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Continuing Education

H. Lee Kagan

The nasogastric tube was killing me. It had been in place for twelve hours now, threading its way up my nose and down my throat, past my esophagus, into my stomach. Try as I might, I couldn’t swallow away the nasty lump stuck to the back of my throat. And every time I tried, it hurt.

Decades before, as a physician-in-training in upstate New York, I’d put in more nasogastric (NG) tubes than I could remember. At the time, I hadn’t regarded NGs as a big deal. But now I was having my first personal experience with this vile little snake, and it sucked–in every sense of the word.

Two days before, I had come down with a viral gastroenteritis, or stomach flu as it’s often called. Twenty-four hours into my illness, the miserable feeling that some dead critter lay rotting inside me still hadn’t eased.

By midnight on day two, I found myself sitting up at the kitchen table with my head on a pillow, the only comfortable position I could find. My belly was distended, and I was into my seventh hour of non-stop hiccups. You didn’t need to be board certified in internal medicine, as I am, to know that something was wrong. This was not how viral gastroenteritis plays out.

Despite her protests, I convinced my wife that I could drive myself to the ER at the hospital where she works as a nurse educator. No need for both of us to lose a night’s sleep. She could catch up with me in the morning.

At 1 a.m. the ER was quiet. In just over an hour, an intravenous line was started, blood was drawn for lab tests, medications for pain and hiccups were administered, and my abdomen was X-rayed. The films showed loops of bowel holding stagnant fluid layered over with gas, a condition called an ileus. It meant that peristalsis had stopped–my intestines weren’t moving things along as they normally would.

The ER physician confirmed my suspicions: Having failed to take in enough fluid and electrolytes by mouth, I’d allowed myself to become dehydrated and depleted in potassium. As a result, my intestines had simply said, “We’re done.”

I thought of the innumerable times I’d admonished my patients about staying hydrated. 

Turns out, I sheepishly admitted to myself, I’m not such a good patient.

By midmorning, my no-nonsense internist was standing next to my ER gurney. My abdomen was silent as a graveyard, and my gut needed to be decompressed. The only way to do that is by gradually suctioning out the fluids and gas via a tube in the stomach.

“There’s no way around it, my friend,” he said. “We have to stop putting off the inevitable.”

“I know,” I reluctantly agreed.

I made no protest as the tube was snaked through my nose and down into my stomach.  

Now here I was alone in my hospital room in the middle of the night, unable to sleep because it felt as if someone had shoved an umbrella handle down my throat.  

I lay in my bed trying not to swallow, ruminating on how we torture our patients in order to get them better. I couldn’t believe how blithely I’d done this to people in the past.

It occurred to the writer in me that here was a story: a seasoned doc, humbled and transformed by his own illness and hospitalization, learns to be more empathetic. It’s a very satisfying arc. 

But no, I thought, it’s a cliché, a trope I’ve seen a thousand times before. It’s a staple of the genre. 

Don’t get me wrong. It’s not an unworthy theme, and it’s certainly a daily reality in medicine. But here’s the real question, I thought, lying there in the dark: Why do I need to relearn this truth for the hundredth time?

I teach this stuff–how to connect with patients–to the students at the medical school. I’d repeated it countless times: “There is no better lesson for a doctor than to be a patient.” And yet, that night, the feeling of empathy for my patients felt like a revelation. Why? 

I recalled a trip my wife and I made to the Gulf Coast in 2005. Hurricane Katrina had recently blown through with devastating effect. We volunteered to work in a small town in Mississippi. The working-class community’s medical infrastructure had been washed away by the storm.

We slept and worked in primitive conditions, but at the end of our ten-day stint we felt rejuvenated, even exhilarated. We’d been swept up in an ocean of giving, and it was almost like a high.  

Six weeks later, we attended a sumptuous dinner at the Aladdin Hotel in Las Vegas, part of a weekend medical meeting. Katrina’s aftermath was still making headlines, and those who sat at our table were eager to hear our accounts of what we had seen and done.

I told them about the man with a tracheostomy, a surgically created opening in his windpipe, whose radiation therapy for laryngeal cancer had been interrupted. His wife had to suction the opening clear of mucus by hand while the couple struggled to survive in a tent with no electricity on the property where their house had once stood. 

I shared how we’d come home to Los Angeles having relearned a number of lessons–about our common humanity with people whose lives are very different from our own, about gratitude and about what really matters in life.

“But alas,” I added, “There’s one more lesson I’ve learned since coming to Las Vegas.”  

All eyes were on me. 

“I’ve learned that I can learn all those lessons, and then, six weeks later, while getting dressed for a fancy dinner, I can complain to my wife that the rooms at the Aladdin are not nearly as nice as the rooms at the Venetian.”  

I’d laughed to myself after making that observation to my wife. What fools we are, I thought, to imagine that the task of making ourselves better human beings is ever finished.

So what exactly is the half-life of a lesson? Is it possible to learn empathy once and for all?

When my wife gets up in the morning, her first waking thought is, What can I do for others? Me, not so much.

But I’m trainable. With a little gentle prodding, I can be put back in touch with the better angels of my nature, decide to play on their team for a while. I think I’m like most people. Life hands us little reminders and, if we’re lucky, we notice them.

At dawn, the day-shift nurse came in to do her clinical assessment of me.  

“Good news. You’ve got bowel sounds,” she pronounced, lifting her stethoscope from my belly.

Fabulous, I thought. Between that and the gas I’d passed during the night, it meant that my gut had reawakened and was back on the job.  

“Would you mind double-checking those sounds?” I asked. “Just to be sure they’re there.”  

She did, and they were.

My personal diagnosis? I no longer needed the NG tube. But I didn’t share this with the nurse, nor did I offer her news of my nighttime revelation regarding the power and fragility of empathy. I just said, “Thank you very much,” and waited for her to leave.

It was Sunday morning. It would be several hours before my physician came in. I didn’t begrudge him the time with his family; but I had an umbrella handle in my throat.

I reached up and peeled the tape from my nose.

Once more, I had learned my lesson about pain and vulnerability.

I know I’ll never forget this, I told myself as my fingers tightened around my NG tube. 

I began pulling and thought, Who am I kidding? I’ll settle for hoping I never forget this. I kept pulling until the tube was out.

About the author:

H. Lee Kagan, an internist in private practice in Los Angeles, is an associate clinical professor of medicine at the Keck School of Medicine of USC. “In the Introduction to Clinical Medicine course, I help students to learn the practical and psychological value of being an empathic listener.” He is a contributing writer to Discover Magazine, and his work has also appeared in the New York Times Magazine and The Intima. “I’ve always had the urge write down my experiences and observations, to shape them into stories, to ‘translate the world into words.’ My eldest daughter, a science writer and poet, is the one who urged me to start writing for publication. I was fifty-seven when I first saw my name in print.” He is currently working on a memoir about growing up with Holocaust-survivor parents.

Story editor:

Diane Guernsey


9 thoughts on “Continuing Education”

  1. Hello Lee! Your wife and my professional colleague — extraordinary Nurse Educator Patty Kagan – shared your article with me. I’ve now read it countless times and probably will read it again many more because it serves as an important reminder of the human experience. You have an amazing gift of storytelling and painting a picture with words! Thanks for sharing your lived experience as a patient. And here’s to never needing another NG tube!

    Dave Hanson, MSN, RN, ACNS-BC-NEA-BC

  2. What a beautiful empathetic piece. I would like to quote you in a blog piece I am writing for Hospital Impact. You clearly define empathy like it should be. My hope is that each physician does not need to undergo what you did in order to truly understand how to practice empathetic medicine.
    Somehow, I believe you practiced it before. Let me know if I can quote you.

    1. Dear Sherri – Yes of course, feel free to quote my piece. And thank you for your kind words.

      Like you, I wouldn’t wish misfortune on anyone as a lesson in empathy. But as I get into the later stages of my professional career, it’s become clear to me that one’s capacity to empathize grows with life experience. Though there are exceptions, I believe there’s only so much most healthy twenty-something-year-old medical and nursing students can know about loss, incapacity, disappointment, betrayal and triumph that make up the fabric of life within which illnesses play out. So we help as best we can by teaching skills, sharing stories and by setting examples at the bedside and in clinics.

      I am flattered that you want to quote my essay and only ask that you send me the link to your blog post when you have it up.

      All best,
      Lee Kagan

  3. Your very personal experience has provided you with the special healing tool of true empathy rather than carrying the more common one of simply sympathy. But, unlike sympathy, which can almost be scripted and operates with no effect on professional function, true empathy, without attention, can affect the physician’s decision regarding best clinical practices for that patient. For example, in your case,if and when to apply a naso-gastric tube into a patient and how long to leave it in place can be affected by your own personal experience and feelings. The challenge for those physicians who have empathy is to, nvevertheless, provide the best in skill and beneficence to the patient along with that special understanding that only one’s personal experience can provide. ..Maurice.

  4. I enjoyed your article. It was very timely in that I read it at an airport where I see a lot of long faces. It was a good reminder to keep my thoughts and spirits in check. I enjoyed the medical insight as well. It was also a good reminder for me to drink more water.

  5. I liked your story. I especially liked when the nurse touched you not just with her stethoscope but with her heart. Leo Elizondo
    P.S. I took ICM as a student and now teach it also. I get more from the students and patients than I give to them. LE

  6. Marita Grudzen

    I feel a deep sense of gratitude for your taking the time to produce this piece. Any writing of this quality takes time, patience, and commitment. For each of these and your transparence, I thank you. Without all of these we couldn’t have read your heart, nor could our been quickened.

  7. I’ve been waiting for someone to talk about half-life. As a person with leukemia, I thought I’d smell every flower for the rest of my life, but diagnoses too have a half-life. We’re speaking about human nature, something deeply organic to our species.That’s why this magazine and stories like this one are so important. They fill in gaps left by our own infrequent experiential reminders. When the stories are so well-written and honest as Dr. Kagan’s, remembering is joyful.

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