CALLUSES | Laura Vater
I’m 16, and my hands are covered in thick, hardened layers of skin across my upper palms—my body’s attempt at protecting me from the repetitive friction of the uneven bars. When my hands are particularly dry, I soak them in warm water, cover them with a copious amount of emollient, and sleep in plastic gloves.
At practice, I press white chalk into my hands before fastening the leather grips around my wrists and over my middle and ring fingers. Then I spray the fabric with water, use a wire brush to gently roughen the surface, and apply another generous layer of chalk. Despite all these protective measures, a sharp, stinging pain soars through my left hand as I circle the high bar. It’s a dreaded rip—the round callus has torn open, and the blood trickles over my palm and onto my plum leotard.
After washing and bandaging the wounded skin, I transition to the balance beam, trying my best to keep going. The sore takes weeks to heal.
Nowadays my hands are mostly callus-free, but my career comes with a different sort of repetitive strain. As a medical oncologist caring for patients with advanced gastrointestinal cancers, nearly 80% of my patients die from their illnesses, and the work is emotionally taxing. No, that’s not even a close approximation. The work is often gut-wrenchingly heartbreaking.
Caring for about 60 patients a week, I’ve learned that it’s a routine part of my job to tell someone they have incurable cancer and support them during the distress that follows. Then I guide them through the difficult events that often ensue: side effects from treatment, progression of disease, anticipatory grief, increasing dependence on others, and eventually, death. Sometimes, an extra layer of devastation blankets an already painful situation—a spouse divorces a patient after diagnosis, or a single parent faces leaving behind a young child.
In training, I often felt crushed by the weight and wondered how this career could be sustainable. By observing my physician teachers, I learned techniques to blunt my emotions until I could step into a bathroom, call room or stairwell to cry. Once, while witnessing a college student with end-stage cancer calmly grapple with the decision about hospice, I had to read the caution sign on an exam chair over and over to keep myself from sobbing.
I quickly learned that how I processed and coped with this lingering grief was just as important as mastering the clinical skills of medicine. Like the grips and chalk of my youth, I reached for tools to help buffer the stress and mitigate compassion fatigue: journaling, therapy, meditation, exercise and books that offered temporary respite. On especially tough days, I’d remind myself that I didn’t cause my patients’ illnesses, nor could I control the outcomes of their treatments.
Several years into my career now, my emotional reactivity has lessened, but my muted internal responses sometimes fill me with guilt.
Recently, I told a patient that his newly diagnosed gastric cancer was more advanced than previously thought. The scans showed metastases in the liver, and surgery was no longer an option. The patient’s wife shrieked out in grief, and the resident next to me was visibly distraught, wiping away tears. I also felt sad and wished they weren’t facing this, but the pain did not wreck me. I wondered if the resident thought I was uncaring, and a flash of shame passed through me.
I left the room, let out a sigh, and went to see the next patient because that is what this work requires.
On the drive home, the shame resurfaced. Had I become hardened? I knew that an emotional callus had formed from the strain of the work, but was I callous?
The words were so similar. An online search revealed that both come from the Latin callosus, meaning hard-skinned or tough. It’s where the thick bundle of nerve fibers separating the brain’s hemispheres—the corpus callosum—gets its name. I scrolled through the examples and stared at one in horror: The doctor seemed callous when delivering the news. Was this how I appeared to my patient and his wife?
I flashed back to a statistic my mentor once told me: I’d share bad news with patients ten to thirty thousand times in my career. Living this reality now, I realize it’s simply not possible to take on every patient’s pain. I’m one person, and my energy and capacity are not infinite. There will be times I must lean back to preserve my well-being, function in my role, and compassionately support my patients through the challenges of illness.
As hard as it is to accept that my emotional responses have changed, part of me is grateful for this layer of mental armor. Just as calluses enable gymnasts to perform incredible feats on the bars, emotional calluses allow us to remain present for life’s most anguishing events when others might turn away. Understanding this has helped me release some of the shame.
The truth is, rips still happen, often unexpectedly.
I’m 36 and standing at my desk in clinic. My next patient is just a few years older than me and has four small children. She’s been through intensive chemotherapy and surgery for her pancreatic cancer, and her scan report pops up. Holding my breath, I double-click: she has new tumors in her lungs and liver, concerning for metastatic, incurable disease.
As I walk to her room, my muscles tense. She and her husband look at me expectantly, then crumple as I speak the unspeakable.
“But my kids,” she sobs. “They’re just babies.”
A pang wallops my chest as I sit with her, and a tear rolls down my face. When she asks for a hug, I wrap her in one.
At home, my mind turns to her while eating dinner with my family, and then again while trying to fall asleep. How much more time will the treatments give her? I think of her children growing up without their mom. Will the littlest be too young to remember her?
In reality, no matter how much our bodies may try to insulate us from the pain, it’s impossible to do this work without being affected. Rips are part of the deal. Perhaps the only hint of relief in all this comes from knowing I still have soft spots.
The next week, she comes to the clinic for treatment, and I softly knock on the door. After we discuss the risks and benefits, she tells me it’s her daughter’s fourth birthday.
“I hope I’m here to celebrate the next one.” Her voice cracks, and her husband slides his hand into hers.
“Me too,” I say, my eyes filling with water. “I’ll be with you every step of the way.”
In the hallway, I take an extra moment to collect myself before looking at my list. There are rooms filled with other patients who need my care, presence and attention, some of whom I’m meeting for the first time. With a long exhale, I try to release some of the ache, then walk to the next patient’s room.
I’ll do my best to keep going.
Laura Vater is a writer, medical oncologist, and TEDx and commencement speaker in Indianapolis. She’s a member of the Pegasus Physician Writers at Stanford, and her narrative writing has been featured in several medical journals and Anna Quindlen’s book, "Write for Your Life." Her essay "Papaya" appeared in the Fall 2021 Intima. Read more at LauraVater.com.