more I do, the greater the gap between what I could do before and what I can do now. Both she and my surgeon are teaching me to manage. This includes my arm, as well as my expectations.
We never expect to become patients until, suddenly, we do. And, when we do, doors slam shut. My neighbor Ron, formerly a pediatrician, had a stroke that knocked out a tiny but crucial artery to an area in his brain that controlled his ability to speak. Words used to pour out of him; now they emerge haltingly.
Ron and I now meet many afternoons at our mailboxes, something we never used to do. Previously, I rarely saw the light of day—I was always working. Now, every day seems like the weekend. I am always home and often feel like I am in the way. My wife does all the driving, unloads the groceries, does the laundry. Until recently, I couldn’t write or type, things I love and also took for granted.
Leaving a job you love before you’re ready to go does feel like a death, and with it comes great upheaval. The nurse who worked with me for 15 years has found a new job. My patients, when they call, are sent to different doctors. Soon, my practice will hire someone new to replace me. Then I will need to clean out my office and turn in my key fob. At that moment, while I’ll still be alive, the death of my prior life will feel complete.
As a neurosurgeon, I was always surrounded by death and disability, but they were never mine. I counseled patients on how to accept their new limitations, urged them to change or leave jobs that caused them injuries due to repeated stresses. I tried to advise them on how to manage their losses and disruptions. But in our transactional world, my awareness often went only so far as the practical and financial, for these disruptions have immediate, visible consequences in those domains. As their treating physician, my opinion frequently held the key to patients' disability determination and monetary payouts. The more profound loss of meaning and purpose that comes with a disabling injury was often invisible to me. I saw, daily, the toll that nerve pain took on patients and the intensity of their suffering but less readily how these injuries led to permanent changes in identity and purpose.
When my younger sister died of leukemia, I finally grasped that I would become a patient, that we will all become patients.1 I knew this was my destiny, but I always envisioned an end like hers—cancer or some mortal illness. Yet working people are 4 times more likely to stop work due to disability than from dying, so the odds of this sort of fate were always high. One of the profound levelers of becoming a patient is the loss of control you experience. With a disruptive injury, the familiar landscape of your life warps in unsettling ways. Pain can easily begin to take over your world. The loss of capacity can shrink and distort your reality. The pace of time changes, as does your self-confidence. Capabilities you took for granted suddenly vanish; for me, reaching for a glass or a fork became prohibitively painful. Sleep is often difficult and interrupted.
These losses require resetting of goals. Small improvements—regaining the ability to bend your fingers or make a fist—feel like victories. The camaraderie of fellow patients also helps because the isolation that comes with illness can be overwhelming. The smallest kindnesses also make a profound difference, as does the recognition of someone else’s suffering.
One of my partners often said: “It could always suck worse.” I never appreciated how true this was, but it is, I believe, a key to moving forward. I can dwell in my loss or continue to appreciate what I can still do, reveling in and exploring the capabilities I maintain rather than mourning those I’ve lost. I am reminded continually of the bravery of my patients, who push forward toward recovery with spinal and brain injuries, not letting their illnesses define them, celebrating small victories, allowing gratitude and awe to fill them rather than bitterness. But this takes work.
I know this isn’t really a death because while I have been dealing with my elbow, my father-in-law, Gary, died after a prolonged illness. Gary lost one capability after another with the relentless progression of multiple myeloma. His death was inevitable, despite all possible treatments. His wife, Margaret, is bereft. They were married for more than 60 years and always together, their lives intertwined. They finished each other’s sentences and often didn’t even need to speak.
Grief is the thread that ties my loss and the loss of death together, yet mine lacks the ultimate finality of death. Grieving for someone who has died releases a flood of emotions, just as the loss of a career triggers an enormous sense of loss. Here the similarity ends: my grief has limits because it does not affect every aspect of my life. Yet it is the sundering of a connection with something I love, the recognition that a chunk of me is gone and is not easily replaced.
I will keep working toward recovery, so there’s always hope this problem will be resolved. While I have lost some capabilities, I will find a new homeostasis that lasts until something else happens (hopefully far into the future). In the end, this is a new beginning, a fork in the road of my life. How I manage it going forward is up to me.
How lucky am I, with my relatively minor losses, to face a challenge that, while daunting, is also an opportunity.In the end, this preserved hope, this chance to rebuild, is the opposite of a death. It is a call to life and to finding new purpose and meaning