Posts tagged reflection

Meeting a friend.
I received an email recently from a friend who is currently going through fourth year medical school remotely. To my pleasant surprise, she was in town for an elective.
After a brief correspondence, we managed to find time this morning to meet for coffee. We talked about our lives, our respective training thus far, and our future plans. It is remarkable to hear how our lives and experiences can be so similar despite how different our programs are, from the challenges of clerkship to the stresses of applying for residency.
The story of medicine is truly a universal one. 

Meeting a friend.

I received an email recently from a friend who is currently going through fourth year medical school remotely. To my pleasant surprise, she was in town for an elective.

After a brief correspondence, we managed to find time this morning to meet for coffee. We talked about our lives, our respective training thus far, and our future plans. It is remarkable to hear how our lives and experiences can be so similar despite how different our programs are, from the challenges of clerkship to the stresses of applying for residency.

The story of medicine is truly a universal one. 

Cancer Family by Nancy Borowick. (republished with permission)

The burden of cancer does not fall upon just the individual, but also upon the family and friends who support them. It is this shared experience that is so important yet often missed in the cancer narrative. We must always consider how everyone else is surviving this diagnosis.

Nancy Borowick’s mother had been fighting breast cancer for nearly 20 years when her husband was diagnosed with pancreatic cancer. They underwent treatment together for a year before he succumbed to his condition.

She sought to document the pain and the challenges they faced in this time but also their strength and their courage together, “from the daily banter they shared as husband and wife to their shifting dynamic as patient and caregiver.

"Cancer gave my family a harsh yet valuable gift: an awareness of time."

Nancy continues to document her mother’s day to day life, from the grief of losing her husband to the strength she finds through her family and friends. For instance, Nancy’s brother-in-law, Paul Flach from the UK, has also lost his father to cancer. He is running the Berlin Marathon this September as part of the UK Institute for Cancer Research fundraising team.

42 CME Credits

Now that I have started residency, I have also invested into an UpToDate subscription. This online clinical resource logs the time you spend researching and reading different topics. In less than three months’ time, I have already amassed 42 continuing medical education credits. 

A single credit is the equivalent of an hour of additional reading. 

In essence, I am averaging roughly 12 hours of reading every month on UpToDate. This is in addition to some other bits of reading I do here and there on guidelines, position statements, and textbooks. 

However, it just goes to show that a little bit every day goes a long way.

A Woman’s Life by Stonehouse.

A preceptor once told me the greatest joy of his profession was watching his patients grow. Some of them he encountered later in their life. Those whom he had the opportunity to be involved with from the very beginning however hold a special place for him. It is the good times and the bad times, the times when the first tooth erupts or the first day they walk, and the times when they first go to school or graduate from college.

That is the special privilege we have to be involved in people’s lives.

That Horrible Feeling

When you see patients with scabies or pink eye and you feel the creepy crawlies just itching under your fingers and eyes for the rest of the day.

Jesus H. Cox, M.D.

Sadly, every one of my colleagues has met at least one person like this in their lifetime. I recently had to work with someone like this and it was not the most positive learning experience. As a learner, I do not have all of the answers, though I do my best to have one; then again, that is what this residency is all about: learning from my mistakes and learning to be better. Perhaps it was allowable in some bygone era to behave like this but not now.

Take a moment and reflect. Do you know someone like this?

On the Same Wavelength

In the span of twenty minutes while seeing a child in the emergency department, we had bonded over a variety of characters including Spongebob Squarepants, Transformers, Toy Story, Wall-E, and Justice League. 

Suffice it to say we spoke the same language and operated on the same wavelength.

Catching Up

Yesterday was special. A classmate and dear friend of mine who has been out of province for her residency came back for a weekend getaway. We had an opportunity to meet and catch up on how our respective residencies have been thus far.

While war stories were exchanged, the focus was never about the medicine side of things. It was more about how life has been and what we were up to. It was a nice change of pace from my regular conversations nowadays.

For four hours, we were able to disarm ourselves of our ward personas and talk about regular, “normal” things. From the movies we watched, to my recent vacation stories, to her relationship challenges.

At four hours, that mental vacation seemed too short.

Two Schedules on Shared Time

The challenge of my current schedule is that I must juggle my responsibilities between my core rotation and those of my clinic, to which I am obligated to spend time as well.

Sometimes it means missing out on some good learning opportunities due to conflicting schedules. Other times, the days off of one schedule coincide with the days on of another. I can be particularly hit hard if, like today, the day could have been spent sleeping post night shift.

Thankfully these scheduling anomalies are few and far between. However, when I think about how well established the challenges of balance are in residency, having an awareness of these issues can go a long way towards improving resident resilience.

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."