My first patient of the day has metastatic pancreatic cancer. She’s had it, in fact, for two years. Getting chemo for two years. Her hair has fallen out, her pain is becoming uncontrollable and she’s been in and out of the hospital.
Her daughters came to the clinic with her. She is tearful. Her daughters pull me aside. “Tell her to focus on the positive,” they request. I wonder if there is ever a positive twist on having metastatic pancreatic cancer, but I keep my thoughts to myself. This is not about me. It’s about this patient who is living with it.
Every question I ask her gets answered by one of her daughters. I point the daughters to the door. They leave, and my patient opens up. She is severely depressed and “wouldn’t mind if she doesn’t wake up tomorrow.” She is depressed about her illness and she is depressed about the treatment. I ask her if she wants to continue. “I don’t know.” We make a plan and follow-up for her depression. “She has a bad diagnosis,” I tell her daughters on their way out. It’s important to set clear expectations.
My next patient is here with his father. He had a stroke a month ago. He just had another stroke that has left him blind. This stroke may be related to a heart infection. He has no questions. He is feeling okay. For someone who just lost vision in both eyes, he seems apathetic. Denial? Depression? I try to probe further without much success.
Next is a patient is someone with cerebral palsy who cannot speak or take care of himself. He has a tube in his neck for breathing, two different tubes in his stomach for feeds and water, and one tube in his penis to collect urine. His caretaker was concerned the stomach tubes might be infected. I examine him and don’t find anything to suggest an active infection. “I think he’s OK and doesn’t have an infection,” I tell her. “You think or you know,” she hissed back at me. Nothing is ever 100 percent in medicine or in life. We also have a language barrier. I call for an interpreter. “She understands me,” the caretaker tells the interpreter. The interpreter looks at me, realizing that she was called because the caretaker didn’t understand me. The interpreter manages to explain to her that “I think” means what my assessment is, not a guess at his condition.
After that, there is a middle-aged woman with a previous heart attack and heart surgery who has been having chest pains for many months. She has had every single test possible. She has heart disease, yes, but her images show stable disease. She is being managed with medications by her cardiologist. She is tearful and I ask her what’s going on in her life. Her husband is traveling for work for the next couple months. I increase the dose of one of them with a plan to call her in a week to see how she’s doing.
My first patient of the afternoon has checked in at lunchtime. I can make her wait or I can go ahead and see her, so I choose the latter. It’s always nice when someone makes the effort to show up early and/or on time. She had a blood clot in her lungs just a few days ago when she returned from vacation on a long-distance flight. She looks good and she understands her blood thinners and how to take them. She looks good and has good support at home.
My schedule also had three patients with colds and two patients with diarrhea. Ugh, flu season really seems like it won’t end. The new flu season will begin in just four short months.
My last patient is a relatively young man with heart failure. The heart needs to pump and relax to push blood through the body. Patients with heart failure often end up with water in their lungs. I took care of this man in the hospital six weeks ago. He doesn’t remember me. “I sent you to the cardiac unit to get a drip,” I remind him. Now he remembers me. He was referred for a heart transplant but was declined as a candidate due to his weight.
He is understandably struggling with his diagnosis. “Doc, I was playing basketball one year ago.” He feels “full of water.” I scan through his scans and films. He was water, yes, but scant. His medications seem to be keeping the water stable. What else could be making him feel so “full?” He mentions his weight, which has only skyrocketed in the last year. I do note a protuberant belly. “This is all water,” he insists. My examination disproves his theory. I struggle to tell someone not much older than me with a poorly functioning heart whose only real hope to live is a heart transplant that he is wrong. “There is a wee bit water and a little bit of room to lose weight too,” I compromise. I reinforce that weight loss is the only way he can qualify for a heart transplant, which may get him back to playing basketball.
It’s the end of the day, and I am exhausted. Emotionally. Life seems too unfair sometimes, and I’m grateful for good general health. I step into the elevator, deep in thought. I always hope that I made the right judgments for my patients. I think about who needs follow-up. I wonder what else I could have done for my patients.
“Thank you for everything you do as a doctor.”
I realize slowly that a man in the elevator is speaking to me. My stethoscope must have given me away.
“I appreciate that. Thank you,” I reply.
“You guys work so hard.”
My eyes start filling up with tears and I manage to blink them away.
Medicine is hard work. Physicians share their patients’ victories and feel each patient setback as a personal failure. We congratulate and we deliver bad news. The pendulum swings across all emotions, and each day is never predictable.
In this moment, it feels good to be validated and appreciated.
Uzma Khan is a hospitalist, blogs at Me and My Stethoscope, and can be reached on Facebook.
Image credit: Shutterstock.com