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The Limits of Optimism

In front of an audience of first-year medical students, a teenage boy with one eye sat with his mother. They told a story of triumph, even miracle: brushes with death, an eye removed, cancer overcome. This young man has become a star baseball player despite his total lack of depth perception (a consequence of having only one eye).

To close, mom shared a cautionary tale with us future physicians: The doctor who first diagnosed her son had detailed all the ways the disease would disable him. Mom was outraged. At that moment, what she needed was hope her son would get better, not this pessimistic prognosis. She has created a list of rules for us to follow so as not to make the same mistake. Two of them struck me: always remain optimistic with patients, and never cry in front of patients.

Before starting medical school, I spent the better part of three years as a counselor for adolescents suffering from psychiatric illnesses. Despite—or probably because of—this mother’s advice, I found myself thinking about some of the patients I came to know—specifically ones whose tragic stories of trauma and loss had left me speechless. What confused, even frustrated, me is that optimism and reassurance alienated these teenagers more often than it created connection. At best, they thought a sanguine attitude was perfidious. How can a patient trust a provider who seems to have feelings so at odds with their own? What is worse, for a person who has been suffering and in treatment for half of their life, saying, “Don’t worry: it will get better,” invalidates and even dishonors their experience.

I do not think this mother’s advice is categorically wrong. She knows what she wanted from her son’s providers, and surely many others want the same thing: confidence and reassurance and a well-defined game plan. For this mother, optimism was comfort. But my experience with psychiatric patients illustrates that faith and certainty are by no means universally tender. Some people want their provider to join them in their despair, share their hopelessness, stand with them “in the glare of that fear [of death]”, as Dr. Rita Charon said—which admittedly can be a difficult approach for those of us invested in helping others.

From where I am sitting as a first-year medical student, the partnership between physician and patient cannot be reduced to a list of rules or platitudes. Some patients want cheerfulness and others want commiseration—and then there are patients who do not even know what they want. It seems to me that identifying these desires calls for intuition and spontaneity as well as experience and careful understanding—some even call it an art.