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Can the Thorns Mean More Than the Petals?

By Fred Varone, MD

“What was the rose and thorn of your intern year?” asked my senior resident one day in the medical ICU. It was my last week as an intern.

“What?” I responded.

A rose and thorn, she explained, are metaphors for the best and worst experiences of the year. They can be anything: an event, a person, an entire rotation, or even a single moment. 

Morbid curiosity drives residents to ask about each other’s experiences, especially early in our training. At first, I didn’t have an answer for her question. As an intern I often found myself sitting on my couch after shifts, exhausted, unsuccessfully processing my daily dose of traumatic moments. The rose and thorn question made me think of a particularly taxing night shift in the MICU. That morning, a notice came over the PA—Respiratory therapy to CT, STAT. I paused. My patient has just gone to the CT scanner. Another resident and I ran downstairs and entered the CT room as the code blue was announced. The table began its slow journey out of the plastic donut, and seconds stretched into what felt like hours. My colleague gave directions to the team. I grabbed an intubation tray, took a deep breath, reminded myself to exhale, and placed the breathing tube into her airway. Two or three minutes later, the patient had a pulse again, and I breathed easier.

Twelve hours later, however, the patient would be dead. 

Returning to the ICU with our patient alive and our hearts soaring, I felt like a good doctor (something an anxious intern doesn’t feel every day). But the patient’s family soon arrived and asked why she had a breathing tube. We learned that she had been chronically unwell and suffering for a long time. Her code status had been Do Not Resuscitate/Do Not Intubate, but she recently changed her mind and asked for all measures to be taken to resuscitate her. Ultimately, her power of attorney and family believed that she would not want to be kept alive in her condition, and decided to withdraw care. My heart sank.

But, residency is more than individual moments. I’ve now been through lots of firsts: tricky diagnoses, great saves, procedures gone awry, and morbidity and mortality conferences for my own failures. I’ve spent so much time thinking about my rose that I’ve had time to watch its entire life cycle. I had been cultivating the seed for years through medical school and intern year. My work paid off when it bloomed in front of me that day in the CT room. But dead petals and thorns now litter the floor of that memory. 

The more I reflect on the rose, the more vividly I remember the painful, ugly parts. I watch the petals brown and fall as I think about each measure we took that may have caused more harm than benefit. I watch thorns sprout, sharp and ominous, as her family’s saddened faces swim in my memory. What did I have to be proud of? I had exemplified the skills and knowledge of a competent doctor but all I felt was self-doubt. We made the right medical decisions in the moment, but was everything that happened in the patient’s best interest?

Did I cause her more suffering? Did I prolong her family’s grief? 

What stands out most about a rose is its duality—beautiful yet dangerous. These qualities are why people have always been fascinated by them. As I reflect upon my intern year and transition into the heavier responsibility of a more senior role, I find myself spending more time analyzing my past experiences. I want a deeper understanding of my decisions and the unique circumstances of every patient. 

The average lifespan of a rose is one week, and nearly all of them have thorns (actually… roses apparently don’t have thorns. They have prickles, which have a slightly different morphology than true thorns or spines, which are somehow different than thorns). These structures serve one purpose: protection. Just as roses fend off predators with their thorns, I use mine to protect my patients from harm.

I find that very few experiences fall into the binary rose/thorn system, and like almost all things they are somehow both at once. Maybe that’s why I’m so preoccupied with the metaphor. A rose inspires us with beauty, and as it ages and wilts we notice its flaws. The dying petals, fading colors, and, of course, the thorns. I view the flower from afar when I think about my successes. I appreciate the beauty of what I’ve done right. 

But to fully appreciate the flower, I have to cut it, bring it home, examine it, and watch as it dies. Sometimes, I get pricked. My wounds heal, and maybe I can avoid getting pricked again if I handle my roses more carefully the next time. But maybe, sometimes, I’ll leave the thorn in my side, a persistent reminder of what I’ve learned.

Image Credit: Evelyn Bertrand via Unsplash

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