As my chief year in Internal Medicine continues to wind down, I often reflect upon the impactful patient encounters I have had in the past few years of training. Some of the rare clinical syndromes led to national posters, oral presentations, and case reports. Others taught me global themes about being a clinician that I tried to pass down through noon conference lectures and hospital ward rounds. However, there is one case that left a lasting impression on me near the first half of my intern year.
The patient was a 40-year-old highly educated man who was one of the most pleasant people I have ever had the privilege of caring for. There was only one problem, he was dying of stage 4 colon cancer.
The sign-out I received prior to starting the wards was the following: “Your goal is to convince him to go to hospice.” I was a sharp intern and task completion was my bread and butter. You see, I chose Internal Medicine because I loved puzzles and helping others was always secondary gain. The puzzles I typically gravitated toward were diagnostic dilemmas, but I accepted this challenge with no less enthusiasm. I figured I just had to talk to him, establish a rapport, set expectations, and naturally guide him toward the option that would allow him to be most comfortable.
I discovered that he was originally from New York, where he was a college professor. He was under the treatment of an oncologist there but traveled down here in Florida to see some family. Recent chemotherapy had rendered him weak. As his fatigue began to progress he decided to go to the ER. He was admitted with a diagnosis of neutropenic fever. After a week of hospitalization, he felt still felt weak, but better than he was. His mind was intact but his body was frail — wasting away from the disease.
He could barely move in the bed and needed assistance with feeding himself. I sat down with him and walked him through his disease course, explaining his prognosis. Ultimately, I conveyed to him that a Palliative Care philosophy and hospice was the option that I supported as it would alleviate his suffering.
His replied, “I want chemotherapy.”
This continued for over a week. I spoke often with the consultants involved in his care. We arranged group meetings with family, physicians, and nurses. The family agreed but the patient did not. I spoke to his oncologist in New York who agreed with our course of action and felt the patient was too weak to withstand chemotherapy and any further treatment would likely hasten his demise. When I passed this information along to the patient, he was steadfast in his request. Was this the first time I was going to fail at the task that was assigned to me? It certainly seemed so.
Every Tuesday and Wednesday of hospital ward rotations, interns spend part of the morning with our dean, a professor of medicine. This intern report is a forum for case presentations to our most seasoned clinical instructor with the idea that we would collectively build critical clinical reasoning skills. Almost always, these cases are diagnostic conundrums, but this time I decided to present the aforementioned patient. I had no other recourse that I could think of.
As our dean listened closely and a robust discussion ensued, he asked me what the patient’s religious beliefs were. After a long blank stare, I realized I had no idea. It never even crossed my mind to ask the patient or the family about this. So focused on puzzles and task completion, somewhere along the way I lost sight that I was charged with caring for a person. It was suggested to me at this forum that I inquire about religious beliefs, ask if there was a cleric in the community that they trust, and invite that individual to come to the hospital with the patient’s permission.
The next day, not only did I learn that the patient was a member of the Pentecostal Church but there was in fact a priest in the community that he wanted to speak with. Additionally, I offered to call one of our hospital chaplains and the patient and family agreed. Within 24 hours, the patient had accepted hospice. I found out that the patient was moved to a hospice facility during the night before I had a chance to say goodbye. His brother was waiting in the room for me in the morning. In that last conversation, I found out about how our chaplain had sat and talked with the patient for hours, fed him dinner, and they both smiled and laughed as stories were exchanged. As pleasant as my interactions were with him, I don’t ever recall him smiling. I certainly was for the rest of that day.
It’s almost an expected natural progression of medical training to adopt our jobs as daily routines, schedules, and tasks to be completed. Yet, we have a unique privilege in which people are trusting us with their wellbeing and often, their autonomy. Some wisdom gained after a modest amount of experience: it’s more than the body that requires our attention.
Mohammed Bhuiyan, MD is currently chief resident in Internal Medicine at the University of Miami Miller School of Medicine Palm Beach Regional Campus. Next academic year, he will be an Internal Medicine consultant at the Mayo Clinic in Rochester, MN
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