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A Piece of My Mind
May 21, 2019

Systole and Diastole, Strength and Openness

Author Affiliations
  • 1Department of Internal Medicine, Bellevue Hospital, NYU Langone Health, New York, New York
JAMA. 2019;321(19):1871-1872. doi:10.1001/jama.2019.5650

“Seize diastole,” my medical school professor said. The words were a clever metaphor for a life well lived. During systole, the powerful myocardium contracts, generating pressure that propels open the aortic valve. Blood flows out into the circulation.

Diastole, the process of letting go and filling up, is not as exciting. It could even be taken for granted, cut shorter and shorter. But without adequate time for diastole, there’s no blood to be thrust forward. Homeostasis crumbles. Just as the myocardium needs time to release and refill, so does the soul.

As a second-year medical student, I didn’t give my professor’s advice much thought. But years later, it proved to be a vital lesson.

Toward the end of medical school, I became severely depressed. During my recovery, the question I most needed answered was simply: What happened? How had I gone from an idealistic, enthusiastic medical student to a tearful, hopeless one? To heal, I needed to be able to tell my story. I needed a narrative that made sense to me.

I was familiar with the usual metaphors of depression. It’s a chemical imbalance. It’s just like diabetes. You’re living in a gray cloud. But the usual metaphors of depression didn’t resonate with me. My imagination searched for others, often drawing from the world of medicine.

I remembered scrubbing in to a surgery as a medical student. With the patient’s chest splayed open, I saw a beating heart for the first time. The richness of its colors mesmerized me. The pericardial fat was so yellow, the right atria so purple, the lungs a bubblegum pink. I had seen so many approximations of the heart: echocardiograms, cardiac MRIs, pathology specimens. But here was the vital organ itself, sustaining life. I was in awe.

After the chest was closed, a voice announced that one of the surgical sponges was missing. We all searched among the drapes and beneath our feet for the little square. It was nowhere to be found.

The surgeon was left with no choice but to untwist the sternotomy wires and reopen the patient’s chest. I saw a hand digging under the heart until it seemed the whole arm was in the patient’s thorax. There, the missing sponge was found.

Many months later, when my depression settled into a heavy, visceral pain in my chest, I thought back to that day in the operating room. Though medically I knew otherwise, I imagined the pain emerging from my heart. I pictured splaying open my chest, so I could inspect it. Maybe I would find a little square sponge that wasn’t supposed to be there. Maybe I could excise the pathology and be healed.

My mind was grasping for ways to make sense of my story. But this metaphor made me feel defective, and it didn’t help me heal. I kept searching, remaining fixated on the heart.

I remembered a patient with severe diastolic heart failure. Edema filled the patient’s lungs, legs, and even the arms. A gentle smile and full head of hair rested just above the flood lines of the patient’s body. When I met this patient, I was in the midst of my descent into depression. Something about this waterlogged body resonated with my internal state. Seeing this patient’s body called to mind my professor’s words: Seize diastole.

Diastole, I had learned in the lecture hall, is jeopardized by stress. When the heart is constantly up against an elevated pressure—hypertension, for example—it adapts. The ventricle gets stronger, able to generate more and more force to meet the demands of its environment. But this adaptation has consequences. The thickened, beefy myocardium struggles to relax and refill. If the heart muscle can’t expand, fluid spills backward into the lungs. Pulmonary edema results and suddenly it’s impossible to breathe.

Though it might sound strange, the physiology of diastolic heart failure helped me make sense of my own story. On the wards as a medical student, I faced a high-pressure system: the long hours, the suppression of my bodily needs, the rigid hierarchy. Attendings asked pimping questions, and I felt like I was constantly being evaluated. I witnessed patients’ suffering and saw death for the first time. I adapted as necessary, like the left ventricle does in the face of high pressure. I got strong and tough. I learned to not cry, and eventually, to not feel.

But these changes came at a cost: my heart lost its flexibility. Without the ability to relax and expand, I fell into a state of decompensated heart failure—gasping for breath, drowning from the inside. I had trouble imagining my future in medicine, or a future at all.

I needed time away from the high pressure, so I took a break from clinical rotations. Away from the hospital, I worked to release the knots in my heart with writing, time in nature, and conversations with a therapist. With time and healing, I could breathe again. I found a narrative that helped me make sense of the past and hopeful for the future. Eventually, I was ready to take on my next challenge: internship.

During my first month on the wards as an intern, I held steady against the torrent of admissions, pages, progress notes, rapid responses, and discharge paperwork. My mind darted incessantly from one urgent issue to the next.

After that month, I was given a reprieve: two weeks of primary care clinic. Weekends off. Evenings at home. Patients who were, on balance, much healthier. One of the cardiology attendings calls this primary care time our diastole.

I imagined that when my pager stopped beeping I would feel intense relief. I would seize diastole, knowing just how important it was. But tranquility eluded me. Instead, decisions I’d made weeks before barged into my consciousness without warning. A shard of memory—the look in that man’s eyes as his mother hemorrhaged before us—pierced an afternoon in the park. I was wracked with anxiety that I had missed something or harmed someone. Late one night, my husband crawled into bed after I had fallen asleep. In a panicked dream state, I asked him, “What is the PTT?” Even in my sleep, heparin drips needed titrating.

I had to remind myself of the second lesson I learned about diastole in the lecture hall years before: diastole is not a passive process. It takes work for the heart to relax. Energy must be expended. It is not enough to simply be away from the inpatient wards for two weeks. To seize diastole, I must continue doing the hard work of processing my fear, frustration, and grief. I must give myself permission to feel and let my heart expand fully. Strength must be paired with openness—and openness is not easy.

Medicine has taught me that there is wisdom in the body. If we would put our stethoscopes to our own chests, we would hear the pause of diastole. We would remember that during that pause there is work being done. A drop in pressure. Relaxation. Expansion. And then, with a full heart, a gush of life.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Colleen M. Farrell, MD, Department of Internal Medicine, Bellevue Hospital, NYU Langone Health, 462 First Ave, New York, NY 10016 (colleen.farrell@nyulangone.org).

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank Jeffrey Millstein, MD, Penn Medicine, for providing feedback on early drafts of this essay and David Hirsh, MD, Harvard Medical School, for encouraging me to embrace diastole, and for letting me publish this information. Neither was compensated for their contribution.

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    8 Comments for this article
    Herbert Rakatansky, MD | Clinical Professor of Medicine Emeritus, Brown University
    I suspect that Drs. Millstein and Hirsh, both acknowledged by the author, felt compensated for their "contributions" after reading this essay in a way no amount of material compensation could equal.
    A perfect metaphor
    Osvaldo Bustos, Clinical Anatomy Lecturer | Uniformed Services University, Bethesda, Maryland
    This is a wonderful essay by a highly intelligent, sensitive, gifted physician with unique writing skills. Her personal experience as a patient suffering from depression, and her subsequent recovery with the appropriate treatment, further sensitizes her to the needs of her patients. She has a brilliant future in medicine.
    Absolutely Beautiful
    Francisco Borja Ponce, MD, MPH | Clínica Borja
    As a physician, I fully identify with this article. We sometimes let our work 'absorb' most parts of our life and we forget to relax, knowing it is an important part of our wellbeing.

    The author cites some of her personal experiences that every medical student would have: struggles with life and death patients and learning how to respect, admire, and love a human life.

    Without doubt, it is an accurate, beautiful, and honest article.
    The Eluded Lesson...
    Chukwudi Nwabudike, MBBS, MD, Ph.D. | Hospital
    A very good essay, which posits the question, nevertheless, of why physicians so often suffer from depression and anxiety.

    We can all easily identify with her descriptions of aspects of physicians work with patients - ward rounds, paperwork, the feelings of guilt, etc.

    Might it all be "because we are human" or because we also lack the same basic knowledge that our patients are also in need of?

    It seems something is missing in medical education, which might make us better doctors and rescue so many from the fall into depression - the answer to
    the question "What am I?"

    If we cannot satisfactorily answer the question "What is a human being?" Can we say we are truly physicians?
    Only in truly understanding the answer to this question can we also find healing for ourselves.
    Mind Body Spirit
    Robert Rollings, M.D. | Memorial Health, Savannah GA
    Your insight and experience are beautifully expressed, and the heart metaphor is simply wonderful. Thank you so much for sharing what you have learned about resilience and restoration, as self compassion in health care providers is an essential lesson for all of us, as the hard work of caring can be debilitating. Gratitude in acknowledging that which has been given to you by both your teachers and your patients is a powerful message which you delivered powerfully.
    Well Written and Insightful Perspective
    Kim Skinner, PT, DPT |
    A beautifully written introspection. Thank you for sharing your struggle and your insight. You have had many wise teachers and in turn, have become one. There are others on a similar journey that will benefit from your guiding light.
    Remember Diastole Therapy
    Cathy Maffry, MBA, BSN, RN-BC | OFMQ
    Sometimes we do not realize we are learning a lesson until it resonates with us later in a "moment", like looking into an open chest at a beating heart. It is a moment of awe that the author brought to life for all of us. As she alludes, it is difficult to leave this work after our shift is over or our patient gone. We remember the looks in the faces of dying people and their families - along with the smiles and excitement when all goes well. The author realized this relatively earlier in her career as she searched for her story. I am glad she took time. I am glad she found her story and glad she shared it with us. Now, I will remember we need diastole therapy to survive and thrive.
    Systole and Diastole, Strength and Openness
    Nathan Strahl, MD, Ph.D. | Private Practice
    What a wonderful metaphor. Brings back memories of MY depression during medical school, my survival through it, the stronger it made me, and the humbling nature of depression when I learned I was not even close to being the brightest and the greatest, but pretty average in fact in a class of brilliant students who have gone on to do great things.

    Through depression, I learned my place in medicine, to not exceed the limits of my abilities, to become excellent at one domain of medicine (psychiatry) and to accept the realities of the medical world I live
    and breath in. As such I have contributed much, have not burned out after 32 years of clinical practice, and will practice medicine until I no longer can.

    Truly, it's a wonderful world.