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The Moments That Define The Type Of Physician We Become

Discussion in 'General Discussion' started by Ghada Ali youssef, Jan 23, 2017.

  1. Ghada Ali youssef

    Ghada Ali youssef Golden Member

    Dec 29, 2016
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    Practicing medicine in:

    “Son, just let me die.”

    Those were the first words Mr. O. told me as I introduced myself. As a 75-year-old stage IV lung cancer patient with brain metastasis, Mr. O knew his time on this planet was limited — the last place he wanted to be was in a hospital with a newly minted clinical student. Mr. O’s neighbor had found him unconscious on his porch earlier this morning, and much to his dismay, called the ambulance to take him to the hospital. Upon further testing, it was discovered that Mr. O’s electrolytes were dangerously altered, and he would have to be admitted. Whether he liked it or not, Mr. O was here to stay.

    I almost felt guilty examining him as a novice in the field. This man had gone through dozens of chemotherapy treatments with a countless number of specialists, all of which had failed. As he removed his shirt for the cardiac and respiratory exam, his joints and muscles began to ache, and his chronic headache worsened with his slow movements. Somehow, writing 7/10 for pain on my measly scut sheet just did not do justice. His skin, withered from the years of battle against cancer, felt leathery and fragile, yet carried a small semblance of the warmth that once ran through him. He was a dying man on his last leg, and I was in charge of taking care of him.

    While we corrected for his metabolic illnesses, more senior members of the caregiving team tried to approach Mr. O with end of life discussions to no avail. Mr. O was fed up with the healthcare system and wanted to just leave. As a last-ditch effort, my attending physician told me to give it a shot. As I approached his bed, Mr. O turned off the TV and looked directly into my eyes with a blank stare. Without saying a word, I removed my white coat and put it on the chair next to me and sat down.

    “I know why you’re here,” he screamed. “I don’t want none of you people taking care of me. I know I am going to die, and I don’t need no hospice lunatics running around trying to make me feel better. I’m going to die — just let me go damn it.”

    At this moment, I reached over and rested my hand over his, unsure of what to say. To be quite honest, I was not even sure why I did that. Shocked by his outburst, I simply had nothing else to offer the man except a gesture of humanism. Almost suddenly, the fiery, disgruntled expression on his face quickly reverted to tears as he broke down crying on my shoulder. I knew this moment would be the defining moment in our relationship, and the numbness I felt quickly evaporated as I saw him engage in his long overdue catharsis.

    “Sir, I began, I am not a doctor, and I am not here to tell you what to do. But I do want to know more about your life and how I can help.”

    What followed was a 3-hour history of Mr. O’s life. Mr. O welcomed me into his deepest and darkest of secrets, sharing with me things he had never told anyone about his time in the armed forces and his personal life. From losing his money in a messy divorce to getting thrown out of his family for being ill, Mr. O had a general distrust in people.

    The cancer diagnosis was simply the last straw, and he isolated himself completely from friends and family and counted down the final days of his life in solitude. From the conversation, it was apparent that Mr. O did not want palliative care to get involved because he would lose the one thing he still did possess in his life — control over his body. After talking a bit more, I convinced Mr. O to at least stay in the hospital while we managed his underlying metabolic illness and allowed us to control his pain with medications. He agreed. As I got up to leave, he handed me a few envelopes with stamps and asked me for one last favor:

    “I know I don’t have a long time left in this world, but I don’t want to owe anyone nothin’. These are some bills I have to pay, and even if I die, I want to make sure people get their money. I don’t trust nobody in my life right now except you. Mail these out for me Rohan.”

    I took the envelopes as if they were gold, because I knew for Mr. O they were. Just by listening to Mr. O talk about his hardships, I was able to better understand his decision-making and gain his trust more than anyone in the world for that very second. What started off as a shaky medical student conducting a physical exam for a “disgruntled” patient became a connection between a patient and a provider, and more importantly, a humanistic bond between two souls that permeated the constraints placed on today’s physician-patient relationship.

    Recently, many have written on the role of physicians in terminally ill patients. The reality is that we spend thousands of hours learning how to keep our patients alive, yet fail them when we know they will die. We become numb, able to sympathize by our inner virtues as humans but unable to help as advocates for our patients. The silos between patient and physician become pronounced.

    We revert to being objective, pushing our patients to say the magic words like “hospice” and “palliative care” so we can punt them off to other health professionals who have the time and resources to care for them. While the way we deal with terminally ill patients may not entirely be our fault, as we are constrained and even incentivized financially to act the way we do, it still does not make it the right thing to do.

    As I was mailing Mr. O’s envelopes the next morning, I could not help but think what would have happened had I not taken the time to learn about his life. To be honest, I don’t think much would have changed. From an outcomes perspective, Mr. O will still count as a death for the caregivers’ records despite their best intent. From a health economics perspective, the patient took up a bed due to poor compliance with his post-chemotherapy diet and his stay was prolonged by a medical student who convinced him to hang around, further depleting the already resource- constrained hospital.

    But yet, while it may or may not be true, I still felt I made a difference in the care of Mr. O that will not show up on the hospital chargemaster. As medical students, we have the unique opportunity to provide the intangibles in caring for our patients by connecting with them as humans, as we are not yet fully burdened with the pressures associated with delivering health care in today’s difficult system. The moments where we go beyond the constraints of the provider-patient relationship and appeal to the humanism of our patients will ultimately define the type of physician we eventually become.



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