Watching someone die was not something I thought I was going to do on April 23, 2024. While it seems pretty apparent that death is a part of medical training, for some reason, death was not a part of what I imagined medical school would be like. I imagined long nights studying, arriving at the correct diagnosis in the clinic, and seeing patients’ health improve as a result of my burgeoning medical acumen.
I did not think about watching people lose their lives. I did not think about how witnessing death is a ubiquitous experience among physicians and trainees. Why would I? I joined the healthcare field and embarked on the journey to become a physician to save lives, not to witness the loss of life. I was motivated to go into this field to be a healer. My perspective on this idea shifted on that day in April.
I was about 40 minutes into a four-hour preceptorship when an ambulance brought in an older gentleman hemorrhaging blood from his mouth. He had been recently diagnosed with tonsillar cancer, and unfortunately, the tumor had eroded into a nearby artery, causing the artery to rupture. The emergency physicians, nurses, and other team members worked in concert to secure his airway and get the bleeding under control. There came a moment when it seemed like the team controlled the bleeding, and his airway was secured via a last-resort effort called a cricothyrotomy. The plan was to get the interventional radiology team to help stop the bleeding through a procedure called embolization. Unfortunately, moments before he was to be transferred for the procedure, he entered cardiac arrest. The medical team worked together to resuscitate the patient and performed CPR for over 15 minutes until it became clear that the patient had lost too much blood too quickly. He had passed away.
Following this episode, the medical team held a debrief where tears were shed and reflections were shared. The team did an excellent job given the circumstances, and this was one of those situations where, despite their best efforts, things ended differently than they had hoped. My preceptor offered me time to collect myself, given that witnessing such a gruesome death can be difficult for a first-year medical student. I’m glad I took the time I did because it dawned on me that this was the first person I had ever witnessed die.
I did my best to collect myself because I knew I had hours left in this shift. For the remainder of the shift, I practiced my abdominal exam on a woman with a history of diverticulitis coming in with left lower quadrant abdominal pain. I observed “pitting edema,” or severe swelling in the lower extremities of an elderly man with congestive heart failure. But through it all, I could not get my mind off what I had witnessed at the beginning of my shift. I left the emergency department and made my way home, thinking about who this man was and just how terrifying his last moments must have felt. I awoke the following day still thinking about it. What did this man feel towards the end of his life? What was his story? Had he experienced everything he wanted to experience in his life? These are questions that will probably remain unanswered.
I’ve written previously about how death and illness have informed the work I do, but those experiences took place before I was a part of the medical complex. Then, I was just a bright-eyed and bushy-tailed first-year medical student, but it is clear to me now that becoming acquainted with death was central to the oath I swore during my white coat ceremony. Ostensibly, death and dying are relatively obvious things that come with being a doctor. However, I primarily envisioned being that empathetic, diligent diagnostician who would heal the sick. I learned that I was unacquainted with what happens when, despite your best efforts, the patient does not get better. One day, I would be the senior resident “running the code,” responsible for a patient’s life hanging in the balance. Maybe it was immaturity, arrogance, or naivety (likely a bit of each) that informed my vision of what being a physician meant, but the veil was peeled back that day in the emergency department. I realized that this, too, was what I signed up for when I committed to being a physician. Seeing and experiencing it with my own eyes changed things for me.
I can’t fully recall where or when I came across the concept of threshold knowledge, but it has provided language to something I didn’t know I was experiencing. Threshold knowledge is a rare type of knowledge that is more than just learning something new. It comes through experiences for which no amount of preparation can prepare us Threshold knowledge transforms our perspective in ways we cannot predict. It can be frustrating, uncomfortable, and irreversible. The concept of threshold knowledge comes from higher education and psychology literature credited to Jan Meyer and Ray Land, typically discussed as a pathway to true mastery of an idea. Threshold knowledge is described as an almost spiritual transformation where an individual has a new way of thinking after crossing the threshold. I also believe that what defines this type of knowledge are the glimmers of truth, once unknown to us, that become revealed.
Learning about threshold knowledge and the experiences that yield it has been frustrating in many ways but powerful in others. I can look back at parts of my own story and realize that there was no way I could have prepared for how things would change me at various junctions of my life. There’s power in extracting lessons from your experiences — good, bad, and ugly — that will change how you see things for the better. It’s also disturbing to know that things are coming down the pipeline for which I am currently unprepared. For me, my beliefs about being a physician have transformed and matured. Being a witness to illness and death is as much a part of being a doctor as curing someone’s disease.
Part of me wants to conclude with something actionable. I want to share what I think you are “supposed” to do when you acquire threshold knowledge. At the same time, I realized that I could not do it. There is no standard approach to handling these things. The only thing I can offer is the idea that there are some experiences in life that we cannot prepare for. It’s deeply frustrating, scary, and unsatisfying. Sitting with those feelings is uncomfortable, and for a long time, I think I would have preferred to play it safe and not spend time thinking about it. But these days, I see the benefit of accepting the discomfort and choosing to focus on what the discomfort is trying to tell me. It seems to me that’s where the threshold knowledge lies.
-kjf
