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In this episode, we delve into the profound emotional experiences of Ryan McCarthy, an internal medicine physician. Ryan shares heart-wrenching moments from his practice, including the day his heart metaphorically rolled off his arm and crashed on the exam room floor as he comforted a grieving patient, Ginny. We explore the balance between professional detachment and emotional involvement, the impact of compassion in health care, and the resilience needed to continue practicing medicine with an open heart. Ryan reflects on how the COVID-19 pandemic shaped his approach to patient care and the importance of maintaining a compassionate practice amidst challenges.

Ryan McCarthy is an internal medicine physician.

He discusses the KevinMD article, “When a doctor’s heart falls: Witnessing raw emotion in medicine.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Ryan McCarthy. He’s an internal medicine physician. Today’s KevinMD article is “When a doctor’s heart falls: Witnessing raw emotion in medicine.” Ryan, welcome back to the show.

Ryan McCarthy: Kevin, thanks for having me.

Kevin Pho: So Ryan’s been on multiple times in the past. Go to KevinMD.com/podcast to hear his story. But today let’s talk about your most recent article, “When a doctor’s heart falls: Witnessing raw emotion in medicine.” Tell us what this article is about.

Ryan McCarthy: Yeah, so this piece is really a reflection on what it’s like to be, I guess I’d use the word ambushed, I would also use the word witness, or to receive a story of intense pain.

And in my particular piece here, it was a patient sharing a story that was painful, and it was not why they were seeing me, but it was clearly a part of their life. Their grandson had been very sick and in fact had died from cancer. And my experience with them was just, my office is a safe place to talk about things, and that happened to come up. And my patient had been brave for a long time, and then when the dam burst, it burst. And so we shared that moment together.

Kevin Pho: You’re a primary care physician and you’ve heard many, many stories in the exam room. So as you were hearing this particular story, tell us what was going through your mind.

Ryan McCarthy: Oh, my heart just broke. And I think you can relate to that, where when somebody just starts telling you something, you know, there’s small talk and perfunctory things that we talk about in the exam room, and then there are stories that we know that are just so heavy and hard.

And I could just tell that what I could really do is just be present, be a listener. I share in the piece about how I pulled my chair up and I put my arm around her, and I just put my big hand on her shoulder and just kept my mouth shut and was listening, and letting her know that I wanted to hear this. I wanted her to unload it, I wanted her to tell it, I didn’t want to interrupt it, I wanted to respect her story in that sense.

And so I think for many of us that come to the bedside, we know when those moments are starting to unravel in front of us. And I was like, you know what, this is what we’re doing today, is I’m going to let you tell this in the way you want to tell it.

Kevin Pho: Take us into the exam room during that time. So as you were listening to the story and you had the acute realization that, hey, this patient is sharing something so painful, so how did she respond, what happened next?

Ryan McCarthy: We have a long-standing relationship, so this was the latest chapter in a much larger volume between this patient and I. So she knew that I was a listener and a safe person to tell this to.

And you know, I grab some Kleenex and I hand it to her, as I wanted her to experience and process this. And so there was no time frame for me to like, OK, well, after a minute or so I’m going to do the next thing. I really let her have that. And then when she was kind of clear that, like, OK, I’m going to dab my eyes, and when she wanted to kind of bring us out of this moment, I let her guide us through that, with tears and Kleenex. And I really followed her cues.

And I do that now in a way that I didn’t at the beginning of my career. Now I know that I’m like, listen, the whole world has just stopped. Like, no matter what else I had planned for the next period of time, this is what I came to do today.

Kevin Pho: And it goes without saying that patients share things in the exam room that they wouldn’t even tell their partner.

Ryan McCarthy: Oh, it’s so true. And as I share in the piece, you know, she shows me a photo from her phone. And that’s so much of the storytelling now. At the beginning of my career, almost a quarter century ago, people would describe somebody or something, and now they do that and then they say, well, let me show you, and then they show us an incredible photo or video clip or something where we get to see this person.

And she showed me this photo, and it was a young man who was a college kid, and he clearly had an advanced illness, you know, a cancer. And that image was just so heartbreaking. I’m a visual person by nature, so when I saw this photo, and I see her tears falling on her phone as it shakes, it was just kind of a heartbreaking moment. But I knew that I had to be strong and be present.

Kevin Pho: You mentioned you’ve been practicing of course for 20 plus years now, and during that time that power of story has taken on less and less importance in the eyes of some health care decision makers. How do you still hold on to how important patient stories are, despite everything else around that chisels away from that importance?

Ryan McCarthy: Oh Kevin, I love that question, and that’s the question I think about daily. And I tell colleagues and medical students and residents that storytelling is the currency of what we do. Somebody tells, somebody listens, whether it’s an acute illness or a longer tale of woe and tragedy.

And I really think, I’m going to call that narrative practice, narrative medicine, those types of things, that storytelling arc and art, it is the antithesis and I think the counterpunch to algorithms. It’s the counterpunch to computers, it’s the counterpunch to now artificial intelligence, in a world that wants to dehumanize us and reduce us to, oh hey, this situation is just like this other set of circumstances.

Storytelling tells us that no, this is a singular person, a singular story, a singular time. And respecting that, knowing that, loving that, I think keeps us as doctors, as medical practitioners, really connected to the soul of what the profession of medicine was, is, and what it really should continue to be.

Kevin Pho: And how difficult do you find that today, to maintain those ideals?

Ryan McCarthy: Oh, it is so hard, and it’s exhausting, and I don’t have to tell you that. I was sharing a conversation earlier this week when somebody said, hey, how do you listen to these stories, how do you have time?

And the answer is, health care requires so much more prep now than it did at the beginning. I remember those days when I’d walk in with a paper chart and sit down, and that was the beginning of any thought I had about the visit. The patients I’m seeing today in my office, I started prepping, reviewing notes at 6:30 this morning, so that I could see their labs and their ER visits and their specialists.

In other words, I do that so that I can have more time talking to them. How have you been, what are you doing, what are your summer plans? That gestalt of, tell me who you are and how things are going, as the latest chapter, the next piece of the story in the relationship that I have with them. So that prep, Kevin, is so much more than it ever was, and it’s exhausting. But I continue to do it because it allows me to keep that storytelling and talking and listening at the heart of what I do.

Kevin Pho: When you were telling your story, you mentioned that you put your arm around a patient, and not every physician does that. Tell us, in that instance, how important that was for that patient.

Ryan McCarthy: Oh, I think it means everything. And I’ve often said that in primary care I’m a listener and I’m a giver, and that people need that literally and figuratively. They need love that is given, and that’s respect and space and the body language that says tell me more. But sometimes they need a literal embrace.

And I’ve often said to medical students, after I get out of a room where I’ve hugged somebody or we’ve cried together, I lean to them and I say, listen, figure out how you are comfortable letting patients know that you love them. Not all of us are huggers, some of us are less demonstrative, but there are so many ways that each of us can tap into our own innate personality and skill set, so the patients really know, she’s listening to me, he’s listening to me.

So when I describe what I do, it’s definitely the gregarious hugging primary care internist. But even if you’re not that type of person or personality, each of us has ways that we can tell patients that we respect them.

Kevin Pho: How do you find the emotional strength to do what you do? Because as a primary care internist you probably see 20 plus patients a day, so that’s 20 plus stories similar to what you describe in this KevinMD article. How do you find those emotional reserves to go through that 20 times a day? Do you ever get exhausted?

Ryan McCarthy: Oh absolutely, Kevin. And I think for the first two decades of my career I didn’t have a good answer for that, because I had not found a skill set or practices to get there.

But over the last four years I discovered narrative medicine and narrative practices, and really thinking about creative ways to embrace storytelling, know that it’s important. That includes writing that I’ve done and I continue to do. And those practices were not a part of what I was doing when I was a young doctor. Now I know they’re critical, that’s how I’m going to process this trauma. Some days I’m too tired to write, that’s for sure.

But the other part of those practices is that when I leave my office or the hospital, I get outside and I get fresh air, and it’s all about embracing what I call the analog experiences. I really stay away from computers and electronics when I’m out of here, and it’s about my relationship with my wife Erica and my children and my dog and fresh air and exercise, and making sure that I get a good night’s sleep, and all of the nuts and bolts things to take care of the engine, the machine, if you will.

And when I couple that with narrative practices of writing, and really embrace of creative outlets, whether it’s listening to or watching a comedy or a show or theater, these arts and humanities bolster me in a way now that I know that it’s not negotiable. That’s a part of what is going to allow me to come in here and be a caring and compassionate person. Because if I don’t continue those practices, I’m going to be crusty, cynical, burned out, and jaded. And it’s a choice to step away from all of those.

Kevin Pho: So go a little more granular. How specifically does writing about these experiences fit into your workflow? And specifically give us an example of how that helps with that emotional exhaustion that you would feel if you didn’t do this.

Ryan McCarthy: It’s a great question. And my particular writing practice, when it started, I used the most convenient thing that I had with me at the time. During the COVID-19 pandemic I had my phone with me one day, and I was putting together a grocery list like so many of us do, and at the bottom of the grocery list I made a comment, today is terrible, I have no idea how I’m going to make it through today. And that was a COVID day. And from that I realized, like, I continued to start writing some thoughts down.

And then if we leapfrog to where I am now, Kevin, if I have a really hard day, or something like the story that I wrote for you, I will take a moment before I leave and I will open my notes app and I will write down the immediate thoughts that I’m having about it. And that’s it, maybe. And sometimes I have just gone through four or five paragraphs, and sometimes a piece comes together lickety-split. Other times I put a thought there and I know I’m going to come back to it.

But the way that helps is, by starting to process it in writing, I’m not dragging it home to my three kids uncooked, unresolved, rolling around inside of me. If I’ve already started that process of thinking or putting it down, that means that I’m allowing myself space to process something that was painful. And that’s what I find the healthy part of it.

And what I want to teach to residents and medical students and fellow colleagues is that simply by doing that, it’s a therapeutic process. And there’s so many things I write that never get published or go anywhere. And just the telling of the story, it helps me and heals me in a way that as a young doctor I never dreamed was possible.

Kevin Pho: As you mentioned before, you are safe to say mid-career, 20 plus years of doing internal medicine primary care. Are you happy with that balance between talking to patients and hearing their stories and being emotionally involved, and your ways of narrative medicine in terms of coping with that emotional exhaustion? Have you found that balance, or do you feel that this is a continuing evolution as you progress through your career?

Ryan McCarthy: It’s definitely an evolution. And I think that striving for balance, I’m committed to that, and I feel good about that. Because I’ve realized now that if something throws me off balance and there’s too much work and there’s not enough time for poetry and movies and reading and writing and laughing, and in my particular house my kids are all in the performing arts, so there’s a lot of music. And so when I think of narrative practices, all of those things come into me to bolster my soul.

And if I go through a run of working, and we all know that at times during flu or COVID or some other season where it’s just like run ragged for a few days, if I sense that balance really shifting in the wrong direction, I know that I need to start pulling back. So I feel really good about my awareness, Kevin, of it. But no, I think it gets thrown off kilter all the time.

But what I’m really grateful for is now that I know that that is what is going to help. It’s not another vacation, it’s not purchasing something, you know what I mean? Like, this isn’t something that retail therapy or material items are going to help with. This is a practice of skills in arts and humanities. I keep going back to that word analog, and I’ll say time tested. So I’m confident that that’s what it’s going to take for me, and I think others can benefit. But no, it isn’t a constant. I’ve got to keep striving every day to make that balance a reality.

Kevin Pho: We’re talking to Ryan McCarthy. He is an internal medicine physician. Today’s KevinMD article is “When a doctor’s heart falls: Witnessing raw emotion in medicine.” Ryan, as always, we’ll end with your take-home messages to the KevinMD audience.

Ryan McCarthy: My take-home message is that each of us is a repository for a lot of trauma and pain in health care, no matter what your role is, whether you’re a radiologist, in the ER, operating room, whether you’re a nurse or a tech or what have you. Each of us is proxy to the suffering of other human beings, and each of us has a choice and a responsibility to care for our own emotional needs through things that are nurturing and helpful.

In my particular practice these narrative medicine skills have really served me well, and I think that if you haven’t tried any of them, take a bite and see just how healthful and fulfilling and helpful it can be for you.

Kevin Pho: Ryan, as always, thank you so much for sharing your story, time, and perspective, and thanks again for coming back on the show.

Ryan McCarthy: Thanks.