Mama’s Gonna Sing You a Lullaby

I have had patients and their families do strange things during a consultation.   Patients taking notes and recording what the doctor says are pretty commonplace these days, as are answering a cell phone and arguing with a spouse over what really happened while giving a history.  Some patients go to great lengths to disconnect from the process, filing their nails, or flipping through a magazine.   I’ve watched babies’ diapers being changed, snacks being eaten and business conducted by text messaging.  I have probably encouraged this informality—I have a consultation room furnished with a comfortable couch and chairs, with soft lighting.  I think it’s nice for patients to meet their doctor and nurse for the first time with their clothes on, as if they were home in the family room.  I thought I had seen everything, but I learned yesterday that I had not, because yesterday, for the first time in my career, a patient fell asleep during our initial consultation.

 

Now I am not saying that I give the most interesting speeches on the planet about the risks, benefits, alternatives to and side effects of radiation therapy.  In fact—a little confession here—I have given the spiels about the various treatments of prostate cancer and breast cancer so many times, that occasionally, just rarely, after an afternoon meal during the dog days of summer I have found myself drifting off mid-sentence and righting myself with a jerk.  Not very subtle, I know, but forgivable, especially during the early sleepless nights of motherhood combined with career.  No one has ever actually complained that I fell asleep during the consultation, so I suspect that my heavy nodding head and half closed eyes were taken as  Yoda like signs of wisdom and empathy rather than tactless boredom.  At least I hope so!

 

So yesterday was a watershed moment in my lifetime of treating cancer patients.  A middle aged woman, otherwise in excellent health, had been given the diagnosis of breast cancer after a routine screening mammogram.  She underwent a lumpectomy and was found to have ductal carcinoma in situ, the earliest detectable form of breast cancer, Stage 0.  She was referred to me for consideration of postoperative radiation therapy, and was seeing me for the first time with her husband accompanying her.  She was lucky—her cancer was detected so early that the likelihood of relapse was low, no matter what treatment she chose.  As I launched into my time worn discussion of her good prognosis, and the finer points of radiation therapy, she suddenly interrupted me, saying, “I just got back in the pool and swam for the first time since my surgery.  I love to swim.  It’s great exercise, but now I am really tired. Do you mind if I lie down on the couch here?”  There are many reasons why I am not a psychiatrist (see three previous essays on the subject for reference!) but generally speaking, I am okay with couches.  I said, “Sure!” and continued to talk.  As I neared the topic of CAT scan based treatment planning, to avoid treating her heart and left lung, I noticed that her eyes were closed.  A few minutes later, a slight snore escaped her lips. Her husband sat at rapt attention, but my patient was out like a light!

 

I am choosing to take this as a sign that she was very, very comfortable with me.  But in the meantime, I think it might be time to spruce up my dog and pony show, for sure!

Let’s Get Physical

In his great book “Cutting For Stone”, Abraham Verghese describes one of his main characters, Dr. Marion Stone, as being obsessed with a certain aspect of the physical exam.  Dr. Stone, as the dictatorial chief of surgery at a major Boston teaching hospital, has drilled into his residents the necessity of performing a rectal exam on every patient.  One intern forgets to do this, and is so terrified of his mentor’s wrath that he proceeds to chase the newly discharged patient out on the street and into a bar to do the deed.  On that particular night in the place where everybody knows your name, “bottoms up!” takes on a whole new meaning. In real life, Dr. Verghese teaches at the Stanford University School of Medicine, and is as devoted to the art of the physical examination as Dr. Stone is in the book.  In a New York Times article published two years ago entitled “Physician Revives a Dying Art: The Physical”, science writer Denise Grady rounds with Verghese and a group of third year medical students who are clearly impressed watching a master clinician point out the stigmata of liver disease and diagnose cerebellar ataxia without a CAT scan.

All medical students are taught to do a careful physical exam. When I was a student, we practiced on real patients. Now there are “standardized patients.” Trained actors are paid to report certain symptoms, and to say ouch when the student hits the right spot. Quite amazingly, there are ladies and gents who get paid to teach the finer points of the gynecologic and rectal exams (as one of my colleagues joked, “Here’s your paycheck ma’am, and would you like a psychiatric consult with that?”) In the fourth year of medical school, a test is administered nationally where students go from room to room encountering 10 or so such standardized patients, and are given 15 minutes to take a focused history, perform a specific aspect of the physical, and write up their findings. They must pass this test to graduate.  So what happens to our students between the time they finish medical school and when they become your family physician who spends 5 minutes with you typing on his or her laptop, “takes a listen” through your shirt, signs a stamped prescription for a Z-pack and sends you on your way?  Time pressures, limitless technology at our disposal, fear of malpractice and fewer opportunities for bedside teaching have all contributed to the demise of the detailed patient exam.

My chosen specialty of radiation oncology has become perhaps the most technology driven in all of medicine.  All of our treatment planning is done from a CAT scan—nearly all radiation therapy departments have their own scanners.  We are fairly low down on the food chain of medicine when it comes to making discoveries on a physical exam—by the time the patient sees us, with the notable exception of head and neck cancer patients whose tumors are best cured by a combination of chemotherapy and radiation, those tumors have been scraped off, whacked out, frozen, melted or otherwise assaulted.  Oftentimes there is nothing really to examine—I have mentioned before my mentor who said “Radiation works best when there’s no disease!”   Knowing that my CAT scanner is just around the corner, I sometimes feel a little silly doing a thorough physical exam.  So you can imagine my complete shock a few months ago when asked to examine a patient who had some very nonspecific complaints of fever and malaise on her first day of treatment, and to hear a big WHOOSH WHOOSH WHOOSH as I listened to her heart. I looked back at my initial physical—there had been no heart murmur two weeks earlier.  I sent her directly to the hospital, and 24 hours later she was in the OR having both her aortic and her mitral valves replaced for acute bacterial endocarditis, an infection of the heart valves brought on by an infected chemotherapy catheter.  I can only imagine the eye rolling that took place in the emergency room when the radiation oncologist called in a case of endocarditis—I mean they all know we’re the guys in the basement playing with computers and pushing buttons!  It was not the first time, but it was probably the most important time that my three years of internal medicine training had a huge payoff for the patient.  It saved her life.

In the NYT interview, Dr. Verghese said something else about the physical exam that struck me as an uncommon truth.  He said that a proper exam earns trust, and is the ritual that transforms two strangers into a doctor and a patient.  My daughter is interviewing for an internal medicine residency at Stanford next month.  If she ends up with Dr. Verghese as a mentor and teacher, she will be very fortunate indeed.