When I Was Young

I am in Boston, on the twenty sixth floor of the Copley Marriott Hotel, waiting out the storm. I have not been to ASTRO, my professional society meeting in three years.  I passed when the meeting was in San Diego two years ago, and Miami last year so that I could come to Boston, because I did my residency training here, started my career and my family here, and lived here for fifteen years.  And besides, New England is so lovely in the fall.  I chose my hotel carefully—not too far from the Convention Center, and very close to the restaurants and shopping in Back Bay.  I had it all planned.  All except for Hurricane Sandy.  I arrived here with my office manager on Saturday night, and managed to get in a half day at the meeting yesterday.  Today they “called it” at noon, and here I am back in my hotel room.  Tonight’s parties have all been cancelled but there seems to be a lively crew at the hotel bar.  I’m sure I will be joining them shortly.

We all say that we attend these meetings to learn what’s new in our field of radiation oncology, but the truth is that it’s very hard to learn anything when you run into an old teacher, or resident, or medical student between each lecture and it is ever so much more fun to sit and talk.  I bumped into one of my very first residents yesterday afternoon.  I mentioned that I had been writing down some of my old stories, and she piped in, “I have one for you—it’s about you!  I’ve never forgotten it.”  I said, “Oh, do tell me.”  I was a first year attending, and being responsible for a resident was a frightening prospect, although I tried very hard not to show it.

She said, “It was during my very first few weeks of residency.  I was called up to the ICU to consult on a 91 year old woman who was at the end of her life, on a ventilator.  The situation was dire, but they called us to ask about treating a large skin cancer on her face with radiation.   I knew that there was no way we could get her downstairs to treat her, but I didn’t know what to say on her chart.  So I came and asked you!”    I said, “What did I say?”   She said, “You told me to go up there and write on her chart: SURELY YOU JEST!”

Apparently my sarcastic sense of humor hasn’t changed much in the twenty seven years since that day. It’s how we oncology folk get through it all

A Room With a View

Space is always at a premium in any bustling medical office, and my department is no exception.  In the four years that we’ve been open, the patient volume has nearly doubled.  We’ve added a second physician, a second nurse and several additional radiation therapists.  My office manager does financial counseling in her tiny office that is more like a closet, and my physicist has doubled up with his own physics resident. Now we have a rad onc resident rotating with us and we’ve had medical students nearly continuously since July, both welcome additions to our daily routine but our “zen” is being stretched a bit thin. The question has come up—where do we put everyone?  As we walk the hallways looking for walls to knock down and more closets to turn into offices, all eyes turn to me, and it is clear that the vultures are circling.  Everyone wants my consultation room!

Long ago my mentors taught me two important concepts.  First, that it is the very first meeting with the patient and the family that gives them the lasting impression of the department and the doctor—first impressions do count.  Second, that talk about cancer and radiation therapy is threatening and scary and is best served up when the patient is fully clothed, in a comfortable chair, preferably in a room with a window.  Not that anyone wants to jump out of course, but somehow the sunlight pouring in makes patients feel like there is an escape hatch from that claustrophobic feeling they have when they suddenly realize that their lives have been forever altered.  As a consequence, all of the departments that I have built or directed have had a room, simply and comfortably furnished, where the patient and his family or friends are taken for the initial part of the consultation.   My consultation room has a couch, a coffee table and two large armchairs .  Landscape photos line the walls and the picture books on the coffee table are mine.  The large window faces south, and the sun streams in all day.

By the time we move to the actual exam room, there is an ease, and a familiarity, like we’ve all just met some old friends over coffee and the undressing and gowning for the physical exam goes smoothly and quickly. From our “customer satisfaction surveys” I would venture to say that most patients leave a lot happier than they enter.  So as we walk the halls looking for more space for our growing department, I tell my vultures to back off—that the large sunny consultation room is sacred and it is not going to go away because it is a neutral space between the fear of the waiting room and the vulnerability of the exam room. It is the space that makes my patients feel like they are human beings, not specimens, not tumors, and not cattle waiting to be prodded down the chute to an uncertain fate.

Now all that being said, there are two little issues I’d like to raise.  First of all, whoever took my coffee table book containing lovely photographs of our local community, could you PLEASE bring it back?  And second, when I sank into that armchair on that warm summer afternoon, I did not, I repeat DID NOT fall asleep as I was explaining radiation therapy for prostate cancer to you.  You only imagined that I fell asleep.  And it was only for a minute.  Really.

Atonement

At one of the boarding and training stables where I took riding lessons, there was a custom passed down through generations of instructors and eager children.  If a horse managed to unseat a young rider, the slightly bruised and dirty little victim was allowed to pull a few strands of said horse’s tail.  The instructor would braid the strands–black, or white, or grey or red—into a thin plait and secure the ends with rubber bands.  This small symbol of failure was sent home with the child with the pronouncement  “You cannot be a REAL rider until you’ve fallen off THREE times!”   Three braids of horse hair pinned to a bulletin board and a rider you shall be.

As a fourth year medical student, I eagerly embarked upon my “subinternship”, a make-or- break rotation for aspiring doctors where the student was expected to function as an intern on the admitting team, which consisted of two or three interns, a junior or senior resident, and an attending physician.  Each “Sub-I” took new patients admitted from the ER  in rotation with the real interns, and we were supposed to perform a history and physical, order appropriate tests, come up with a differential diagnosis and present the results to the attending physician on rounds the next morning.  My first “admit” was an elderly woman, massively obese, who had been found at home alone on the floor, in an altered state of consciousness.  After an EKG in the ER showed she had not had a heart attack, she was sent up to the floor to be evaluated. No one had been able to draw her blood in the emergency room—they could not find a vein and since she was stable, they sent her on up.  I was well trained in the art of blood letting, yet after two hours of poking and prodding various sites where veins were known to hide, I reported to my senior that I had not been able to coax out a single milliliter.  He said, “Well, go on home then, we’ll get the IV team to do it when they come around to start her IV.”  I arrived the next morning for rounds and terrible news.  At 2 am, my very first patient had had a cardiac arrest, and in fact she had died when the “code” team could not rescusitate her.  But, oh, they had gotten blood out of her then.  Her potassium level was 7.5, incompatible with life.  She had been in kidney failure and we had not known it.  The blood test which had not been done the evening before might have saved her life.

As a senior medical resident, in charge of such an admitting team, I rounded daily with the interns, dispensing sage advice on each patient on our floor.  Three days in a row we rounded on a lady with late stage breast cancer, in the hospital receiving chemotherapy, then given in the hospital due to significant side effects which in those days had few remedies.  Three days in a row, she had complained of leg weakness, which we attributed to the debilitating effects of her chemotherapy.  Of course she was weak, she had CANCER and was getting CHEMOTHERAPY.  On the fourth day, she was to be discharged home.  As we rounded, her complaint of leg weakness had changed.  She said, “I cannot move my legs.”  Indeed, she could not move her legs.  On our watch, she had suffered a spinal cord compression from metastatic breast cancer to her spine and was paralyzed.  Spinal cord compression is one of the most dreaded complications of cancer.  Unless detected in the early stages of weakness and numbness, it is nearly always irreversible.  Almost unbelievably, as an inpatient attended daily by a multitude of students, interns, residents and senior physicians, this woman walked into the hospital and left in a wheelchair, never to walk again.

In the emergency room, a macho mystique presides.  Again, to quote Samuel Shem in “The House of God”, the goal is to “buff and turf”:  Tune ‘em up and get ‘em out!   This somewhat testosterone fueled mentality results in an unstated reluctance to admit patients to the hospital—no senior medical resident in charge of an emergency room wants to be seen as a “wuss” by his or her peers presiding over the floors—the fewer the number of patients admitted, especially at night, the more sleep your fellow residents and interns can get, and the more they will thank you in the morning.  Each patient in the emergency room is triaged by the nurses first, and the senior residents last, nowadays with the blessing of the attending physician, but back then we were on our own in the wee hours.  One night during my senior internal medicine residency, a young healthy man in his early 30’s came into the ER, complaining of chest pain.  He was a budding young chef at an up and coming local restaurant.  He was slightly overweight, a condition which was exacerbated by his chosen profession.  To remedy this problem, he had decided to start jogging.  Earlier that day, he had gone for a three mile run.  During his run, he began to have chest pain, substernal chest pain radiating down his left arm.  The pain had subsided when he stopped, but he came to the ER to be checked out, you know, just in case.  His heart rate and rhythm were normal.  His EKG was normal.  The blood tests which we now do routinely to rule out cardiac muscle damage were in their infancy, and took 8 hours to run.  He had no family history of heart disease.  He had no heart murmur.  He was only 33, for goodness sake!  There was NO way this man could be having a heart attack. No way.  I sent him home.  But, just in case, I scheduled him for a stress test to be done a few days hence.  At 8 am, my 24 hour shift was up, and home I went.  Twenty four hours later, I returned.  In the conference room, the attending was rounding with the interns and residents.  He took report on the previous night’s admissions.  One of those admissions was a 33 year old chef who had returned to the ER less than a day after I had discharged him, clutching his chest in pain and fear, having a massive heart attack.  He was admitted to the ICU. He survived.

Perhaps it is the same with physicians as it is with children taking riding lessons—you cannot be a REAL doctor until you have made three mistakes that you will never forget.  Doctors hate making mistakes, and hate admitting them even more.  This is the reason for the conferences which take place at every teaching hospital in the country called “M and M’s”, which stands for Morbidity and Mortality.  It is where physicians, young and old,  stand up and say, “This is what happened and this is what I learned and that is why I will never let it happen again.”  Rarely do they say, “This is what happened and it was my fault and I am truly sorry.”  When I was in training, the conventional wisdom to avoid malpractice liability was to call Risk Management but to NEVER admit you were at fault.  That was for the insurers and the courts to decide.

That has changed now, for the better.  Now we are counseled that it is better to admit one’s mistakes, and to apologize.  I have my three braids of horsehair pinned to my brain, and to my heart.  And there are probably more.  I am sorry.  Truly sorry.