Today I met a 23 year old with terminal cancer.

Today I met a 23 year old today who is dying of metastatic cancer. I’ve met terminal patients before and had the opportunity to work with a doctor delivering palliative care in one of the city’s hospices, but today was different. Today it was hard to dissociate myself from the patient, it was hard to separate myself from her situation. She was young with a family and under other circumstances could have been a friend and this was different than what I was expecting.

I arrived early today for my patient assignment. Today the goal was simple – I would have an hour to complete a history and physical for an unknown patient. After I had done this I would have to present my findings to the attending doctor who would then discuss the case in further detail. After the case presentation we would then head back to the patient where the doctor, myself and another student would go over the findings once again and review aspects of the exam that I had missed. I was nervous but excited – this is the closest I have come to actually practicing medicine after 2 years of study!

Things went smoothly this afternoon. I was primped and pressed, wearing a tie and a little white coat. My stethoscope and id badge in clear view, a small satchel containing some clinical exam books and other paraphernalia I thought I might need or use (an otoscope, tendon hammer, measuring tape, marker, etc). I arrived 5 minutes early, presented myself to the secretary. The secretary passed over a little sticky note that had the patient’s name as well as a chart number written upon it, promptly paged the attending to tell him I was there and ushered me up to the 4th floor. On the 4th floor I made a bee line to the nurses station where I introduced myself (always, always be nice to the nurses) and asked to see the patient’s chart.

…….hmmm, ok – age (23), id, latest vitals by the nurses (thank-you…I’ll make a note of this in case the attending asks), chief complaint – the big C. Cancer. Worse yet. Metastatic cancer. The medications tell me that this patient is on a second line of chemo – this is confusing because this is a young adult and not one that I would expect to have cancer advanced to stage where it is essentially incurable.

“Excuse me”, I ask the closest nurse, “Is this patient on palliative treatment?” Thinking that perhaps I have made a mistake and that the cycle of chemo is not really meant to be palliative.

The nurse looks through the chart for a moment, leaves and comes back with different file. “Yes – it looks like this patient is receiving palliative care.” I finish my notes and hurry to the patient’s room as I am already behind on my allotted hour.

Like I say I don’t know what I was expecting. I had read 23 years but I think I was still looking for someone older. I am standing in the doorway looking into a room with a number of different people – mother, husband, small child, and friends. Amongst these people there is one that is sick and dying. For a moment it is the worst game of “Where’s Waldo” that I have ever played. I mean it could be anyone here – or it could be the slight, thin woman on the chair in one corner of this too small room.

I start into my dialog – this is the part I’m good at – the introductions, the making of people feel at ease, lightening the mood at little. I can be personable, and in this scenario I am in some ways auditioning to not only gain the trust of the patient but also all the family and friends present. One wrong move and it won’t be the patient that I will have to worry about, it will be her mom – chasing me down the hallway battering me with her handbag. But today I prevail, and manage to weasel my way close enough to the patient to begin the interview.

Even though I have made a good first impression, I am still not out of the woods. The patient is guarded, her mother present and her husband watches from close by. It’s hard enough to gain the trust of one person in a short period of time to a point where they will talk about about intimate details, but it is exponentially harder to gain the trust of multiple people in the room and yet (somehow) I am able to do it. This means that after 30 minutes or so I can finally begin to talk to the patient in earnest and hope to get a smidgen of the physical done as is expected of me by the attending doctor.

The details of the interview are of course private. The only thing I can say is that it occurred to me that my impression of this person’s disease and her impression of her disease were completely different. In some ways the sheer idea of a terminal disease, especially someone younger than me, is terrifying. For the patient, the disease was a challenge and a cure was the hope. I knew from her chart that she will die soon, but I couldn’t say if she had been told by her doctor as to how bad the cancer in her body really was…and honestly who really could sit her down and take away the little hope she has with such a brutal discussion. I have a respect for those who do this, who work with the dying. I have seen how they have frank discussions with patients still not ready to accept and I could see one such talk happening in this persons future and it made me sad.

For the moment, I take comfort in that the person I met today is surrounded by friends and has a beautiful family. For her, she will have love and support until the end. And for me, I have her to thank for time that she gave to help with my learning despite it being the most limited thing she has left.

Pediatrics, Week 1

This is the first week of the the last block of this semester … thank god. I’m actually at a loss of what to say as the weeks have begun to blur into one another. It really doesn’t matter whether its a weekday or weekend the schedule is pretty much the same give or take a couple of lectures. The routine centers around studying – with the goal of making it through the material a couple of times before the tests hit. Some, it would seem, are first pass, high yield types – who simply read the notes once and retain enough to write the exam. I am more of a multiples man myself. I need a good twice to three times through the notes before I feel confident. The first pass is always the most time consumptive and then I find I can focus on areas of weakness.

Aside from exam preparation there is little else going on. The rest of the class found out what their third placements were on Friday. The six of us who made it into the community hospital program were excluded from the draw, as our fate has already been decided. Still, for the rest of my classmates, Friday held a certain excitement as third year became that much closer. At this point in the semester you really take what ever you get that’ll motivate you to keep at it, to keep the focus, to maintain the discipline needed to push on through for another month. It’s all good – the end is in sight and there are exciting things in the not-too-distant future to look forward to!

Reproduction, Week 4

It occurs to me that winter is refusing to go this year. It’s hanging on, fighting spring with tooth and nail. I step outside yearning for a little sunshine but get, more often than not, more rain and cool temperatures. The winter season has seemed long and reflects the semester which is dragging on in excruciating slowness while passing at a frightening rate. That is to say that as much as I want things to be finished for the semester, I am dreading the coming exams.

Today was the last day of our reproduction block. Come Monday we start the last block of the year (Growth and Development) with a new group for PBL. I am hoping that the material we cover in the Growth and Development block is lighter than the other material that we have covered so far in the semester but I know it’s naive to do so. The Reproduction block had more material in it that I think I, or my peers, were expecting and has added another pile to the growing stack of paper that I need to review before exams hit in a month. It’ll get done by the end, it always does.

And it’s not all bad…in fact despite the growing piles of work and the approaching exams I am in pretty good spirits these days and I would guess that most of my friends are as well. I think the bulk of this stems from anticipating the summer and all the things it brings, such as the rural placement and a little traveling on the side. I also think that the goal of third year is a lot more real, a lot closer than it ever has been before and people are excited about this. I know that I am.

My excitement stems from the fact that I just found out that I got accepted to third year program offered by the school in a smaller community hospital. What this means is that a small group of students, six in total counting me, will complete their clerkship year in a community setting as opposed to working within the larger city hospitals. There are advantages either way, but given what I know about myself and learning habits I thought it would be best to work in a smaller center as opposed to the larger urban one. My excitement also stems from the fact that several of my friends also got accepted, which is an unexpected bonus in many ways. Confirming my placement this past week has buoyed my spirits and given me something to look forward to in the fall…but I am getting ahead of myself here. I had better go crack a book because there still much work to be done before the semester is over!

The sweet art of fertilization…

Watch and learn…

This is from Ads of the world (here), and is an ad for Centea, a banking company in Belgium. It seems to fit with the theme of the week. Enjoy!

Reproduction, Week 3

I don’t know what to say other than it has been a busy couple of weeks. I am currently trying to stay afloat of the classes I am currently taking while studying the classes I have finished. On top of this there is love, life and everything else which all require time, a resource in short supply right now. I am more focussed than I have been at any other point in the semester so far, which is feels good (it’s about time!).

In school the past couple of weeks have continued to cover aspects of Reproduction (primarily focussed on female health). Last week (week 2 of Reproduction) covered menopause, while this weeks material covered childbirth. Of the two weeks, there seem to be a large number of resources and groups dedicated to childbirth vs. menopause, even though far more women will experience menopause than pregnancy. Interesting …

Perhaps one of the neatest resources I came across this week was the childbirth video posted above. The short video is from a company known as Nucleus Medical Art, which specializes in medical illustration, animation and interactive media. The animation is one of the companies most popular having been viewed well over a million times on YouTube. It’s well done and makes the process of childbirth look graceful. Take a look and judge for yourself.

Other than classes, this is the time of year people begin to look forward to the third year of medical school, as rotation options for the clerkship year are now available for us to choose. The biggest decision at this point is whether it is better to do “the big three” (that would be paediatrics, surgery and internal medicine) first or second semester. Of the two 6 month semesters in third year, the one which has the “big three” in it is usually the harder of the two. Some students choose on the basis that they need to have experience in the smaller rotations (Psych, Derm, ER, Ortho, etc) to gain the confidence to tackle the larger, more intense ones. Other students would rather jump into the harder rotations first, when they have the most energy and enthusiasm for school (i.e. right after summer holidays). There is a third option available, which is the one that I’m leaning toward, and that would be to do the third year in a smaller community based hospital. The deadline for everything is the end of this week (hey that’s today!)…and the results will be out by the end of next week. So until then – I’ll keep you posted as to how things turn out.