Reflections in a Head Mirror

The capacity to give one's attention to a sufferer is a very rare and difficult thing.
-Simone Weil  


The e-mail message about my long-term patient was disturbing.  

In retrospect, her initial cancer treatment had been nothing short of a miracle. A large tumor of the mouth was completely controlled with a limited surgery and radiation therapy. When her cancer recurred again a few years later, treatment again came to the rescue. She did well for a long time.  

Eventually, though, treatment side effects developed. Over the years, the problems caused by the aggressive cancer were replaced by problems caused by the aggressive therapy. She suffered.  

In the months before I received the e-mail message, several physicians, nurses, and therapists had been involved in her care. Her weekly schedule was jammed with medical appointments.  

One day, I received an e-mail from one of her friends telling me that she was dying and that the family was struggling. “The family is under the impression you didn't want to see her anymore.”  

I was stunned. I am a surgeon and it is true that I had nothing to offer her surgically. From my perspective, though, each office visit had involved extra time to review her options and discuss what was happening. I thought I had always tried to answer her questions. I was always careful to remind her that she could come and see me anytime.  

However, I knew that our scheduled return appointments had gone from every few weeks to every few months to an open invitation to call if she wanted to return.  

From her perspective, apparently, it was clear that I had given up on her.  

As I re-read the message I wondered: Would she have felt differently if our office visits had become more frequent instead of less frequent as things became more difficult? Is it possible that an office visit is a sign of hope or an expression of caring?  

I thought of my experience with this patient as I read Dr. Pauline Chen’s book, Final Exam: A Surgeon’s Reflections on Mortality. Writing about her dying patients, Dr. Chen laments, “I want to sit and linger with my patients but know that such inefficiency would never work in a clinical world. I want to soothe my patients’ suffering without the burden of knowing the inexorable future courses of their diseases.”  

I am certain that I have the same anxieties as Dr. Chen. In addition, I struggle with the knowledge that each office visit generates a bill for which the patient is partially responsible. Medical care is expensive and I do not like charging people when I have little to offer. On top of that, there are only so many appointments available in my weekly clinic schedule. How do I see everyone who might benefit from an appointment?    

No one should ever feel abandoned. My patient died a few days after I received the e-mail message. Her legacy is that I will somehow find new ways to accompany my patients as they approach the end of their journeys. 

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The following is feedback received for this blog: Very nice essay. Maybe that is why patients love the newsletters, patient receptions and your blog. It keeps that connection. Could survivorship clinics possibly serve this need in a meaningful way? - Kathy Very thoughtfully written. It is a struggle to find a good solution. The visits may offer hope, but they can be costly not only in money but the time and effort it takes as the patient weakens. No easy solution. - rlbates http://rlbatesmd.blogspot.com/ Thoughtful article. As a psychiatry resident, I find that some 'stable' patients subconsciously take fewer visits as a sign of abandonment and some of them might even become sicker. My solution is simply to ask them, 'When do you want to come back?', and most of the time I'm able to go along with what they want. On the other hand, it is worth considering how we as doctors bring much more than just medical treatment to the table. Yet, this 'other care' is often undervalued, (certainly by insurance companies) and we feel unable to help a patient when faced with an untreatable disease. This may not always be true. - En Jay Medical school, residency and our early years in practice imbued us with lots of technical expertise but our patients (and by extension their family and friends) teach us so much beyond that, we just have to make sure we keep listening to their message. - Deborah Benzil http://womenneurosurgeons.blogspot.com/

The aim of education is the knowledge not of fact, but of values.
- William R. Inge    


“If there was one thing I would have every medical student learn, it would be this …” The woman was talking to her companion while moving down the clinic hallway. I passed her going the opposite direction and strained to listen for the end of her sentence. Unfortunately, by the time she reached the punch line, she was around the corner and out of earshot.  

Still, it got me started thinking. What should every medical student learn? What are the most important lessons – both inside and outside of the curriculum? 

Here is my attempt at a few things I would hope every medical student learns before graduation:     

• That they will help their patients heal by simply being attentive, empathetic listeners.   

 

• That not doing something is much harder than doing something.          

 

• That they really can and should help their patients quit smoking.      

 

• That they should always ask themselves, “What else might it be?” before settling on a diagnosis. (Borrowed from Jerome Groopman’s book, How Doctors Think)     

 

• That procedures and tests don’t always help, are sometimes painful, and are usually more expensive that they could ever imagine.  

 

• That they should never be satisfied with how much they know about either the science or the art of Medicine.  

 

I will never know how the woman in the hallway finished her sentence, but I would bet that a lot of you have a thought about this topic. You have seen my quick list. Hit the “Feedback” link below and share what you think are the most important lessons every medical student should learn. I will try to print many of the responses.  

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The following is feedback received for this blog: I am a nurse here are a couple of things I would suggest: If the student was in that hospital bed how would they want to be treated/spoken to or touched? Please wite your orders and sign your name so it can be read. None of us learned how to read squiggley lines in school! When you become a resident and we have to call you for orders/pt updates or changes be nice. We all have long days/nights when we havent had alot of sleep or nothing seems to be going as planned.(not just medical students or Drs., nurses get tired and crabby to at timees) How ever good or bad the situation it will change. Laugh or cry with someone. It's more healing than doing it alone. Be confident in what you say and do even though if you don't feel like you are. Every person who works in the medical profession needs to know what the patients needs are this includes: mental, physical, social, financial, present, past and future needs. If they are seeing a doctor they should be treated by that doctor. We all have more than one need in our lives. B w Nurses know the patients. Listen to their opinions and yes...even their suggestions. i particularly respond to the one about tests. i certainly understand the need to reduce uncertainty, and that's good, but there have been so many times with our son when we've felt like we were a part of someone's "fascinating experiment" that never went anywhere. thanks for raising this important and [somewhat] risky issue. - Richard Holloway I am a radiographer/CT Tech/educator. I once had a med student ask me for general advice. This is what I told him. "Before you order a diagnostic test, ask yourself if the information you get from the test will enable you to improve the patient's outcome or quality of life. If the answer is no, don't order the test. - Mary Hood

Whatever begins, also ends.
-Seneca


One final story from our visit to El Salvador …  

Our return trip to Milwaukee included a two-hour layover between flights. Five of us who had made the journey together sat in the waiting area at Houston’s Intercontinental Airport sharing photos and telling stories, anticipating a scheduled arrival back at Mitchell Field about 10:00 pm.  

In some ways, our experiences in El Salvador had differed. A woman from Sheboygan had served as a translator; because she is a native Spanish speaker, she easily befriended many of the Salvadorans and always had a crowd of giggling kids swirling around her. A woman from Milwaukee had led empowerment workshops for the Salvadoran women, developing deep friendships in the process. A woman from West Bend had been involved in the non-traditional and spiritual therapies, finding herself touched by the number of ways people experienced healing. My wife, Kathi, and I had worked as a nurse and a physician, seeing the physical challenges and sensing the joy of the people we met despite the frustrations of the language barrier.  

In other ways, our experiences were shared. Despite the disturbing levels of violence throughout the country, the people we met, from government health ministry officials to San Salvador’s homeless, were friendly and thoughtful. Despite the dust and mud, the people were clean and dressed as nicely as they could afford. Despite the clinic’s long lines and protracted wait times, the Salvadorans were, to a person, patient and grateful.    

As we waited at the airport, two hours turned into four then into six. A major storm on the East Coast had caused a chain-reaction of delayed flights all over the country. Later, after our plane had finally arrived at the gate, there were no flight attendants available. The Houston ground crew worked overtime trying to get us home.  

Our little group continued sharing stories. One of our friends had been outside of the clinic building late in the afternoon on the last day. The local organizers had shut off the line so we could pack up our things and get back to the guest house. Some of the Salvadorans who had been waiting all day to see one of the doctors or dentists were now being told that the clinic was over until next year. Despite this setback, some of the people had hugged and thanked the clinic volunteers. “Thank you for coming,” they told one of the staff. “We will see you when you return.”  

The story seemed almost unbelievable, especially as I watched three American tourists returning from vacations in Cozumel tear into the airline employees about the delays and how important it was for them to get home. They exploded again with each delay announcement storming around and pointedly shouting into their cellular phones.    

Of course, I knew why they were upset and maybe I have been that upset at some point in my life. But, for the moment, the extra time in that airport offered me both the opportunity to hear some more stories and the possibility to be grateful for a bit more of the healing that is best experienced by, sometimes, just living in the present.

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The following is feedback received for this blog: So nice to read a bit about your trip! Thanks for keeping up with this blog, it remains inspiring to me. - Mary Buckler

The elderly man came to the San Salvador Lutheran Medical Clinic nearly blind and almost completely deaf. Our interpreter helped me figure out what he wanted.  

“How can I help you?”  we shouted. 

"I have a cough and get headaches sometimes. Can I get some medicines?”  

“Sure,” I said. “Let me take a look.” The interpreter moved to another of our physicians while I performed an examination.  

The patient had undergone cataract surgery at some point which had improved his vision a bit. I peered in his nose and focused my headlight in his mouth. His last few teeth were in pretty bad shape. Otherwise things looked pretty good. No obvious infection and nothing worrisome. The neck was okay. His lungs were clear and his heart was steady. His belly was soft and there was no swelling of the ankles.  

I peeked in his ears. Both were full of wax.  

“Would you like me to clean your ears?” I peeked at my cheat sheet with a few Spanish words. “¿Limpio los oídos?”  

I’m not at all certain he understood my question, and I wondered if I had chosen the correct word for “ears.” Nevertheless, he turned his head and let me dig in his ear canal.  

The wax was very adherent to the canal wall. I continued to work and the man was clearly uncomfortable.  

Just as I was about to give up, the plug of wax moved. I reset my instrument and slowly worked the solid mass of wax from deep in the canal to the opening. Suddenly, I triumphantly pulled out one of the biggest plugs of ear wax I had ever seen. Clearly, he had been working on this masterpiece for all of his 85 years. Now it was out.  

He blinked and stared at me with his softened gaze. I suspected he was hearing from that ear for the first time in 20 years.  

“The other?” I attempted in Spanish.  

He grinned and turned his head to present the other side. Soon, despite some discomfort, I had delivered another plug of wax as large as the first. He stared at the plugs of wax on the gauze. He wrung my hand enthusiastically. “¡Muchas gracias!” he said.  

“De nada. You are welcome. Thank you for coming!” Pretty soon, he had received a flu shot and was heading home with his small bags of vitamins, calcium, and acetaminophen.  

I’m not altogether certain how many patients I helped while visiting El Salvador, but I am pretty sure there is one 85-year-old nearly blind man who is very glad that I was there.

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The following is feedback received for this blog: Very nice story. As always, thanks for sharing! - Jen Awww ... that's such a neat story. You made his day. I'm glad I read this. - Leigh Ann Otte http://thedoctorwriter.wordpress.com/ Just the small things can make a world of difference for everyone. Thank you for sharing. - Scot Go figure, all the years of training and skills acquisition and removing ear wax is still one of the most gratifying thing we do. . .enjoyed the story. - Merry Sebelik I *hear* the biggest difference we often make, is often one we don't realise - Jabulani Awww.... I loved this story! I'm so glad you took the risk to visit this memorable place. - Penny Just had to add this. I am a physician, a radiologist, but somehow keeping the wax out of my ears has always been a problem, I mean really, getting somebody to dig around in my ears, nobody seemed interested, maybe the ENT guy's nurse if I was lucky. I didn't see anybody interested in going after that awful stuff. Even the nurses never seemed to get it all. At least in my own clinical days I used to soak that stuff with drops of soap held in with some cotton balls for about 30 minutes which allowed me to blast it out with the little water gun we had in the back office. Yes I really enjoyed doing that!! But good luck when it came to my issues!! Finally I picked up on just soaking that wax with hydrogen peroxide. Only takes about 20-30 minutes per side and after awhile all that bubbling is pretty pleasant and one has to be careful not to fall asleep which might possibly lead to H2O2 burns. When all the wax is gone the bubbling stops, it's that simple. Cheers. - Steve D. What a great story. In pediatrics - we use a liquid stool softner (Colace). Fill the canal with the nice pink stuff and flush in about 10 minutes. Somestimes we have to repeat the process. We flush with warm water in a 10 cc syringe connected to a cut-off butterfly tube. The one inch or so of tubing slips into the canal nicely. Works every time - then you can see to China or through to the other side as we tell the kids. Thanks for the story and for your trip to help those people.