"I feel very dizzy with standing," was Ms. Adam's chief complaint. She originally came to the emergency room for sudden onset double vision and severe balance issues. After briefing myself, I took the stairs to the fourth floor and found her. When I arrived, Ms. Adam was the only person there. She was wearing a silver visor and a crisp white shirt. A native of west Texas, she loved her BBQ, local football, and farming. I went through my usual routine and gathered her history, then proceeded to the physical exam. I listened to her heart, breath, and belly sounds, then palpated her cervical and clavicular lymph nodes with my fingers. What I read from the primary team's note matched what I felt — a hard and slightly mobile mass in the left clavicular region: Virchow's node. It is known to be a strong indicator of abdominal cancer. I processed this in my mind and tried my best to not look worried. It didn't work.
"Hey, Ms. Adam … have you noticed this small lump next to your collarbone?"
"Ah, yes, I have actually. It showed up suddenly about a week ago. Doesn’t bother me though. Do you know what it is?" she replied.
I told her a white lie: "I'm not sure what it is, but we will look into it more today and hopefully get an answer."
"No worries, do what y'all got to do; I don't want no stone untouched. I feel strong and great so hopefully it's nothing. Just get my eyes and balance right and I'll be on my way," she said with a smile.
An incidental CT scan, ordered two days prior, showed a small bowel tumor with metastasis to her liver. Subsequent scoping of the duodenum did not reveal the tumor, which gave me some sense of relief. But I knew the scoping did not provide a definitive answer.
The next morning, after we finished rounds, I stayed with Ms. Adam for a fine needle aspiration (FNA) of her clavicular mass. She was as nervous as I was, and I told her to look at me and squeeze my hand as hard as she wanted. As the FNA proceeded, Ms. Adam told me that she lives alone and often gets around by asking neighbors to help drive her to and from town. At home, she uses a walker and often has her neighbors help her with house work. Unfortunately, she’d recently found out that one of the neighbors took advantage and vandalized her home. A mere day into her hospital admission, she’d been notified by the police that she’d been robbed of all her valuables.
"I was told by a friend that everything was stolen … funny thing is that I don't feel outright bad about it. I value my connections with people much more than material things. But … it was still shocking that someone I knew would do that to me …" She trailed off.
I asked Ms. Adam if she would like to see a social worker, but she said she would be alright.
"I just want to get my eyes and my balance right and go home, things can't get any worse for me, right?" She said it with a laugh.
The next day, I visited Ms. Adam and she told me that her primary team was discharging her because her vision and balance had both improved substantially. Then she asked me about the biopsy results, and I was honest with her.
"The results could be malignant but we don't know for sure yet."
"If it is malignant, can chemo do the job?"
"If that's the turn we take, then yes, chemo is certainly an option."
"If I need chemo, let's do it. I just want to get out of this bed, go home, and take care of things. You know me and I told you this before, I hate sitting on my ass all day. Every time I saw the group of doctors and students each morning, I always noticed you. You always took the time to talk to me even though I know you are busy."
"Would you feel jealous if I spent more time with another patient?" I teased her.
"Of course!" We both laughed together.
"You know, if it does end up being cancer, I'm in a good place. I've been blessed to have lived a long life. I've made no enemies, always looked out for my friends and family, and kept God close to my heart. He's guided my path from day one and I know that whatever is next, there is a purpose to it."
The next morning, as we were nearing the end of rounds, I walked past Ms. Adam's room. I casually asked my attending if he knew what her FNA results were.
"Her FNA came back positive for advanced pancreatic cancer. There is not much we can do for her at this stage besides chemo . . . " I felt a hand placed on my shoulder.
The hardest thing about medicine is that after we care for patients and they leave the hospital, we almost never know how things end up. Did they truly get better? Did they make it to their follow-up appointments? Did they have a good support system at home? Did they make it to their chemotherapy or dialysis sessions?
Regardless of the illness or disease a patient faces, we are all human. By truly listening to every patient’s story, I’ve come to believe that we connect on that fundamental level — regardless of race, religion, color, creed, or sexual orientation. Every time I hear a patient’s story, I remember again what drove me to become a doctor. By listening to patients, I become a better advocate for them. Most of all, I never forget that human suffering is a phenomenon that can happen to any one of us at any moment in time. Understanding suffering starts with their story.
Ton La, Jr. is a MD/JD candidate at Baylor College of Medicine and the University of Houston Law Center. He is applying to Internal Medicine residency programs for Fall 2020. He sits on the American Medical Student Association Board of Trustees as the Vice President for Membership and previously served as the Student Editor of The New Physician.
