“Ms. Mary is very excited to spend time with you,” the nurse said on my first day of hospice volunteering. From behind the nurse’s shoulder, I saw Ms. Mary rolling her power chair toward us, a toothless grin on her face. She looked up at me, her nasal cannula hissing with oxygen, and greeted me with her hoarse voice. I turned around to see that the nurse had dashed away, and left me alone to take care of Ms. Mary, who had heart failure, COPD, chronic pain and many other medical conditions.
How can doctors-in-training learn to have hard discussions with their patients? Will, a fourth-year medical student intending to become an internist, recounts two formative patient encounters he had during his third year. In the first, he learned from an attending physician and a man dying from cancer the challenges of determining when it’s time to end treatment. In the second, he realized a non-English speaking patient did not understand that she had lupus, and thus took the initiative to more effectively translate to her what the condition meant.
“He’s had enough, you don’t want to put him through any more.” Dr. Acharya’s soft jowls folded into a cool smile, as though he hadn’t thought of acids unfiltered by failing kidneys. I dug my fingernails into my palms. Glancing at the bed where my grandfather lay, I watched his bare, gray skin grip the scar that split his ribcage in two. Behind his parted eyelids were unfocused blue eyes, glazed with whitish film. He hardly knew we were there — hovering over him — deciding whether he would have a chance to live and suffer, or whether he would suffer and die.
“What is the meaning of life?”
A perfectly reasonable question, albeit a strange one considering that I was in the third grade, it was recess time, and I was having a philosophical conversation about death with a grasshopper I had just caught.
The traditional structure of medical education begins with teaching normal anatomy and physiology followed by the various pathologies and treatments. Once students reach the clinical years, we are taught to think in the form of a SOAP note. First, perform a history and physical; then, order the necessary diagnostic tests to obtain your subjective and objective information. Next, form your assessment and plan — what is the problem, and how do you fix it?
Recently, I’ve found myself dwelling on the past. Maybe it’s just a phase, but I hope it’s a sign of maturity, that I’m moving into a new stage of my life. Usually, I find myself thinking about a dreary February day I spent in Toronto. I was there for my grandfather’s funeral. I can’t recall much because I was seven. However, there are few things I remember: heavy, gray clouds smothering the sun, the gloominess and gray scale of a suburban Toronto cemetery, and the hoards of somber and unknown people, all lost to the sadness and reverence of those final moments.
To my dearest dying patient: / May I emulate half your strength, / and a portion of your wisdom, / just a part of your life’s length.
A flannel button-up and house shoes wear a man / Sitting to my left, with a right ear just trying to keep up appearances; / Just as deaf to the / echo of firework safety / Then, / As to my voice / Now.
Whenever someone hang glides, / They pick a place to land. / Somewhere soft and somewhere close, / Somewhere that they planned.
“In all seriousness,” the attending physician says, “he can wear women’s underwear to minimize the pain.” “Can he really?” “Absolutely,” replies the attending. “If we can’t prescribe any pain medication, then tighter fitting clothing can help keep things from jostling about too much.”
Empathy: it’s what supposedly drives us to become physicians, and what we’re told to demonstrate through our extracurricular activities and during our interviews. We yearn for that perfect patient interaction in which we comforted or understood in a way that changed the patient’s perspective on medical care.
A woman once told me that babies cry at the slightest breeze because that is the greatest level of discomfort that they have yet experienced in their short lives. It is a reminder that we can persevere through life’s tribulations. That we grow from adversity. That new challenges make past trials smaller. That this, too, shall pass.