I have always been taught to treat the patient and not the disease. As a first-year medical student, I am not sure I know how to treat either yet, but I know that putting a face to a disease is crucial to my training as a physician. I have always been intrigued by human stories in medicine that involve difficult and often stressful conversations because they have a tendency to become flashbulb memories that impact patients’ lives forever. Typically, I associate these conversations with breaking news of a patient’s passing to their family members after a code, particularly in fields of life and death like emergency medicine. My inexperienced, first-year self never expected to hear a deeply devastating declaration of difficult news in the nephrology clinic.
Mrs. A’s chart had been showing glomerular filtration rates (GFRs) in the teens and twenties for the last few months, so the trend towards dialysis seemed a sad yet logical progression. To Mrs. A, the hemodialysis news uttered by her physician might as well have been pronounced in a foreign language. Hearing the word “dialysis” was not within her plans for the day, the week or her lifetime. To me, dialysis represented a positive and necessary medical intervention to get rid of the harmful substances accumulating inside of her. It signified hope; it also just seemed to be a common medical procedure that I hadn’t previously given much thought to in terms of its burden on day-to-day life. After all, two in every thousand Americans require dialysis every year.
But Mrs. A sat there, shocked. She was speechless for ten minutes. The physician gave her the space and time she needed to process this news. During every minute of silence, I wanted to scream reassuringly, “It’s okay, you’ll be okay! It’s just dialysis, no one is dying! You’re not dying! You will still be able to live and continue most of your daily activities!” Right? Well, good thing my role that day was to be a mere fly on the wall and that I had no assignment to utter a word.
Just dialysis. “Just dialysis” was actually quite an abysmal fate of pain, fatigue and inconvenience. Yes, it is a lifesaving treatment that is preferable to a slow death from kidney failure for most people. To Mrs. A in the short term, however, dialysis meant a painful, initial surgery for the graft, being poked every other day and then devoting a minimum of twelve hours every week, four at a time, to sitting in an uncomfortable chair. This is beside the hazy sea of complications and infections she had vaguely heard about before and probably dismissed as something she would never experience. Before all of this, the first thing she asked was, “Who’s even gonna take me to all these dialysis appointments?” She did not want to be a burden on her daughter amidst recent family conflicts.
This definitely contextualized her reaction and added an extra layer of complexity to almost every disease I am learning about in medical school. Prior to this encounter, my naivete had led me to believe that difficult medical conversations only happened in the setting of a cancer diagnosis or after an unsuccessful code. That list has expanded quite a bit. I am realizing how even relatively common and non-fatal diseases like rheumatoid arthritis and Crohn’s disease, which have established treatments, can be crushing news for patients, especially if they interfere with their personal lives. As I thought about my clinical years ahead, I realized the irrevocable presence of breaking difficult news in every specialty; they all just have a slightly different flavor.
Until that day in the clinic, I almost felt like I was learning diseases nonchalantly, flipping through flashcards and diagnosing biopsies for patients in my practice questions. Little did I know that selecting “B) focal segmental glomerulosclerosis” sentenced my fictional patient to a life of immunosuppression, a second home in the hospital and an unyielding obsession with the amount of protein in her urine. Suddenly, the thought of diagnosing these illnesses became almost trivial next to the heavy burden of communicating them to patients. People — physicians and patients alike — run away from talking about terminal illness and death. Yet, unlike a large portion of the general population, physicians will be haunted by these conversations over and over. I think it is a rare privilege to be there for other people in their most difficult moments and to deliver the news in the best possible way. I want to be skilled at this someday.
For the first few years of my journey, I will likely have patients who will suffer my inexperienced and nervously articulated string of words as I try to convey a difficult message. As a first-year, the small task I have assigned for myself is to learn overarching strategies by closely observing different physicians’ styles of communicating difficult news and noticing patients’ reactions. I will adhere to the SPIKES framework for breaking bad news as a novice in this art until I develop my own style. Planning can only go so far, however. These conversations are, by nature, so unique to the giver, receiver and circumstance. Sometimes even a compassionate acknowledgement to the patient that a conversation will be difficult can provide trust. Currently, I speak from little experience. Years down the line, regardless of what niche of medicine I occupy, I hope to become competent at speaking with patients, choosing mannerisms and words that flow like rivers, as I engage with the difficulty of the conversation at hand.
Image Credit: “nerd alert” (CC BY 2.0) by drcw
Contributing Writer
Emory University School of Medicine
Leenah Abojaib is a medical student at Emory University School of Medicine in Atlanta, Georgia, class of 2027. In 2022, she graduated from Rice University in Houston, Texas with a Bachelors of Arts in Biosciences and Spanish Studies. In her free time, she enjoys weight-lifting, long-distance running, crocheting/knitting and connecting with friends and family. She is interested in pursuing a career in critical care medicine.