Donald on 2-East

A reflection from my Internal Medicine clerkship.

Posted by Abhi Desai on October 24, 2017

BACKGROUND During my second week at the Beth Israel Deaconess Plymouth Hospital, my attending and I received a midday admission from the emergency room downstairs. The patient, Donald, was an eighty-six year old man who presented with excruciating sacral back pain. He happened to complain of a sore throat while in the emergency room, so the ER physician also sent for a neck soft-tissue CT at the same time as spinal imaging. That chance neck CT revealed a spiculated lung mass – spinal imaging would reveal an enormous sacral metastasis that biopsy would confirm as metastatic small cell lung cancer. Donald has a 100-pack-year smoking history.

Over the span of Donald’s 10-day-long admission to BID-Plymouth, he was my patient. I went and got signout from the ER doctor. I took the biopsy myself under the guidance of an IR physician. I called his son and daughter-in-law, and broke the news to his family that he had metastatic cancer; told them that they should come to the hospital as soon as they could. Every day I would see Donald first when prerounding, and last in the afternoon before I left. I spoke to him about his goals of care and the process of establishing advance directive. I wrote his discharge summary, and was there to say goodbye when the EMTs came to take him off to rehab.

FIRST The modern world does not allow for gracious, ignorant death. Barring calamitous accidents, almost all of us will one day be faced with the decision between continuing to attempt to stave off the machinations of disease and aging, or to accept the beginning of the end of our lives. The people who bury their head in the sand – “I don’t want to think about it, I’m young and healthy, why bother?” – do not reach that terminus any later; they are simply less prepared when the time comes. The default assumption in modern medicine is to Always Do Everything – it is up to the patient to grasp their own mortality and to come to peace with their lives. We can help, of course: with advance directive counseling, with palliative care counseling, with family meetings, with ethical and compassionate and holistic care……but if the patient cannot come to terms with their own looming death, the physician can do nothing.

SECOND Addiction is the worst disease mankind has ever known. It is a product of our own minds, a horrible bastard child of our primeval craving for dopamine and our uniquely human ability to destroy everything about ourselves in pursuit of that craving. For so many of us the term “addict” elicits revulsion, an image of a haggard pariah alone on the streets with nothing in life besides their suffering and substance of choice. No single disease can possibly have sapped humanity of so many souls, of so many families, of so many childhoods. No single disease can possibly exist so draped in secrecy, so shrouded in fear and shame, so pandemic among the communities that can bear its burden the least.

THIRD Donald had an L1 kyphoplasty performed 5 days before his admission to BID-Plymouth. He had been referred to the orthopedic surgeon who did the procedure by his PCP following a complaint of new-onset low back pain and limited mobility – a thoracic X-ray revealed an old, stable compression fracture, which the surgeon promptly operated on without any further work up even though Donald had a consistently elevated white count for several days before the procedure.

That surgeon did not give a damn about whether Donald got better or not. He found a “problem” he could “fix”, billed for his procedure, and sent our patient on his way. Donald got an entire surgery he absolutely did not need! When I found this surgeon eating in the breakroom and told him what we had found, he told me had to go to the OR and promptly got up and left. There was no desire to learn from his mistake, no remorse that his patient had deteriorated and that he had failed to diagnose the correct problem. How can our patients possibly trust the medical community, their Doctors, when our profession is infected with people who simply do not care?

Perhaps even more frustrating, what can I possibly do when I inevitably face a future colleague like this? When I know a patient I care about might be harmed by negligence borne out of apathy?

FOURTH I have a lot left to learn. No other profession exists at this particular intersection of science and art. I don’t think I really understood the vastness of medical knowledge before beginning medical school – I’m pretty sure I still don’t really see the full picture. Every new patient comes with a plethora of things I do not yet know, treatments I am hearing about for the first time, skills for me to master. There is an endless stream of new information, all with the implication that if I do not master that knowledge I will provide suboptimal care to my patients. It is incredibly daunting.

However, the doctors I admire most are both phenomenal clinicians and also exceptional communicators. Either skill is meaningless without the other. If you can’t communicate what you know to other people, that knowledge is effectively useless. It is obviously important that I spend this time during clerkships developing clinical knowledge, but it is also crucial that I develop my ability to communicate.