Sunday, July 19, 2009

Patience with Patients

From the beginning of medical school, we have been taught to extend the same attention, compassion, and skill to each patient we see. A noble expectation, no doubt. So what do you do when you have a patient that is so dreadful, so condescending, and so entitled, that every interaction feels like verbal assault? Let me tell you about S.M., a 61 year old female with newly diagnosed Endometrial Cancer. Her cancer was caught so early, that we were able to cure her with the most benign of GYN Oncology surgeries – a transvaginal hysterectomy. Now this is a surgery that is so minimally invasive, women usually head home the very next day. Wonderful news, right?

Not for this particular patient. S.M., a heavyset Caucasian woman with a wild coif of graying hair, was convinced she was on the verge of death from the moment she arrived onto our hospital floor. How dare we ask her to roll on her side so we could listen to her lungs! She was suffering! And it didn’t matter that she had doctors to guide her medical decision-making – she was going to tell you what kind of medications she wanted. “I only want Demerol”, she ordered, “And Tylenol too! But not the generic, it has to be brand name!” And when she needed her IV replaced, we were ordered to bring up the Anesthesiologist from the OR to do it. No mere nurse could come near her. It had to be a licensed physician who placed her IV. Within her first 24 hours in the Oncology unit, after having to wait about 5 minutes for a nurse to fulfill one of her many demands, she picked up the phone and called the hospital C.E.O. to complain. Everything was wrong with her care. The food was bad. It made her nauseous. She didn’t get the right pain medication. The care was sub-par. How could we treat a little old lady so egregiously?

S.M. complained about anything and everything under the sun. So much so that after a while, I found it hard not to tune her out. Especially when I had a floor full of truly sick or dying cancer patients. Whereas normally I will pop into my patients’ rooms to chit chat throughout the day, I found myself avoiding hers like the plague.

By the afternoon of her second hospital day, she complained of worsening belly pain. And just like each exam before, she moaned and groaned when I touched her belly. The nurses and I rolled our eyes. Dutifully, I reviewed her vitals. Wait a minute. Her heart rate was up. I looked back at her labs over the last two days. Her hemoglobin had dropped 5 points since before her operation. A tell tale sign that she was losing blood somewhere. A CT scan later that night confirmed this. There was a large hematoma (blood collection) in her pelvic cavity where her uterus used to be. And it was making her sick.

The evening was spent stabilizing the patient. We transfused her. We did serial checks of her blood counts. We gave her pain medication. We did all the things we would have done for any other patient in the same condition. And in the end, S.M. was fine.

That night, I couldn’t stop thinking about this patient. She had been 36 hours out from her surgery before I noticed her drop in hemoglobin. Why? Was it just carelessness? Would I have missed that in one of my more beloved patients? Had I let her attitude affect the medical care I was providing? I knew the answer to these questions. I had let myself miss something in my patient, simply because I didn’t like her. And I was ashamed.

S.M. was discharged home on Friday. And thankfully I can say I strived to be a different kind of doctor after this incident. I know that I am limited by being human and I would be lying if I said I ever grew fond of this patient. But I learned a valuable lesson about keeping the practice of medicine separate from the emotions of human nature.

Sunday, July 12, 2009


Being a resident makes you cranky. There are the 14 hour days that begin before sunrise. There is the constant reminder that you are on the bottom of the hospital totem pole. There are the attending physicians that only acknowledge your existence when you screw up – but never make the effort to ask your name. There is the incessant feeling that no matter what, you just don’t know enough… that self-deprecation that comes along with having to say “I don’t know” another time. There is the anxiety that comes with trying to manage a floor full of patients and the incredibly long to-do list that comes with it. And inevitably forgetting something important off the list. Intern year is just a humbling and ego-swallowing experience.


Being a resident also makes you thankful. In the past three weeks, I have met a 35 year old female with cervical cancer so widespread, she had to have her uterus, ovaries, vagina, bladder, and rectum removed. I’ve cared for a 55 year old woman with ovarian cancer who went to the operating room only to have the surgeons discover that her disease was so extensive, they could do nothing but close her back up. I’ve cared for a 19 year old who was told in her home country that her ovarian mass was benign – only to present to us with a 20cm malignant germ cell tumor that was eating away her abdominal wall. I wiped the tears off the face of a 56 year old woman with end stage liver disease, chronic lung disease, and degenerative joint disease – who stayed with us for 15 days without a single visitor, get well card, or flower.

All of these women had problems much bigger than my own. Yet, each of these women, in their own ways, had hope. I watched them take joy in simple victories. Being able to eat and hold down solid food. Visits from loved ones. Freshly washed hair. Being able to get out of bed and walk to the hall. What I didn’t see, not once, was bitterness. Sure, there were sad moments, anxious moments. But there was never that “why me?” attitude I expected to find on the Oncology service. Instead I found women who face their realities with such grace, it leaves me humbled. It fills me with a resolve to quit my complaining and be thankful for the many, many blessings I have in my life.

Monday, July 6, 2009

My First LEEP

The GYN Oncology rotation is one of the most dreaded rotations of intern year. You are relegated to spending 12-14 hour days on the floor managing moderately to very sick cancer patients. As the go-to person on the floor, all the abnormal vitals, labs, imaging, nursing concerns and patient issues come your way. Add the litany of paperwork each patient requires and this makes for incredibly chaotic days. What makes this rotation so hard is that, unlike other surgery rotations, we don’t get to break up our day with the fun of going to the operating room. We are 99.9% handcuffed to the Oncology unit.

So imagine my joy when my senior resident asked me on Friday to head down to the OR to do a LEEP procedure*. It was the end of a long week of scut work** up to my eyeballs. I could think of nothing better in that moment than the reprieve of going to the operating room and working with my hands to do something definitively to help a patient.

It had been more than 6 months since I had seen the inside of an operating room but I wasn’t too nervous. I mean, the attending doctor knew I was an intern. He would show me what to do, right? I head to the OR and meet the attending doctor and the fellow. We scrub, get into our sterile gowns, don our sterile gloves. After the patient is getting prepped and draped, the attending hands me the loop. “Here you go.” Then he sits back and waits. Hmmm. Here I am, standing between the patient’s legs, with the loop in my hand, not quite sure what to do next. How deep do I go? Where does my excision start? Where does it end? I mean, I am all about being proactive, but this is a woman’s cervix I’m working on. Not only do I not want to be the one to mess up her girly bits, but it’s now or never that I learn how to do this right. “Um, Dr. T? Think we can do some practice runs? So I can get the motion down right?” Fast forward to 7 practice runs later, yes seven, and I am ready for the real thing. My hand is no longer shaking from nervousness. I hold the loop in my hand, push down on the edge of the cervix, push the “cut” button on the bovie, guide the instrument up until the perfectly round surface of the cervix is excised. “Look at that. That is great cut!” says the attending and I beam. It’s silly what a sucker medical trainees are for positive reinforcement.

By the time we get the patient cleaned up and out of the OR, it has been a mere half hour that I have been gone. But I was re-invigorated. Re-inspired. My quick surgical jaunt reminded me of all the operating that awaits me over the next four years…

* A procedure in which the surgeon shaves off precancerous lesions from the cervix using an electrically-powered loop

**Scut work: the glorified secretarial, errand-running, busy work that makes up the day to day life of an Onc intern (as described above)