Precarious Journeying: The Forked Paths of Medical Training
At the end of the same Autumn week I stepped into my third year of medical study - ready to leap through clinical specialties, to grow the skills and the experience of the pathways we guide patients along - my grandfather stumbled a step backwards and fell.
My first thought was a distance calculation, plotting a course to carry the clinical skills freshly grown into my own hands. I have more than enough ready to help an old man on a cold floor in obvious need. I was willing, trained and available, but not commissioned under the high tower of an NHS trust. I was wary of the governance advice to avoid treating family members. The journey was 3.5 hours in the dark. I knew this need should have a blue light paramedic response within 3 hours. My best course was to stay home, ready for study the next day. I chose not to travel this road. Despite all I knew and could see, I felt a frustration that I couldn’t help.
We face choices from cradle to grave, decisions at every step through education and life. These hours proved the last Grandpa would spend with his wife of 70 years. Although his broken femur was fixed in surgery, and he returned to his feet within weeks, he never made it home. He had become cruelly confused, even delirious after surgery, as the trees of his memory were battered by the inflammatory storms of his organ systems. It was judged unsafe to send him home. Grandpa’s pathway led him into danger from Covid-19, lurking along the lonelier, more precarious roads so many of our most vulnerable and elderly folk have been forced to tread. He caught the virus on a rehabilitation ward, and his journey led to his grave just before Christmas. The last words I shared with him were of a poem he had taught me, my voice traversing the web of WhatsApp as another pilgrim of our healthcare professions kindly held his hand in my place. Despite this compassion, my own mind smoldered with anger at what was beyond my power, and the smoke has clung to my thoughts ever since.
My grandparents travelled throughout their lives and brought home a love for a variety of cultures and languages. In my Grandma's grief, I have recognized the acceleration of her dementia, and with it an uncharacteristic rejection of - even a deeply troubling racism towards - some of the carers she now depends on. I have been captivated by an image of a brain as a tree advancing through the seasons. The autumn colours mark a progressive loss of function and identity as the branches, twigs and leaves of neuronal networks wither, burn and die. It reminds me of a painting of hers from her life in Pennsylvania. I stumbled across this image while reflecting on the damage done by stroke in the mind of a patient I was caring for during a clinical placement, as that fellow pilgrim before. A series of clots had starved patches of brain of sustenance, leaving them withered to winter and set dry to burn as the surrounding cerebral tissue remained in a late summer. It was too early to tell which clumps of movements, forests of memory and identity might be lost forever, and which might be able to re-connect with the budding regrowth possible at any age. I grasped the analogy to comprehend and cope with the precarity around me. Dementia, particularly when fueled and fanned by grief, is a slower burn. Its smoke is a pall over thoughts, bringing tears to the eye and poison to the tongue. However, the more we tend and nurture even the oldest branches, the more likely they are to bloom again, no matter what fires have swept before.
On a parallel path, less travelled by medical students, I have felt a different precarity. My wife gave birth to our daughter during the last lockdown. We were grateful for the warmth and security from Covid that the ward staff offered, having stumbled closer to another edge as cases rose through Christmas. This new spring is a reminder of the hope at each turn, regardless of the burdens or precarity of paths glimpsed ahead. The sleepless nights have clouded my way in mist, adding to the wisps of smoke and making my steps less sure. Her cries in the dark clear to smiles in the early morning sun, shining with value beyond the grades I might attain on any given day.
Two roads diverged in a wood, and I— / I took the one less traveled by, / And that has made all the difference.’ Robert Frost’s poem is lodged in my head. It invites a reader to play in the rich stream of analogy and metaphor welling up from our shared past, to travel, wander, hunt and gather through a landscape. Frost's words also speak – intentionally light-heartedly but sincerely – about human choice.
In training for a medical career, I hope that choosing my pathways with care and compassion will lead in the right direction. Some junctures are painfully difficult to navigate.
Some forks lead to steps of aggression and anger, stumbling downhill into swamps of depression, dissolution, disorder and discrimination.
Concepts from the forests and rivers of evolutionary and social history have been meaningful, attractive, and pedagogically helpful to me. So has the literature which keeps them alive. Our ancestors live in the stories that guide our children. Some have helped me find a clearer way wandering through academic growth and personal reflection. Every case I present is a journey itself, the route to accurate clinical judgement becoming firmer with each repeated step, as professional and personal routes weave together. Medical education lets me draw my own map to understand how I may best travel with - and in the interests of - the patients I cross paths with. Even if my feet feel heavy and the roads wind long, I choose to take every small step with care and compassion.
