By Dr. Dara Kass
Emergency Medicine Physician
We start medical school wide-eyed and ready to learn. On the first day we are draped in short white coats, handed down dog-eared textbooks, and given brand-new stethoscopes, which hang around our necks like medals. We are granted a seat at a pungent anatomy table where we finally get to see inside a human body. We learn to ask questions and research answers, to get tested on medical facts, to learn about the body, but above all else, to listen to the body. We are grateful that each passing grade gets us closer to a career we love, one of taking care of real, live patients and saving lives: a career as a physician.
But the truth is becoming a good doctor requires more than just an education. It takes an instinct. It is one thing to be able to recognize the devastating diagnosis when lab work comes back, it is another to be able to deliver that news to a person whose life will be forever altered. You need to be able to read people—not just X-rays—making sure that what you are saying is being heard. You need to understand when to stop talking and just listen or when to let quiet fill a room. Eventually, you recognize this skill as your physician’s gestalt. Gestalt, like all great Yiddish terms, evokes a feeling rooted in your gut. It is the recognition that things have come together—from places you can’t describe—to finally make sense. And that sense often points you in a new and often unexpected direction.
Physician gestalt develops and grows as a product of your formal education, your lived experience, and your deep visceral gut. Physicians are trained first as generalists in medical school and then as specialists in residency. My residency was in emergency medicine, which meant that I was taught how to take care of any patient, with any problem, at any time. We used to say that emergency physicians are jacks-of-all-trades but masters of none. But, in fact, we are masters of quick thinking and getting to the point.
Patients arrive in the ER undifferentiated: they rarely come bearing a note that says I am eighteen, missed my period, am likely pregnant, have terrible belly pain, passed out in the bathroom, and my ectopic pregnancy is ready to burst. Please call the OB-GYN and get me to the OR. Instead, they are moaning on a stretcher, holding hands with a friend, afraid to look you in the eye, waiting to be seen, and praying their belly pain will go away. And it is your job, as you walk past that stretcher, to take a closer look, quickly lay hands on their belly, ask the nurse if their pregnancy test is back yet, and bump their case up to the top of the list of patients you have been running in your head.
As emergency physicians, we spend our whole careers fine-tuning our gestalt to be able to see a life-threatening emergency before that life is really on the line. Put simply, that may be as straightforward as realizing someone in front of you is subtly critically ill or is at risk for permanent injury, and you need to do something—right now—to address it.
Sometimes, that feeling happens when you look into a patient’s eyes and realize he’s not able to look back, leading you to wonder what is going on beneath the surface. Other times, it’s when you use all your senses to monitor a patient after they receive a medication, looking for subtle signs indicating the medication is working. We learn to listen to the voice in the back of our head saying Something is off. Figure it out while you still have time. Often that voice gives you a head start, before things become dire, signaling that you need to act.
Studies have been done in emergency medicine that look at the comparison between physician gestalt and objective algorithms in diagnosing serious medical conditions, meaning, the difference between a physician’s instincts and objective data. This includes a 2016 study in the Annals of Family Medicine that looked at physician instinct versus clinical decision based on medical knowledge and how both are used in finding a pulmonary embolism (PE), which is a clot in the lungs that can be life-threatening. It can also be hard to find and declare itself when a patient is very sick. It is one of our so-called can’t-miss diagnoses in emergency medicine, meaning if you miss it, someone may die. This study, which combined a specific blood test with gestalt or an algorithm, found that while the decision rule was slightly better than gestalt, they were both very good at determining the presence or absence of a life-threatening clot in someone’s lungs. In other words: intuition is real, and when properly used, it works.
My clinical gestalt—my instinct—triggers that voice in my head to speak up when I’m in the hospital and pressed against time to make a life-or-death decision. But it has also informed so much of who I am as a woman and a mom. I have often borrowed this skill in my personal life, foreseeing patterns and outcomes that seem to indicate things may be headed in the wrong direction. (Let’s call it mom’s gestalt.) It is the voice in my head that tells me our children need help before they even ask. And frequently, my personal and professional worlds intersect, in that I can identify when someone needs medical attention in my own family.
I have three children, and my youngest, Sammy, was born smaller than I had expected. At first, I did what I was told. I leaned on his doctors, breastfed him on demand, and gave him supplemental formula. When that didn’t work, I started hearing that voice in my head. For me, whether in medicine or in my home, it always starts out as a small whisper, like someone is telling me an important secret in my ear, only it’s my own voice speaking.
When I looked down at Sammy’s newborn face, I heard the voice say Are his eyes yellow, or is it just the light? I looked closely and realized they were, in fact, yellow. The voice got louder. Why can’t he gain weight? Which organ isn’t doing its job? Is there something wrong with his heart or his liver? Once answers came, the voice quieted down. I had a whole new list of things to do.
Yes, his eyes were yellow, and it was because his liver was failing. Sammy Kass, our baby, was sick and eventually we realized he was going to need a liver transplant. He was just under a year old when we started to prepare. The dual doctor-and-mom voice inside me told me that I was likely the right person to be his donor, and after several tests, sure enough, this fact was confirmed: I was a perfect match. On the eve of Sammy’s second birthday, doctors at Columbia University Medical Center replaced his diseased liver with a piece of mine, and today Sammy is a happy and healthy nine-year-old kid, living a good life.
My connection to my gestalt—my gut—has gotten me through every kind of disaster and trauma, even the very worst in New York City. In 2001, I was just a third-year medical student in the emergency department at Kings County Hospital when the Twin Towers fell on 9/11. I vividly remember being thrust into all-hands-on-deck mode. At that point, my only instinct was to help wherever I could. Watching those with more experience than me jump into action, mobilizing resources and planning for the worst, was something imprinted on me for decades to come.
Because of the magnitude of the trauma of 9/11, all medical students were called to duty that day, helping doctors move stretchers and get the hospital ready for what would surely be a massive influx of patients to come in from the site of the crash. Even more devastatingly, the rush never came. Though if they had, we would have been ready.
A few years later, newly out of residency, I was working as a doctor on Staten Island when Hurricane Sandy hit our shores. The voice once again whispered in my ear, Emergency departments tend to be on the ground floor of hospitals, which is great for patient access but not so great for catastrophic flooding. We sprang into action before the worst of Sandy had taken hold of New York, discharging any and all patients who could safely go home while moving the rest to higher ground. We sandbagged most exits and sat in wait for new patients. Unlike 9/11, patients did come, and it was because of the collective listening my colleagues and I did to our instincts and intuition that many who came in were saved that day, including those we moved to higher floors before a single raindrop had even fallen from the sky.
However, the biggest emergency I’ve experienced as a doctor was much more recent: the COVID-19 pandemic of 2020.
Word of a novel coronavirus in China had spread in December 2019, but I didn’t really start paying attention until mid-January 2020 when we started screening travelers in the ER for signs of a respiratory illness.
I had lived through infectious disease outbreaks in the past, and none of them materially changed our lives. Initially, I expected the same of COVID. But by the end of February, I sensed something was different with this virus. The voice whispered in my ear, It’s coming. Get ready. I listened.
At first, it manifested as my taking special precautions without any definitive reason for doing so. A patient, who had no travel history, would come in with a respiratory infection. Could this be COVID? I asked myself. I put an N95 mask on myself and began my exam. She didn’t have the flu, and it was definitely a virus, but we didn’t have capacity to test, so I just gave her supportive instructions and sent her home.
Before long, the first wave of COVID had hit New York City, and our hospital started seeing a bump in patients needing care for respiratory illness. Many of these patients could still stay at home and do a telemedicine visit, which helped keep them out of the ER, but I sensed things would not stay this simple or safe for long.
This new virus wasn’t just a risk to patients, it was also a risk for health-care providers treating those patients. For the first time in my medical career, I had to consider the risk to me and my family. As we saw in China and Italy, before COVID had struck America, doctors and nurses were dying from the virus left and right, with high rates of transmission within families of those infected at work. Sammy, the voice inside me whispered. You have to keep Sammy safe before this virus explodes everywhere. Seven years after the liver transplant, my son was doing well, but he was absolutely considered high risk for infection or complications of COVID. I knew I had to act fast to protect him from what he could be exposed to, through me and my work in the emergency department.
Almost overnight, infections surged in the city, and emergency rooms were overwhelmed with patients struggling to survive. I was getting ready to go back to work in the ER in just a week, and I knew I had to do something to protect my family and do it fast. How could I protect myself at work and decontaminate myself at home? Do I move into the basement or out of the house? How will I know if I am exposed or even infected? There were so many questions and uncertainties in those early days.
I did what I do when I need to quiet the noise and let my instinct take over. I went to SoulCycle and rode a bike in a dark room. And at the end of the sweaty hour, I walked back home with my husband and said, “I know what to do.”
“What?” he asked.
“We need to move the kids in with my parents, and you need to sleep in a different room. This thing is going to get very bad very quickly, and there is a high likelihood that I am going to get COVID. I don’t want to infect anyone. We need to move them out of the house before I head into the ER. You can stay, but we need to be six feet apart. We will reevaluate things in a few weeks when we know more about this virus.”
And that is what we did. I moved my kids in with my parents Friday, March 13, 2020. The next day I went to work in the ER. It was unlike anything I had ever seen. Patients were sick, and they were getting sicker, but given how contagious the virus was, we knew this was just the beginning. People came in awake with oxygen levels the lowest we’d ever seen before. We started treating each patient as if they could give us the virus. We pulled together as health-care workers do. We were all in this together. Techs, nurses, doctors from other services, the sense of solidarity was palpable all over the hospital and throughout the city.
On Monday, March 16, I started having muscle aches. I thought I was tired from the weekend of nonstop shifts. I picked up extra telemedicine shifts to decompress the volume and help people at home. On Tuesday, I lost my sense of taste, and by Wednesday a telemedicine patient on Zoom asked me about my cough. That night, I scheduled a telemedicine visit as a patient and told the doctor I probably had COVID. By the grace of God, I was able to get tested (something virtually unavailable to patients who didn’t need hospitalization), and on Thursday, March 19, I found out I had COVID.
I took a deep breath. In fact, I took a lot of deep breaths. Some were just to check if I could still breathe. So many of my medical friends were finding out they also had COVID, and some were getting hospitalized. I was definitely afraid. But fortunately, I was only afraid for myself. My husband was in the clear, since we had been six feet apart since before my likely work exposure. My kids were safe, especially Sammy, because we had moved them to my parents’ place in New Jersey. And I was okay, taking it one day at a time, facing this new virus now as a patient, not just a physician.
I had a symptomatic but mild course of COVID. I went back to work a couple of weeks later, just as NYC was in the worst of the pandemic. Fellow physicians were wearing garbage bags as personal protective equipment because there was a massive shortage, and I lost a physician friend to suicide. Those weeks were some of the toughest of my life, but through it all my family was safe. Which made all the difference.
The voice inside me that tells me when to act and how fast to do it, or when to make a hard decision, has helped me navigate some of the most critical moments in my life. It has helped me protect my family, my city, and my country. It has made me the fighter, the mother, the wife, the disaster-whisperer I am today.
I’m the woman telling you something vital, something you need to hear, something that could save your life or someone else’s or my own. I say it in hospitals, or with my friends at dinner tables, or in front of an audience at conferences, or on the nightly news when I’m on as a guest, or while tucking my children into bed. I’m the one who leans in to myself, to hear what is being said, who trusts that voice more than any other, and who wants to share it with you, too.