Monday, April 4, 2011

The saddest rounds

Today's rounds were the saddest I've ever been a part of.

Mrs. R has tracheal cancer. It is metastatic and terminal. She's received treatment already- a trach tube, chemotherapy- and there is no more that we can offer her. She can't speak, so she writes, whenever there is something more complicated than can be communicated with a nod or a gesture. Her level of education is low, and she writes in all capital letters, and mis-spells words- which somehow makes thing even more poignant. Something about those few words in large capital letters, a few letters swapped here and there, seems very urgent, very desperate. We ask her how she's doing, and she shakes her head.
"What is it, Mrs. R? What's wrong?"
I push over the pen and paper, and lower the table so she can write to us.
"You tried to call your nurse? You needed something?"
We apologize, we try to reassure Mrs. R that we will do everything we can to make sure she's comfortable. She had had trouble breathing last night, and nursing reports this morning were of liquid tube feedings oozing out around her trach site-- not a good sign, and not something you'd want to happen to a woman receiving "comfort care". Suffocating on your food is far from comfortable. In fact, we discuss in the hall, what may be best for Mrs. R's comfort right now is to stop the tube feeds altogether. Which is a dismal thought, but indeed perhaps better than a death due to choking on liquid feeding formula.

From there we go upstairs to visit Mr. M. Mr. M has bladder cancer that obstructs his urinary tract, and for which the only treatment is surgery. Which he cannot have, because his heart is not strong enough to survive it. He has been on our service for weeks, first while we negotiated with the surgery team whether there wasn't some way to get Mr. M the only surgery that would save his life- and then, when that failed, to arrange for hospice placement. Today we have good news: there is a bed for him at a small facility run by nuns, that the social worker assures us is lovely.

When we walk in the room, a chaplain is sitting on the edge of Mr. M's bed, and I can tell by his body language that they have gotten to know each other well over the last few weeks. We tell Mr. M the good news. It's hard to hear his response because he speaks softly and has no teeth, so we are all leaning forward. The resident is about to answer the question he thinks was asked, which is, "How long do I have to live?" when the chaplain corrects him.

"No, he said, 'how long will the rehabilitation be?'"

We look at each other, a little panicked. The resident wants to be straightforward, to convey to the patient what everyone else in the room understands and accepts, because it is not our life's end that we are discussing, and it is much easier to avoid denial when it is someone else's death. But he also does not want to be blunt and heartless; he wants to maintain good rapport with his patient. And so he dances around his words a little. Not enough to seem dishonest; but enough to seem a little uncomfortable, which to me is reassuring: seamlessness when discussing the end of a patient's life betrays overconfidence, or something worse.

"Mr. M, what we want you to understand is that this cancer that you have, we think it's the thing that... that will ultimately be the cause of your death."

More questions from Mr. M., increasingly desperate: Why can't I have the operation? Why didn't they find my cancer sooner? Why can't you just take the tubes out and let me be?

"Mr. M," the resident continues, still trying to find the right mix of straightforward and comforting, "you need to understand that if we take those tubes out, you'll... you'll pass away in the next few days."

Mr. M is struck silent, finally tells us that he wants to be alone, and we walk out. We talk about the difficulty in accepting an approach that does not have cure as its objective, and the necessity of explaining the same thing several times over, of not assuming the patient is at the same stage of acceptance that you are. We write our orders and move on to the next patient, because there's no time in the middle of rounds to linger on sadness.

Wednesday, December 1, 2010

On case presentations

The attending's advice:

"Tell it to me like you're trying to sell me a car.

...But, you know, tell the truth too."

Wednesday, July 7, 2010

On surgeons and being nice

"Nice doctors kill people," the surgeon told me, apropos of a question I'd directed elsewhere.

He explained: when doctors spare their patients pain by skipping tests or aspects of the physical exam that are uncomfortable, they end up harming the very people they'd set out to help. And he has a point: If you don't palpate an abdomen because your patient has belly pain, you could miss a surgical abdomen, and your patient could die (this resembles something that happened recently on the pedi ward, although I don't think that death was preventable; but that was the version of events that happened in the responsible resident's head).

But I wondered: can't you be nice and competent at the same time?

Sometimes I think, yes, of course, the best doctors are those who are nice and who listen and explain things clearly and give an encouraging smile before leaving the room. With something as complex as health, in which the power of the mind is startling and patients' outcomes have more than a little to do with their attitudes, being nice may actually heal.

But, I do understand his point. And the more I work with surgeons, the more I get it: being nice doesn't take you very far if it means you skip more tests or spend less time learning about more effective treatments and procedures or pay less attention to the detailed nature of your daily tasks. There's only so much time for learning and teaching in one day. If you're the average patient, you don't want a doctor who will scream at you, but you really don't want a doctor who doesn't know enough to perform procedures well.

So, while you can always be nice, and there's no justification for flat-out aggression, there probably is some trade-off between niceness and competence.

And it might just be that I've spent the last two weeks walking amongst them, but I'm feeling more like an asshole surgeon every day. What do I need to know before walking into the OR-- the name of the patient, or the name of the procedure? Well, it would be nice to know the patient's name, but as a surgical student, what's more important is the procedure. And I kinda like working with assholes: at least you know where you stand, and you know you can push back and have that be perceived as strong rather than pushy.

This probably has a lot to do with my background of being a nice person with a focus on the more behavioro-psycho-social aspects of medicine. Coming from a place in which surgeon is a dirty word (a figurative place, that is; wouldn't want to implicate of my previous places of learning), I can only be pleasantly surprised by the surgeon's perspective as I learn to adopt it. Competence, after all, is what any patient wants more than anything else that his or her physician might offer.

So, another realization in the road to medical knowledge, and another goal: to find the right balance between competent and nice.

Monday, February 8, 2010

Eulogy for EN

My assignment was to write a reflection on the experience of having, or not having, a longitudinal geriatric patient. I wrote this. It's probably not what my teacher wants.

My patient, EN, was overall a very healthy 81 year-old at our first meeting in April of 2008. She had also recently been diagnosed with SCLC in January of that year, as an incidental finding on CXR taken when she was in the ER for a pulmonary embolism. When I first spoke to her, she seemed to understand what that diagnosis implied, but was resigned to everything her future had in store – especially in light of having been a “heavy smoker” in her youth and middle age. However, she was quite upbeat throughout the interview, joking about family members and friends in the residence in which she and my preceptor lived. I was also able to create a good rapport with her because she was friendly and welcoming, and because we shared a love of travel – hers evident in the world photographs on the walls of her apartment. For a few moments after the H&P was over, we had a chance to talk about Africa, where I had spent two years as a Peace Corps volunteer and a few months as a researcher. She had been to South Africa recently, saying that after Apartheid ended, she “just had to go”. And that people in her generation never thought they would “see a free South Africa”.

EN clearly valued family and spoke fondly of her daughters, but was too independent to follow them to the cities in which they lived. Instead, she spoke of traveling with them. At our third visit, EN told me she and her three children had traveled over the Christmas holiday to the home in which she grew up in Connecticut. It was something she had long hoped to do; I got the sense that having accomplished that visit, EN felt that much closer to a peaceful death.

My visits with EN were not free of awkwardness. Knowing something about the prognosis for SCLC, I never knew exactly how to ask about EN’s plans for how she would maintain her health, which was necessarily unsteady. I said goodbye not knowing if I would be able to greet her again. On our third visit, EN was hooked up to an oxygen tank, which was out of sight in her room as we talked in the living room. The cannula snaked around the coffee table and back through the doorway. I tried to appreciate the freedom that the device allowed, rather than concentrate on the loss of function that it signified.

My preceptor wrote me that EN died a few months after it happened. He told me he’d spoken at her memorial service, and told everyone that she had insisted on following up with the medical students whom she’d begun to see despite its increasing difficulty. I appreciated this, and, strangely, didn’t feel sadness, exactly. I felt the loss of a strong and unique person, and I imagined the photographs being taken down from her apartment by her children and the oxygen tank returned to the hospital or medical supply unit. But it occurred to me that sadness is a syrupy emotion, provoked by displays of pathos. EN, never wishing to be anyone’s victim, never projected that. She resisted portraying herself as weak and incapable, choosing instead to relate to others on the basis of shared interests and ideas. She will be missed, but never whimpered over.

Wednesday, December 9, 2009

Sympathy for the factitious patient

I went to the student health center last week for my annual exam. I showed up a few minutes late, and so rushed to fill out the paperwork while in the waiting room, expecting to be frowned at and told I should have arrived on time.

Instead, I was met with smiling faces, as the nurse ushered me in to an examining room, allowing me to drop my bag and jacket, before guiding me to a seat in the hall from where to take my blood pressure and temperature.

"Well, isn't that nice," I thought. "Like having a personal aide who tells you where to be and administers personalized services." Right then, I understood -- well, to some extent -- Munchausen Syndrome patients.

Patients with this disorder manufacture symptoms in themselves, usually through ingestion of toxic substances or inappropriate medications, in order to receive attention from healthcare professionals. While I don't really think I'd ever be capable of that -- Munchausen patients generally have personality disorders or history of abuse, so there's more going on than just a desire for some attention.

But in a very impersonal world, in which you can get through a day, or maybe a week, or maybe more, without any real meaningful human contact, especially if you're perhaps a little introverted or perhaps have a small-feeling job in a cubicle, this kind of attention feels really nice. It's attention not to how much work your team has produced or when you have entered and exited the building, but to you and your well-being. For a few moments, the efforts and thoughts of several professionals are focused just on you, and nowhere else. I don't have a small-feeling cubicle job, and am a student in what is maybe the most attention-intensive medical program in the country. But I can most definitely understand the desire to prolong those moments in the clinic.

Tuesday, November 17, 2009

It comes from all sides

Me: "Do you have any advice for me as a medical student?"

Patient: "Study incessantly."