Now with More Patient Wisdom in every box!

Another Wednesday, another happy Oncological encounter, Now with more patient wisdom:

For better or for worse, patients in the VA hospital are of a fairly unique breed. They don't resent medical students, they don't say "No Residents! I only want to be treated by attending physicians." They sit there and patiently tolerate our awkwardly in-depth histories and our bumbling attempts at physical examination. Not only are they amazing folks, they also feel the need to leave us with deep, meaning full comments on the experience of being a patient.

Enter Patient Biker Dude. CC: Itchiness, headaches, dizziness. Preceptor knows the patient and tells us to skip the history.

"Bostonian, do the physical. Other guy, do the physical afterwards"
Bostonian: "His spleen seems to be enlarged"
OncoDoc: "We'll discuss that after Other guy has his turn"

Biker Dude's spleen is literally the size of a regulation NBA basketball!!! He actually has a long-standing polycythemia secondary to some kind of neoplasm, platelet count is about half a million, he's been having all kinds of CNS disturbances lately so he came in to get checked out. So we're shooting the breeze while he has his therapeutic phlebotomy (read: BLOOD LETTING!!! Literally dumping 450 ml of this guy's blood into a giant glass bottle. I thought they stopped doing that in 1800's). Biker dude is telling us how we have to be able to read patients and interact with them in kind. He tells us that he will only come to see my preceptor, 45 miles away from his home, because the oncologist closer VA tried to remove several hundred ml of blood therapeutically with a 10 ml syringe (Sticking the patient multiple times until the patient said that he'd had enough), gave him the "run around" with scheduling appointments and spoke down to the patient on numerous occasions. The way Biker Dude sees it, without veterans there would be no VA hospital and this doc wouldn't have a job, so why is he being treated like crap? Towards the end of the chat this gem comes out:

Biker Dude: "...and I don't like to be treated like a N*****!!!"
Bostonian and other medical student: Being the polite, east-coaster medical student gentlemen that we are, we pick our jaws up off of the floor, smile and nod and wish him good luck. Preceptor doesn't even bat an eye while typing up the chart.
Biker Dude: Walking out the door, placing his western-style hat on, raises his hand without turning around "Best of luck to you fellas, God Bless!"
OncoDoc: (Thick Indian Accent) "You see, this patient does not like being talked down to. Always treat your patients with respect!"

Nothing like a good racial slur followed by a hearty blessing to warm your heart...

Then there was the patient with a history of alcohol abuse who couldn't remember how he got HepC and was surprised when told he had a mass in his liver. I'm guessing that it wasnt the only memory missing from that time in his life. He tells us that he read some patient education material saying that most people with HepC don't even know that they have it.

Normally, I have a little bit of trouble finding the liver edge, but this guy had a nice firm cirrhotic liver sticking down 2 cm below the ribcage, he must have been a hard drinker back in the day. Favorite quote from him:

"These things just keep sneaking up on me..."

He must have missed the part of pamphlet where they said "you've got a significantly increased chance of hepatoma with HepC, which is only exacerbated with heavy alcohol abuse." Lucky guy caught it pretty early. His last sonogram was negative a few months ago, but this one caught it.

Then there was a sweet old man getting his chemo for a fairly involved pancreatic cancer, optimistic as all get out that he's going to beat this thing. He was chomping at the bit to look at the graph of his tumor marker levels (CA19-9 I believe) which wasn't scheduled until 2 month from now. Damn near broke my heart. He kept on telling us that we were very brave for going into the medical field, that it took a special person to be able to look into the eyes of a patient and honestly tell them exactly what is going on. It felt like trying to hold a straight face after being kicked in the gut.

His infusion pump signaled that his chemo treatment had finished, he smacked his lips and said "Good to the last drop." His optimism was very heart warming, yet it was still a sad interaction knowing his prognosis.

Every day that I go through this routine, I wonder when my emotions are going to stop being dragged into the process. I vacillate between abject horror at how poorly these patients are being treated (both medically and socially) by so many of their private physicians, laughter with the patients at the funny moments, sad when my patients are crying, solemn as I recuperate after a mere 3 hours of precepting. I haven't really had a problem putting on the professional mask when the white coat goes on in front of the patient, it's when the white coat comes off and I have to go back to the library that I start rehashing and actually dealing with my feelings. I don' think I could do this for the rest of my career without developing a serious substance abuse problem.

I'm finding that the work of an oncologist is a labor of frustration, of integrating all of the loose pieces of the patient's fragmented medical care, of attending to the emotional, spiritual and medical needs of the patient, and of patiently waiting for the disease process to respond. I'm not a patient enough person to deal with that kind of waiting for results and that level of craptastic discontinuity of patient care.

1 comment:

The Lone Coyote said...

Wow, what a rough day. Mine was not much better. The attending had to try to explain a new cancer diagnosis in a toddler to a mother who barely spoke English (and refused to have a translator come) and had very limited education. At least with Peds Heme Onc there is better continuity of care since most of the kids are seen at routine visits and it is caught early. And there are more cures than with adults. Oncology is rough. They say the emotional part "gets better with time," but I could never do it.