Monster.

It was in Cardiology Clinic, during my opening week of intern year, that a patient first broke my heart as a doctor. His voice was gravelly and occasionally difficult to understand, and the words spilled from him like an undammed stream. I had walked into the exam room and after asking what brought him to clinic, I was met with a solid wall of text. He seemed to talk without drawing breath, veering from topic to topic, gaze directed downwards. After several minutes, I gently tried to redirect the interview and it was then that he looked up, meeting my eyes. “I don't know what's happened to me.” He gestured down at himself, indicating his belly. He was dressed in slightly stained sweatpants and a wrinkled T-shirt that stretched tight across his midsection. “I don't recognize myself anymore. I look in the mirror and suddenly I see a monster.” A monster. Hearing the stark description, I felt his pain acutely. I wanted to give him some comfort, or solace, but I was left at a loss for words. During that visit, we discussed strategies for coping with stress, and for preventative cardiovascular health. As with every encounter, I tried to learn something of the complexity of medicine to take to the next patient. But what sticks with me most is that description. A monster. Part of the reason it made such a deep impression on me was that he had perfectly articulated the way illness feels to so many people. It is not just that you don't recognize or understand what is happening to you, you don't recognize or understand you. In his paper “Illness as Unhomelike Being-in-the-World: Heidegger and the Phenomenology of Medicine,” Fredrik Svenaeus1Svenaeus F Illness as unhomelike being-in-the-world: Heidegger and the phenomenology of medicine.Med Health Care Philos. 2011; 14: 333-343Crossref PubMed Scopus (123) Google Scholar uses the philosophy of Martin Heidegger to explore how illness can make us unfamiliar to ourselves. “In illness the body shows up as an alien being,” he writes, explaining how profound that sense of alienation can be precisely because “there is nowhere else to go, because the body cannot be left behind.” For my patient, changes in his life had left him feeling isolated in several ways. A loved one had been diagnosed with dementia, and he was left as their caregiver, confronted daily by the chasm between who they had been and who they were now. Some of the organized social activities he had participated and found meaning in had moved from in-person to online, a setting where he found it more difficult to connect with others. The changes he saw in his own body were a final betrayal, and although he was able to identify some of their banal causes (“I eat too many chips,” he told me “and never go on my treadmill anymore”), there was a sense of powerlessness and of shock in the way he spoke. Svenaeus1Svenaeus F Illness as unhomelike being-in-the-world: Heidegger and the phenomenology of medicine.Med Health Care Philos. 2011; 14: 333-343Crossref PubMed Scopus (123) Google Scholar uses metaphors of alienation, otherness, and the uncanny to describe a sense of “unhomelike being” illness can elicit. My patient took things a step further, invoking the monstrous. Paradoxically, I found that hearing this self-characterization humanized him profoundly. A monster. It's a powerful word, but fitting, I think, for such an overwhelming emotion. Months later, I found myself on rotation in the Emergency Department, being unceremoniously invited to leave by an irate patient. “Why don't you just get the fuck out of here?!” He made a shooing gesture, his arm, like the rest of him, terribly emaciated. Maybe it was something in his expression or voice, but I heard the fear and the pain behind his anger too clearly not to dig deeper. When I returned to his room some time later, ready to take a second crack at building rapport, I learned that he had been sent to the Emergency Department from the operating room, deemed too unstable to receive the reconstructive facial surgery he'd been scheduled for. His first facial surgery had been for a skin cancer, and he had gone in not really knowing what it would entail. “I've never had to have stitches before in my life,” he said, describing his experience of that first surgery. “When I woke up from that surgery, something felt different. I asked the nurse for a hand-mirror, and when I looked into it, I saw this Frankenstein.” He waved his hand, indicating the thick row of stitching across his forehead and nose. His reference to Frankenstein was eerily similar to my patient back in Cardiology Clinic. And in much the same way, this patient faced multiple life stressors. In his case, an invasive cancer had abruptly thrown him into a medical system he had little experience with and found constantly confusing and frustrating. In the same way, he felt his health, his control, his very sense of self slipping away, and the unexpected change in his physical appearance after surgery made the sense of alienation unbearable. Svenaeus talks in his paper about the loss of a sense of belonging that comes with illness. He describes how sickness can set our world off-kilter, making the normal sense of existing into “an un-homelike character, in which the otherness of the body addresses us in a threatening way.”1Svenaeus F Illness as unhomelike being-in-the-world: Heidegger and the phenomenology of medicine.Med Health Care Philos. 2011; 14: 333-343Crossref PubMed Scopus (123) Google Scholar The metaphor of illness as a state of being un-homed is fitting, and there was something of the disorientation and unhappy perplexity of homesickness in these two patients in Cardiology Clinic and in the Emergency Department. If I were to describe their overall emotional state, the word I would use would be “lost.” Svenaeus points out that, although there are other circumstances that can make us feel unhomelike in the world, illness is unique in that it “is characterized by a fatal change in the meaning-structures, not only of the world, but of the self.”1Svenaeus F Illness as unhomelike being-in-the-world: Heidegger and the phenomenology of medicine.Med Health Care Philos. 2011; 14: 333-343Crossref PubMed Scopus (123) Google Scholar In their deeply poignant descriptions of themselves as monstrous, my patients captured this profound alienation as well as the revulsion and the shame that can accompany sickness. Back in the Emergency Department, I explored options for my patient. Medically, he was safe for discharge, but the way he had echoed the sentiments of my patient in Cardiology Clinic from months before struck me. The ache of that self-description of “monster.” So when I spoke with the surgeons and they offered to come to the Emergency Department to remove his facial stitching that day, I felt a rush of relief. I explained to my attending the context of this patient, and why it was so important that we wait for the surgical team to come down; how much this would mean to him. Svenaeus refers to a “fatal change in the meaning-structures,”1Svenaeus F Illness as unhomelike being-in-the-world: Heidegger and the phenomenology of medicine.Med Health Care Philos. 2011; 14: 333-343Crossref PubMed Scopus (123) Google Scholar and I tried to convey some of this sense of urgency as I explained my patient's situation. Fortunately, my attending was exceptionally understanding, and agreed to hold off on discharge until the surgeons could come down. It was the end of my shift, and before I left for the day, I stopped in at my patient's room to let him know the plan. When I told him that his surgeons were coming down to remove his stitches, he broke into a radiant smile that left his whole face transformed. Behind his repeated thanks, his relief and hope came through. As a resident, it can be too easy to become numb to the alienation so many patients feel, an alienation not all of them will be able to express so articulately. I try to carry forward these interactions when I see other patients, to remind myself of the unhomelike nature their world may have taken on, the shock and distress they may feel at looking in the mirror. For this patient, I hope that I was able to make him feel less of a monster, to make his world, as alienating as it had become, a little more homelike.