Posts tagged centerpiece

Our Deepest Condolences

One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner. 

By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief. 

I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis. 

"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.

By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.

Or so we thought.

It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”

Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward. 

We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.  

Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.

But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many. 

These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.

"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."


The echoes of my steps resonated within the expanse of the hospital garage. As I made my way to the end of the aisle to my stall, a couple caught my eye.

A tall man, his hair only beginning to turn grey, faced a woman of similar age, dressed in a beautiful white summer dress. Next to them a car, its trunk agape, half packed with a box of personal belongings and a white plastic bag full of clothes sat waiting. Still, they stood, pausing, ruminating.

They stared longingly into each other’s eyes, a deep seeded pain overwhelming them as tears trickled down their delicate features. A warm embrace as they held each other tightly and wept.

I wondered what terrible tragedy had befell them. Did a loved one’s health take a turn for the worst? Did a loved one just pass away? Did their mother, father, daughter, or son, just perish from this earth? I could not help but wonder.

But it was not my place to ask.

I watched helplessly as they buried their heads in each other’s shoulders and comforted one other.

I continued walking.

A Word with Fourth Year

For the students who have survived their foray into clerkship, congratulations for making it this far. You are only a year away from finishing your medical schooling. Here are some words of wisdom as you draw closer to the end as an undifferentiated stem cell and down the new path as a resident.

  1. Stay healthy. Surely by now you will have managed to find a daily routine that allows you to work hard but also enjoy time away from medicine. However, third year is also a time when one can pick up bad habits. Plan ahead, and take this opportunity before residency begins to really iron out the sore spots in your life.
  2. Explore your interests. Fourth year is really about finding your career interest and honing in on that goal. This is where you can start to expand on your career choice and take electives that give you inspiration, skills, or both. 
  3. Prepare early. Residency applications are meaty things and the deadlines come sooner than you think. Research the programs early, write cover letters early, and think about planning your electives early and in line with the residency matching schedule. 
  4. Have a backer. In third year, I mentioned that making a good impression was important. That trend continues on in the fourth year electives as well. The good will and social capital you accumulate with your attendings are what will fuel good reference letters. For a competitive program, these letters, particularly if they are from respected members of the faculty, can make or break an application.
  5. Study and keep studying. Elective choices can change the entire atmosphere of fourth year. While flexibility is welcome, it is never a license to take the easy road. Still take some time to read and study. At the end of it all, regardless of what program you match to, the licensing exam tests you on all facets of medicine.
  6. Big brother, big sister. When you began third year, you were the fresh face on the ward. There was some stuff you knew back then but a tonne more you had no idea about. Remember how stressful and terrifying it was once.
    Now that you are a fourth year, do not forget how that felt. When you meet a third year student on your team, help them along, guide them, impart your experience to them. Remember the kindness of your senior students and residents and pay it forward.
  7. Have fun. Medical school goes by very quickly. As a student, there is a flexibility and freedom that you will simply never come across again. Enjoy your rotations with your peers. Make the most of your electives. Take the residency interview tour as a nation-trotting adventure. Never forget to have fun on this job.

Related posts: A Word with First Year. A Word with Second Year. A Word with Third Year.

Today, I saved a life.

A narrative piece by docedace.

And I wish I could tell you a story about fancy heroics - about an exploratory laparatomy, a chest thoracostomy, or a patient that coded and I was the last person to perform the chest compressions that brought them back to life.  But I can’t.  But I can tell you that I saved a life.

An Encounter with a Stranger

There was a time when I did not hide behind a veil of anonymity on this blog. It was many years ago now. But since reaching that conclusion, I have always tried to keep my two identities separate. Having said that, how to separate two sides of the same coin?

The majority of my readers have yet to meet me in person but a few have. Some of my initial readers were within my close circle of friends and acquaintances. It would come as a surprise on a few occasions since, that I have met people whom I have been acquainted with that also read this blog. Some of these people discovered it by accident, never fully realizing it was I who penned these posts. Others heard from a friend of a friend, as these things tend to go.

But recently, I met a complete stranger who recognized me at a bus stop. It was a chance encounter, based on the memory of who I was before I became the anonymous Tom of the Medical State of Mind.

"This may seem crazy, but I think I follow your blog."

"I beg your pardon?" I was taken aback.

"Do you keep a blog? I think I might be following it."

"What blog is it that you follow?" I decided I would neither deny or admit to anything.

"The Medical State of Mind."

I paused. The gig as they say, was up. I gave a smile in acknowledgment. It was a strange feeling to be recognized this way in public. I knew nothing about this person yet they knew everything about my medical schooling experience for the last four years. While everything I share publicly online I curate heavily and have no regrets, for a brief moment, I felt naked and exposed.

We spoke a bit about my blog, about school, about where my training would take me before this person thanked me as we boarded our separate buses.

A digital identity in today’s world is an extension of who we are in reality. It is an inseparable presence that we must all be conscientious of. Everything I write is heavily curated, fictionalized, and anonymized to protect those mentioned in the experiences I have had in these last four years. But the one thing I hold constant and true on this blog is myself. It was this honesty that led to this chance encounter with a stranger.

I have always been comfortable with who I am and what I write. However, out of respect to my faculty and my governing college, I have explored a different path to allay their concerns. The encounter left me not with a feeling of anxiety or fear but of relief and acknowledgment. While there are risks with social media in any situation, when used appropriately I am confident it can make a difference, as it seemed to for this individual. 

At least one thing is certain though.

We live in a small world.

The Day I Started Lying to Ruth

A cancer doctor on losing his wife to cancer.

A year ago, after a busy night on call, I received a phone call from my mother. Instead of her usual self, she sounded anxious, with an urgency in her voice I seldom hear. I would learn that a close friend of hers had just been diagnosed with cancer.

"Do you know anything about it?"

As one of the mandatory components to our curriculum  I certainly knew it in broad strokes. It was this education that allowed me to deduce based on some of my mother’s description of her friend’s results and symptoms, that the prognosis was poor.

"Yes, I do."

I wrestled with myself over the phone. How much should I say? How little? Was it my place to say anything at all? But my mother was worried for her friend. Having lost my father to cancer only years ago, she wanted at least some reassurance.

Even despite my limited experiences as a student though, I knew I could not offer any. I hesitated.

Instead, I put on my suit of armour that was my white coat and spoke objectively about what the results were, what the symptoms meant, and what the doctors may offer her in the coming weeks.

"But I do not have the full picture." I cautioned. "Her doctors are there evaluating her and this is obviously their specialty." 

In a way, I was trying to wash my hands of the responsibility. I did not want the burden of knowledge that I now possessed that my mother desperately wanted. I answered her questions as best as I could. Intent not be optimistic or pessimistic.

But people always hear what they want to hear. She felt that there was still a possibility of a reversal. A recovery. A new lease on life. She just was not ready to go through everything with my father all over again. I could not muster up the strength to say anything in return.

When my father was diagnosed with cancer at the end of his days, I knew nothing about it. I was the ignorant and oblivious observer. I could still hope. I could still maintain optimism.

But now, armed with a wealth of knowledge, I fear the day when I must confront a similar situation again. When I can understand the disease, interpret results, and foresee the future. It is both a power and a curse.

Some day in the distant future, when all of my family members turn to me for guidance in those dark hours asking those questions that nobody ever wants to ask or answer - “How is he doing? Will he get better? What can we do?” - I hope I have the courage to say what is right.

Part 4: References

The crux to any good application is the reference letter. You could have a stellar application but if there is no one to vouch for you, it can be an uphill battle to the specialty you want, especially if it is highly competitive.

Part 3: Understanding CaRMS

Since 2002, the residency application process has been managed through the Canadian Residency Matching Service (CaRMS). Everyone who is a Canadian medical student is automatically enrolled into the service. Others can apply to be apart of the process. For medical students in their final year of training, this is where the magic happens.

Part 2: Choosing Electives

One of the first major challenges of applying to residency is making yourself presentable, to tailor your experiences to the career you want to achieve. The last year of school is generally reserved as the time to pursue electives in the various disciplines.

In general, every school has certain requirements that must be achieved, such as having at least one elective in medical, surgical, and primary care specialties. Beyond that however, you have the flexibility to choose whatever you want to do.

Part 1: Knowing Yourself

At some point in the natural order of things, you begin to realize that the journey to medicine is not as straightforward. There was once upon a time when being a doctor meant knowing everything about everything. In this day and age, that has become an impossibility.

With that in mind, you reach the crossroads for a second time: what should I do with my life?

There are many ways to conceptualize the thinking process but it always boils down to three simple questions you should ask yourself:

  1. Do I want to work with your hands?
  2. How comfortable am I not knowing the full picture?
  3. Do I want to know a narrow and deep well of knowledge or a wide and shallower pool of knowledge?

For example, someone who enjoys working with his hands, is comfortable not knowing the full picture and likes a wide but shallower pool might be better suited for emergency medicine.

These three questions are fundamental to understanding where your values and interests lie. As your education progresses, take a moment to reflect. You might be surprised how often and how dramatically things change.

The most crucial time to consider these questions is in the clinical year. Consider how your newfound experiences change or reinforce your choices. 

This becomes important when choosing your fourth year electives.

Making the Match
Part 1: Knowing Yourself

Part 2: Choosing Electives
Part 3: Understanding CaRMS
Part 4: References
Part 5: Research and preparation
Part 6: Creating a schedule
Part 7: Travel planning
Part 8: Interviewing
Part 9: Ranking