Graphic text "We Have a Disease"

In a recent NEJM Perspective, Dr. Rana Awdish writes of her experience seeing one of her own patients with COVID in the ICU. In her lovely essay, the encounter becomes a liminal space where she reflects on the 15 years she has spent caring for this patient then turns to look forward and consider possible outcomes. This contemplation leads Dr. Awdish to a new understanding of her current position in this time of COVID as an “in between” place that she can now tolerate with a growing hope and ability to look toward the future.

The concept of liminal space is usually thought of as the transition from one state to another, from the way things were to the way they will be. As a pulmonologist, one of my favorite examples of liminal space is the alveolus in that brief pause at end-inspiration —a place and time when the old air with its carbon dioxide departs and the new air, rich in oxygen, arrives.

Liminal space is typically associated with a pause, usually brief, but sometimes perceived as a suspension of time. It is a place of mystery where transition occurs, associated with ambiguity and a sense of disorientation.

Although not so brief, our current position in the pandemic world fits comfortably into this category of liminal space. It is as though we are in a broken elevator stuck between the floor of the pre-COVID world and the destination floor of the unknown post-COVID world. We hang suspended, dangling in a place that is not at all like the one we knew, and we have yet to see our destination.

The Danish philosopher, Soren Kierkegaard, said “Life can only be understood backwards; but it must be lived forwards.” In essence, the only way we can approach our future is by examining our past. I think Kierkegaard would suggest that those who find themselves suspended in the broken elevator of pandemic should use that pause for examination of their past to determine how they will inhabit the destination floor once they arrive. He would urge us to reflect.

Reflection is a powerful tool. It is the study of the history of ourselves. Ideally, as with the optimal study of history, it should also guide us to avoid replicating previous mistakes. Reflection is also a narrative process. It involves not just what happened, but how and why it happened. We create the stories of our past, and find the lessons in those stories that can guide us in responding to the future world we have not yet seen. Reflection is also a great source of hope. It reminds us that we have faced difficulties and challenges, and yet we still exist.

For most of us, our pre-COVID world was frenetic, filled with so many important things to do. Indeed, this pressure to do more and more has been an important contributing factor in the crisis of burnout that we have seen in recent years. Many of us have yearned for time to pause and reflect. But reflection takes time, and most of us were convinced that we did not have time to devote to this process.

Until now. Now we are stuck in the elevator, watching Netflix. Many of us now have the time we need to reflect so that we can be prepared to face the new world of our future. Only one thing is certain about that new world…it will be different. To prepare ourselves, we need to create the stories of our past, to examine their lessons and learn from them.

How can you approach this reflection? One way to think about your professional life is to consider it as a story. You likely already have the raw material in your CV or resume. Your CV contains the what. But you want to bring out the how and why that a more narrative form can reveal. You want to tell the story, because that narrative is where the lessons reside. Set aside a little time to take a look at your history and think about it in this new way. See where it takes you. If you feel really bold, you could do it with a friend or a group of trusted colleagues, learning from the shared stories. 

Armed with the lessons of your stories from the past, you can return to the process of preparing for the future. To be actively engaged in preparing for the future we need hope. That hope is derived from the lessons of our past, the products of the reflective exercise. We learn how we and others persevered in the face of challenge, how we overcame obstacles. Hope also requires imagination; we have to create visions, multiple visions, of what the future might hold and how we will respond and thrive in it. The business world calls this forward projection process scenario planning. By reviewing our past experiences, we also learn that sometimes we have to wait in order to know which plan will apply. Hope also means being prepared to wait.

We are living a new experience, one that feels extreme. But this is really nothing new. People have always faced challenging experiences. History is replete with stories of war, famine, pestilence and plague. Spending some time to carefully examine our personal histories will yield new perspectives to guide us as we cross the threshold and depart this liminal space to enter into a new world.

August 12, 2020