An oncologist reflects on his inpatient internal medicine service

asco-logoI recently finished 2 weeks of inpatient hospital service, and the sense of relief was so palpable it felt like taking a breath after swimming the length of a pool underwater. At first, there is anxiety and a sense of excitement at the challenge, but soon you feel strong and assured that you’ve got this under control. The house staff team is sharp and the census manageable. Just over halfway you realize that you are already starting to suffer quite a bit and that you still have a long way to go.

Admissions come in on Wednesday for simple procedures that can’t be booked until the following week and insurance requests for placement authorization linger unanswered and, oh look it’s Friday afternoon so I guess we’ll check again Monday. The final stretch becomes exponentially harder as your body cries out for a return to its normal state, and you wonder if you’re going to make it. After the 5th page from the ED between midnight and 4 a.m., you are reminded of my favorite law of Samuel Shem’s immortal House of God: “They can always hurt you more.” However, the end is in sight and with a final effort you break through, take a deep breath, and reflect on your accomplishments and regrets.

It is easy to joke about inpatient service, which many oncologists dread as an unpleasant but necessary evil to keep their RVUs up, but personally, I enjoy my time attending on the wards and, this time, more than most. Yes, I didn’t see my wife and son much for 15 days, I had to move into the spare bedroom to preserve marital harmony, and my New Year’s resolution to eat better and exercise was quickly put on hold, but there were many positive aspects as well.

As a subspecialist in lung cancer, my time on the wards is my only chance to be a general oncologist and see patients with everything from multiple myeloma to malignant melanoma. I get to diagnose new cases of high-grade lymphoma and stretch my chemo CHOPs beyond my standard fare of platinum doublets. I can even test my old internal medicine skills (board certified but not participating in MOC). Is that atrial flutter or was the patient shivering when this EKG was taken? The patient is eating a hot dog and watching the playoffs, but was admitted for sepsis because his lactate was high? Who wants to hear about pretest probability and how that affects the likelihood of a true positive test? (By the way, do not try to teach this concept over the phone to an ED physician at 2 a.m.)

In truth, I rely heavily on my residents for most of the internal medicine management, and I am there mostly to teach and lend my “wisdom” to our patients’ care. I was acutely conscious of their experience on the wards this time, though, after reading a recent publication in the Journal of Oncology Practice: “Inpatient Hematology-Oncology Rotation Is Associated With a Decreased Interest in Pursuing an Oncology Career Among Internal Medicine Residents.”

The gist of the paper is that residents feel they have little autonomy on cancer wards since the outpatient oncologist makes any important decisions, and the constant barrage of sadness, sickness, and dying patients ends up reducing both their empathy and resilience. This horrifying experience leads to them not choosing hematology-oncology as a career and instead following their dream to launch an organic coffee shop in Northern California. While that last part may not be entirely truthful, I was acutely aware of how my residents perceived their role on the team in regard to patient care and their perception of oncology as a career.

None of the residents on the team (2 interns and 2 senior residents) were considering hematology-oncology when we started. Both seniors had matched already, in critical care and in infectious disease, while the interns had partially differentiated into cardiac myocytes which is common at our institution. Nonetheless, I made it my goal to give them the best possible exposure to our field, and to allow them as much autonomy as possible. We explored their patients’ diseases and, when patients had no local oncologist, we discussed both possible treatment and end of life issues. Their patients were their patients, and I encouraged them to be as involved in their patients’ social and oncologic lives as they were comfortable being. Perhaps surprisingly, they embraced this opportunity.

I noticed the differences when no one was watching, often after signouts had occurred at the end of day. They were going back in to say goodnight and make sure that pain adjustments were taking effect before leaving and not just when we came in for rounds. Making second and third calls to worried family members who had missed us on rounds, and detailed calls to distant oncologists to arrange quick follow-up on discharge. Their anger and frustration when consultants refused to perform procedures due to “poor prognosis from underlying malignancy” were shared emotions with their patients, and rapid improvement after urgent chemotherapy was greeted with equally shared joy.

One of my proudest moments was talking to one of the seniors late at night when he called to tell me a patient was actively dying. We had discussed this possibility earlier in the day when the patient was started on comfort care, and he had taken the lead on the discussion about goals at the end of life. Although I offered to come in, our preparations helped him feel comfortable speaking to the family and managing the patient in their final hours. I can envision many such discussions in his future life in the MICU and think this type of experience can only help him develop as an intensivist.

Maybe it was just my heightened awareness, but in my opinion, there was no lost empathy this month on the inpatient oncology service, no lost resilience. Maybe they still didn’t want to go into hematology-oncology (was that myocyte looking a little dysplastic?), but every one told me they had enjoyed their time on service and the opportunities they had to take “ownership” of their patients. Maybe this is sacrilege, but I think that this relationship is what makes being a doctor special and is most in danger of being lost in all the handoffs and “team-based” care. At least for this month, the gates held firm.

Nathan A. Pennell is an oncologist who blogs at ASCO Connection, where this post originally appeared.

Image credit: Shutterstock.com

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