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Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden.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."
From the Agamemnon of Aeschylus (written c. 458 BCE)
Pathei Mathos can be translated as learning from adversary, or wisdom arises from (personal) suffering, or personal experience is the genesis of true learning.
Understood in its original context, Aeschylus expresses that wisdom arising from personal experience is more valuable than what any impersonal words, faith, or doctrine can impart to us.
I saw a patient on the ward on call recently where the patient’s complaint was some mild shortness of breath. Upon reviewing the progress notes, one of the issues low down on issues list was titled PE.
My heart skipped a beat.
Pulmonary embolus. My thoughts raced at the possibility that this patient had a recurrence. I quickly went back to see the patient but found that his story and physical exam did not quite add up to what I had imagined. I decided to go back and read the chart notes carefully again.
The more I read the notes in its reverse chronology, the less this PE sounded like a pulmonary embolus until I finally found the source, some ten pages back, buried in the middle of their already thinned chart.
Over time, a relatively benign finding had been unintentionally shortened to a grave and emergent issue by the student writer. I breathed a sigh of relief.
It was yet another reminder of how shorthands and acronyms can cause miscommunication.
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.
Today marks the end of my first week as a doctor. To say the least it has been exciting, interesting, but above all, scary.
I have hit the ground running here, starting my first rotation in internal medicine. The days thus far have been long, hard, and busy. Everything feels more real, more high stakes; after all, I am now the one who needs to make the decision overnight.
However, every resident feel like this when they begin practice. What I would like to share instead are some of my other experiences:
There are still two years ahead of me in this residency and much to learn, see, and do. Expect more thoughts on this transition in the future.
In the 1970s, Noel Burch described four stages of learning any new skill and it could be summarized as follows:
Everyone strives for unconscious competence. The mastery of a skill has become so complete that you can do it effortlessly. The scariest state to be in is the first stage. “You do not know what you do not know.” That can be a terrible position to be in, especially when a patient’s life is on the line.
That is why receiving feedback is so important. That is why we train for so many years, under the watchful eye of so many experts to be a master of the craft. Sometimes, in order to make that transition to the next step of our competency, it requires someone else to point out where we need help.