It was several years ago. I was a first-year internal medicine resident. Keen, tired, overworked, and still idealistic. Mr. Smith was a 45-year-old lawyer who rolled into St. Paul’s Hospital Emergency room, while our medicine team was on intake. He was a healthy appearing lawyer who noted that for the past month he had become more short of breath performing his regular exercise. Things were especially bad for him during his morning treadmill workout, so he came in for evaluation. The ED started the standard work-up including blood work and a chest x-ray.
The x-ray came back showing a large right-sided pleural effusion. A concerning finding in someone with no prior medical history. I presented the case to my senior resident. She went through the differential diagnosis with me. We were both concerned that this could represent cancer, and none of the cancer possibilities for this were particularly good.
We explained the x-ray to Mr. Smith and described the thoracentesis procedure we would need to do.
“What could this be?” he asked. I hedged. At this stage of my life, I was still getting used to the idea of dealing with very sick people with terminal diagnoses, even though I already had experience with my mother who had been diagnosed with complicated chronic myelogenous leukemia. I still did not know how to approach the difficult conversation that needed to happen.
I saw Mr. Smith several days later in follow-up.
“How are you feeling?”
“The breathing is definitely better. Did the lab tests come back yet?”
I typed in my password to our primitive electronic medical record and scrolled through the results. The screen read: Non-small cell lung cancer. I paused.
I went to seek out my resident supervisor to determine how to proceed from here. This was the first time I would have to give news of this magnitude to a patient. I didn’t know where to begin. My supervisor was tied up with an overflowing clinic, so he was not readily available. I took a deep breath. I would try to navigate this on my own.
I reentered the room. Mr. Smith looked at me expectantly.
“I’m sorry, I was just looking for my attending …”
I was starting to fumble and must have looked nervous.
“I was able to look at your lab test, and unfortunately it shows that the fluid in the lung is caused by cancer. And the cancer …”
Wait,” Mr. Smith cut in, “Cancer, how could this be? I have always been very healthy and have tried to do my best…”
He stopped, and then went silent.
“I know, “ I said, blushing and nervous.
“What kind of cancer is it?”
“It looks like a lung cancer. Something called non-small cell.”
“What does that mean? How do they treat it, what is the prognosis?”
I took a step back and admitted what I knew: “I don’t know a lot about lung cancers, but the next step is to get you an appointment with the oncology team. They will be able to give you a lot more information about this and discuss how to treat it.”
He was still stunned, as was I.
“Thank you. Thank you, doctor, ” he stammered.
A month later I was driving home from a night on call. I was stopped at a light. It was one of the few sunny days that we had that month, and everyone was out walking. Suddenly, I noticed a man and his son crossing the street. Mr. Smith. He glanced briefly at my car, looked right into my eyes, and moved on. Did he recognize me? I was back in street clothes, hidden behind the glare of the windshield, but his gaze penetrated through me, like a knife. I froze for a moment, and then slowly drove on. Do his son and family know? What is his prognosis? How long does he have? I felt badly for him, but from my perspective of a 27-year-old intern who was newly married, with no children, and feeling like his life was ahead of him, I didn’t grasp the full gravity of this man’s situation.
Fast forward to the present. I am an attending myself, in my early 40s with a wife and children. I have seen and cared for many sick patients since that time. And now I have the added perspective of knowing what Mr. Smith had at stake. I have thought back on this many times. Is he still alive? Did he make it? If he died, how did he live out his last days?
Voltaire wrote that doctors are people who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of which they know nothing. And all this is true. Except that we are all human beings who share the same hopes, dreams, fears, and challenges. Being able to acknowledge this fact in medicine is sometimes one of the hardest things to do. As physicians, there is no course to teach us how to do this, no textbook or online resource to help. The only resource is personal experience.
In this era of medicine where things are becoming more corporate and electronic, it is important, more than ever, that we as physicians remember why we do what we do, and what is at stake. We must, at all costs, preserve our empathy. As physicians, we need to step back a moment and put ourselves in the shoes of our patients. One day we will be in those shoes. Empathy is as important as getting the diagnosis right, and demonstrating clinical skill. If we do not acknowledge this fact, we do the worst harm of all: We objectify our patients, and ultimately ourselves.
Michael Levy is a vascular surgeon.
Image credit: Shutterstock.com