I have always found fountain pens to be intoxicatingly beautiful, but I never brought myself to buy one. Partly I simply did not know where to look, partly I was also lazy. I had grown up using throwaway pens and they worked fine for me. But I was inspired to consider them more seriously when I saw my attending writing with not one but four fountain pens on the ward. “Why?” I asked him. He told me: because his hand ached at the end of a long day of writing page after page of notes; the fountain pens had put an end to all of that and they got rid of the callouses on his fingers.
I looked down at my right hand, thick callouses along the side of my three fingers. I decided it was time to get a fountain pen.
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.
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.
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.
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 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.
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.