Track 4, Side 2: Mrs. Robinson by Simon and Garfunkel
Learning to get comfortable with getting uncomfortable
My dad taught me every epic journey deserves a great soundtrack. My PalliMed Mixtape is the story of my Palliative Medicine Fellowship year, told in 15 songs.
In the early 2000s I saw old copies of Simon and Garfunkel’s Greatest Hits on vinyl everywhere. Used book stores. Thrift shops. Junk sales. In fact, I think having a used copy of this record in a cardboard box atop a folding table was a permitting requirement for any garage sale in my neighborhood.
I wondered, at first, why everyone was getting rid of their Simon and Garfunkel. I’m not a superfan by any means, but they’ve got some real bangers—Cecilia, Mrs. Robinson, The Only Living Boy in New York, The Boxer, I Am A Rock. Why ditch this album?
I eventually realized they weren’t hating on this album in particular, they were just dumping all their vinyl. Everyone was going digital, and I saw this particular record everywhere because literally every American born before 1975 had purchased it at some point. (It’s the same reason I saw Kenny Rogers’s The Gambler and John Denver’s Greatest Hits on vinyl at every garage sale and thrift shop, too.)
The music of Simon and Garfunkel pervaded the culture during my youth. I heard it all the time in my home and on the radio. Their lyrics are deeply imprinted on my brain. How many times have the words of Cecilia bounced around in my head? Or all the “Lie-la-lie”s from The Boxer? How many times have I said to myself “I’ve got my books, and my poetry to protect me” like Paul Simon sings in I Am a Rock.
I guess it should be no surprise, then, that the refrain “Here’s to you, Mrs. Robinson” spontaneously popped into my head after leaving a patient room earlier this year. In fact, it was walking away from that room and singing that refrain to myself gave me the idea to tell all these fellowship stories through song. Mrs. Robinson, in a way, birthed my mixtape. Let’s get to it and fire up a little Simon and Garfunkel.
I was walking through the halls near the ICU this winter when my attending physician (the doctor instructing me) told me something very unexpected. “Tyler, my goal for you this second semester is for you to get fired by a patient.”
Huh? How odd. This attending physician seems so nice. Aren’t we supposed to be nice to people—especially in palliative medicine? Why would she want me to get fired?
“Get fired? Really?”
“Yes. You do a great job establishing rapport and building trust, but you need to learn when to push. And if you push hard enough to get fired by a patient every once in a while, then you’re probably on the right track.”
I immediately knew it was true.
There had been times throughout the year when I knew I needed to push a little harder—needed to push back on fantastical thinking, should have more strongly confronted denial, been more honest about medical futility, needed to weigh in more strongly on a recommended treatment—but I hadn’t wanted to risk losing rapport. Rapport’s what I thrive on! That’s my fuel! I had wanted to preserve my welcome to come back into the room, to remain a “good guy,” but maybe that wasn’t always the right move.
That very week Mrs. Thomason, the mother of a patient in our ICU, provided me a fresh opportunity to get fired. Her grown daughter had a devastating injury that would require months and months of rehab. The sooner we could get her off the breathing machine, the better, but she wasn’t waking up enough to safely come off the ventilator. She would need a tracheostomy, a surgical airway in the front of her neck. Since the patient was unable to communicate, the medical decision-making fell to her mother.
We approached this situation like we always do. Before jumping into all the medical details with Mrs. Thomason, we went about building rapport.
We'd like to know a little bit about you for our files / We'd like to help you learn to help yourself / Look around you, all you see are sympathetic eyes
We learned all about the patient and her family, their happier times together. We learned about their values and their faith. We promised to walk this tough road with them and stay by their side. Our efforts were appreciated, and we found ourselves on a good therapeutic footing.
Done. Rapport established. Now let’s get down to business.
“Mrs. Thomason, your daughter needs a tracheostomy in order to move forward in her recovery,” I explained one morning. That’s when the wall came up.
“How do you know that?” she testily asked.
“Well, you see…” I started to explain, but she immediately cut me off.
“I don’t think she needs surgery at all. You know, you doctors don’t really know as much as you think you do. She’s gonna get better and you’re not gonna give her a trach.”
I respected the strong faith that led Mrs. Thomason to believe her daughter would have a quick turnaround, but I also explained to her that the tracheostomy would actually speed along her daughter’s recovery.
God bless you, please, Mrs. Robinson / Heaven holds a place for those who pray
It didn’t matter how I approached her from then on. I tried everything, day after day. Emotional acknowledgment, goal alignment, spiritual agreement, even medical logic. Through it all, Mrs. Thomason remained a wall. She wouldn’t budge. She couldn’t wrap her head around approving a surgery into her daughter’s windpipe. What a terrible decision to face! I wouldn’t wish it on any parent.
Laugh about it, shout about it / When you’ve got to choose / Every way you look at it you lose
One day I came by again to check on her, and the ICU team told me I shouldn’t see Mrs. Thomason anymore. The mother didn’t like me at all and was sick of talking to me. I was fired.
It’s the darnedest thing, getting fired by a patient or a family you are trying to help, especially when you feel you have tried to be very thoughtful and patient. It doesn’t feel great. I wondered how I could have used language differently along the way and had a different outcome with Mrs. Thomason. Did I stumble in my words? Did I fail to ask permission before tackling big topics? Could I have explained things more clearly or sought to better understand her concerns? I’m honestly not sure.
Like most doctors, I’m sure, I generally hope my patients like me. Connection and rapport are among our most important therapeutic tools! At then end of the day, though, it’s not my job to be liked by my patients and their families. My job is to understand their goals, explain clinical realities clearly and simply, with empathy, and help them find the path forward that best aligns with their values. That often means sharing hard truths. Doing this job well means that sometimes patients may not like me because of those hard truths, and may even fire me.
I walked down the hall away from her room, wished the mother and daughter well in my mind, and sang quietly to myself:
And here’s to you, Mrs. Thomason / Jesus loves you more than you will know / Whoa, whoa, whoa
My attending physician wasn’t exactly happy I got fired—that’s never the actual goal. She applauded me, though, for learning to get more comfortable with getting uncomfortable for the sake of our sickest patients.
Tell me, Crash Cart Campfire friends:
Ever been fired by a patient, a client, or a customer when you thought you were doing your best for them? How did it feel? What did you learn from it?
What’s your favorite Simon and Garfunkel song? Mine’s The Only Living Boy in New York, which was inexplicably snubbed and excluded from their Greatest Hits album.
What’s on your mixtape?
I’ve been asked by more patients than I can remember that they want a different doctor. I always try to deescalate those situations and find ways to meet or understand expectations, but some encounters just won’t be successful if success is the doctor and patient end on the same page of thought with accurate understanding of each other.
My favorite Simon and Garfunkel song 🤔 I’m too indecisive to pick a favorite and that catalog of songs is too good, and it gets even more challenging when you add in Paul Simon on his own. Some notable favorites off the top of my head: The Sound of Silence. Homeward Bound, The Boxer, I Am A Rock.