• abatacept
• adalimumab
• amyloidosis

'Hope’ by Dr Kushboo Sheth is a profound and moving depiction of the inner life of a rheumatologist confronting the COVID-19 viral pandemic. The feelings that Sheth describes are as varied as they are powerful and range from fear to rage to distress. Burdened by the weight of these feelings, she vows to adapt, persevere and trudge onward. Most of all, she strives to get beyond the pandemic, aspiring to be a better person whatever battering and damage may come along the way.

The feelings that Sheth describes are inescapable at this time given the upheaval that the pandemic has caused in all aspects of life. Vulnerability is universal. Anyone can infect me and I can infect anyone. Those who can infect and be infected are the same: families, friends, patients, the checkout clerk at the grocery, a random passerby walking too close to you on the sidewalk.

In this calculus, infection is a matter of bad luck or, to use a word that has fallen out of fashion, fate. Even if infection does not lead to hospitalisation, it can lead to confinement at home, an isolation tantamount to imprisonment.

What I find striking about ‘Hope’ is not the range and depth of Sheth’s feelings but rather the identity of the person who is experiencing them. Sheth is a physician. Physicians by training should be accustomed to sickness and death and, indeed, have developed coping mechanisms that make professional activity as well as ordinary living possible.

The transformation of an ordinary person into a physician is a remarkable process. It entails far more than the acquisition of knowledge or the mastery of technical skills. The transformation is also psychological and it is spiritual: to learn to confront misery on a daily and sometimes hourly basis without it becoming overwhelming and debilitating.

When the shift in the hospital or clinic session ends, ordinary life must resume. There are dinners to share with families and friends, children’s sporting events to attend, interludes of delight with lovers. All must transpire without the residue of work—the disappointments, pressure and stress, the proximity to tragedy—impeding participation and enjoyment. Health professionals can acquire a shell so sturdy and effective that trying to achieve a life–work balance is not only possible but expected.

The shell that surrounds physicians is built gradually by accretion, with clinical training in medical school providing the first layer. I find it intriguing that the initial clinical experience of medical students in internal medicine occurs on the acute inpatient service of the hospital. There, the absolutely sickest patients receive their care. These are often older people with multiple comorbidities and, depending on the training environment, an array of psychosocial problems that defy solution. At present, many of these patients are infected with the virus.

Amazingly, the clinical clerk, armed with a snippet of knowledge in anatomy, biochemistry and pharmacology, is expected to dive into the thick of things—to serve on the front lines, to engage the patient as caregiver and to assume the role of physician.

While it might make more sense for medical students to begin learning medicine on an outpatient rotation to ease into the care of patients, I think that the goal of the first inpatient rotation is to start building a shell. I am not familiar with the training of nurses, respiratory therapists or social workers but I believe they all start in an acute hospital environment.

The training process that commences in medical school intensifies and accelerates during house staff years when responsibilities and duty hours increase and include nights on call in the hospital, often without sleep. (As an intern, I had rotations where I spent two straight nights on call in the hospital but, thankfully, those days are over.) While the process can be taxing and even harsh—sort of like ‘boot camp’ for a soldier—over time, the trainee learns to handle the exigencies of caring for the very sick and dying and develop defenses and coping strategies to compartmentalise their lives.

Is the shell built over the years impenetrable or can the exposure to too much sickness and too much death cause the shell to fissure and crack? Tragically, the disasters confronting healthcare professionals right now are so relentless and so extreme that the defence systems can fail; this is very evident in the big city hospitals where infections surge dangerously and colleagues and coworkers can also perish.

During catastrophes such as the COVID-19 pandemic, ordinary human feelings can surface in a physician as the protective shell crumbles. As Sheth elegantly recounts, a physician can break, cringe, rage and cry—even if not immediately on the front line. The demands on the hospitals, especially the intensive care units, are so massive that terror permeates the whole system and can afflict everyone. This is not burnout. This is a raging fire.

While physicians may be desperate to express feelings of dread, anxiety and uncertainty, resources and ‘safe spaces’ may not be available to accomplish this important function. Counselling services, wellness activities and ‘heal the healer’ initiatives may offer benefits, with those involving peer-to-peer interactions particularly valuable. I think that all institutions should have these programmes to help their staffs cope with the care of patients with the virus.

Among the many acts that Sheth describes, ultimately, hope may be the most saving. I am glad that she titled her article that way. Hope is something that everyone can do since it transcends philosophy, worldview and religion. To me, prayer is a vehicle for hope. I was intrigued to learn that one of my colleagues—a tough critical care physician and solid atheist—now begins each shift with his MICU team by leading them in prayer.

For the care of very sick patients like those who have the COVID-19 virus, hope is possible even if death looms inevitably. While hope for a miraculous cure—the magic silver bullet—never extinguishes, hope may simply seek for the patient to have a visit with the family, relief from pain or a death without suffering.

I agree with Sheth. As physicians and healthcare providers, we must adapt. We must persevere and, even if we can do no more than trudge onward, we must also hope. Hope is the foundation of all medical care. It is a source of strength, an essential act that affirms the meaning of life and defies the pull of loss and despair.