Michelle Cagan - Patient Centered Ethics: Pathography

Jan 21, 2022 at 01:27 pm by pj


    During my third year in medical school, we had two four-week rotations called “flex rotations” where we could choose any specialty we wanted to rotate in. I thought, “Wow, this is awesome, so cool, I am going to do some really flashy specialties that I would love and enjoy.” So, first flex rotation was plastic surgery. That was pretty sweet, let’s be honest. But for my next rotation, my friend had constantly been nagging me to do a rotation that would benefit me more in terms of developing a solid base in internal medicine and preparing me for step 2. That specialty was nephrology. After a lot of back and forth from colorectal surgery to cardiothoracic surgery to all the surgical specialties, I finally caved and said “ok, fine, if will help me with step 2, then so be it.”

    So here I was, first day at XYZ Hospital, ready to start this rotation and absorb and learn as much as I could. Fast forward to the end of my first week, sitting in my room, staring at a wall recounting the past week of patients, thinking about the fact that probably more than half of the patients I had seen will be dead within the next few months. Little did I know, nephrology is a specialty that deals with the sickest of the sick, and often, patients are very near their end of life. I had not truly experienced a rotation like this before and the emotional toll was surprising. I had gone into my second week with a hardened face ready to face another week of death and dying, severely ill, and depressed patients.

    During this rotation, we rounded on hospital patients, as well as dialysis patients at multiple clinics, followed by seeing patients in clinic. It was during my second week, Tuesday afternoon during clinic, when I had met an 89-year-old male patient awaiting pathology results on a lymph node biopsy for which the diagnosis was fairly clear based off clinical presentation and labs. Sitting in my preceptor’s office prior to seeing the patient, I was being briefed on the next patient and his most likely terminal diagnosis of leukemia with life expectancy of less than two years. With this in mind, I mentally prepared for an emotional encounter, fully expecting the patient to be distraught and break down.

     When I first walked in the patient room, on the exam table sat a tall, lively man, wearing a white and blue paisley button down shirt with a bedazzled bolo tie, stark white khaki slacks and black, white and blue embroidered white leather cowboy boots. He greeted me with a smile on his face, and a “Well nice to meet you, young lady.” I instantly felt a change in the somber demeanor I had anticipated appropriate for this encounter, and smiled back, with a “Well, it is nice to meet you, Mr. John Doe, how are you today?” The conversation was pleasant and he laughed throughout as I conducted the patient interview awaiting my preceptor to enter the room to deliver the “bad news.”

    As my preceptor entered the room and sat down, I was expecting the sense of unease from patient to finally come forth, but still, he sat there, smiling and conversing. As my preceptor shared with him the results, there was no change in his smile, no drop in his shoulders, nor any shine at the corners of his eyes. At the end of the encounter, he looked to my preceptor and me and as he smiled even more broadly. He said “I am a happy man, I have lived a full life, I have taken my bike to every mountain I have wanted to bike, I dove into every body of water I’ve wanted to dive into, I’ve visited all the places in this world I have wanted to visit, and I have loved and been loved. I am not scared of death, I don’t feel I have anything left that I would regret not having done or left anything unsaid that I wished I had said. I am a man at peace and have lived a blessed and happy fulfilling life. I’m ready!”

    I think about this patient almost daily now and as I walk into patient’s room, I no longer adopt a specific demeanor I expect is appropriate for the encounter. Patients are humans with unique experiences and can often teach the physician more than they themselves learn during visits.








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