Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, October 11, 2009
    Saying Goodbye

    It's the hardest thing in the world.

    The process of dying being what it is, it's rare that you get a chance to sit and talk with someone knowing that this will be the last time. The Last Time. This is because dying patients are usually confused, narcotized or comatose and aren't aware enough to carry on a conversation. They don't teach this stuff in med school - well, that's not a fair statement. These days medical schools and residency programs do teach end of life care, or at least try to. But there is no way to explain what's going to happen when you go in the room to talk to a patient, someone you know, knowing that you will never meet again in this world. It's scary. It's puzzling (is it okay if I weep? Should I be professional?) and it can be incredibly rewarding. These are the conversations I remember, the moments that keep me practicing medicine.

    I had one such conversation many years ago with the mother of a patient who had AIDS and was dying of progressive multifocal leukoencephalopathy (a particularly nasty and slow way to die). He was living in a long-term care facility where I was on staff and she had come to be with him; we worked together for months. Although the other doctors on staff were involved with his case I know that she felt the most comfortable with me. I had scheduled a vacation abroad with my mother months before, and as the weeks passed and the patient slipped into a near-comatose state it became clear to me that he was going to die while I was out of town. His mother had asked to meet with me the week before I left, and during our conference I said: "I need to tell you that I'm going out of town next week. I would cancel this if I could, but I made these plans months ago and I can't. So I wanted to tell you..." I paused... "that I won't be here."

    She understood what I was saying and said thank you, and hugged me, and we cried. I told her how much I'd liked taking care of her son - and I had; he was a wonderful guy. When I returned from vacation the patient had in fact died and I never saw her again.

    This weekend I met with a patient in her nineties who was diagnosed with cancer months ago. We gave her treatment for her symptoms and she improved for a while, but now she's been failing for a month or so. She bounced in and out of the hospital a few times and the hospitalist raised the issue of hospice care; she and her family agreed to stop treatment. She was transferred to a nursing home pending hospice arrangements and I went to see her there.

    She took my hand and we sat on the side of her bed. "I'm so glad to see you!" she beamed. It was stunning to see the good spirits she was in. Denial was not an issue: she was completely aware of her prognosis and accepted the fact that she would not live much longer. Every time she comes to see me in the office she tells me that she loves me and she said it again today: "I love you, Doctor. You're the best doctor I ever had. My family's so glad you've been taking care of me. I've known you for what, now, fifteen years?"

    "Close," I confirmed.

    "Well the first time I saw you in the waiting room, I said to myself: 'That's my doctor.' And I was right."

    We were sitting on one of three beds in a three-person room, curtained off from the other occupants. I stared out the window at the alley for a moment and thought what a strange place it was to have such a conversation bordering on eternity, then thought: well, what would be a better place? There is no appropriate place.

    "Do you feel okay?" I asked her. "Are you in pain?"

    "Not right now, but doctor, I been in some terrible pain. Some nights I used to ask the Lord to take me now. I don't want no more pain."

    I reassured her and told her the hospice staff would set her up with medication: "All you have to do is ask for it." She had asked to go home rather than staying in the nursing home and I promised her I would make those arrangements. Then I took a deep breath and, fighting a lump in my throat, told her how much I had enjoyed being her doctor.

    "I love you," she repeated.

    I hugged her. "I love you too."

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    Thursday, October 08, 2009
    Sentence You Don't Want to Read

    When the radiologist who did the biopsy forwards you the path report you don't want his email to read simply "Hi, she needs an oncologist."

    The sentence you don't want to say to the patient: "The biopsy did show cancer."

    It's especially hard to get those words out when you hear a happy infant burbling in the background.


    Wednesday, October 07, 2009
    Evil Doctor Conversations

    Tonight in my usual evening telephone chat with V. I began reading to her from the Phobia List, which I had just discovered online. As with so much medical esoterica, one could probably spend hours just reading through this list. The sheer entertainment value of phobias is incredible.

    "Lachanophobia," I read aloud."Fear of vegetables. That's probaby why I don't like going to nursing homes."

    We both dissolved into laughter.

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