Sunday, October 28, 2012

An example on how NOT to break bad news

While on my surgery clerkship during third year, my colleague decided to break some bad news to a patient. The day before, we had performed a hemi-colectomy plus extensive lymph node dissection, which was found to be stage III colon cancer, which was a recurrence (she was "in remission" for several years prior to this surgery). She was a fairly young woman as far as colon cancer goes, in her 50-60s, and she had a very admirable performance status. Being that we had become aware of her poor diagnosis during a frozen section during her surgery, my colleague, "Breanna", decided that she would inform the patient of her diagnosis.

It was about 5:30 in the morning when Breanna decided to enter Ms. Hemi-Colectomy's room. After waking Ms. H-C, Breanna proceeded to ask her many questions regarding her recovery from surgery and her previous experience with cancer. Breanna then decided to divulge the diagnosis to Ms. H-C, while mentioning the fact that it is "not curable" and that "hospice might be able to help you stay comfortable". As you can imagine, tired and lonely Ms H-C did not take to this diagnosis and prognosis well - she began sobbing uncontrollably at her "hopeless" situation. That's when Breanna decided to leave Ms H-C to herself. Breanna came over to me and started complaining about "how hysterical my patient was in there; all I did was tell her the diagnosis. I explained to her that we can get hospice involved - I don't know why she's so upset".

About a half hour later, after Breanna had left the floor, I was rounding on a few other patients when I heard a nurse complaining about something... "My poor patient! A damn medical student woke her up to break the news to her that she has terminal cancer at 6 o'clock this morning, and now she can't stop crying! So I've been in there for the past 45 minutes, trying to talk with her...What the h*** was that stupid student thinking!? It's 6 in the morning and she's all alone!!!"

I was in complete shock - this story is so distressing to me that sometimes I think I must have only imagined it. But this true - this poor woman learned her diagnosis from a brand-new, third year medical student who could barely string a sentence together in normal conversation (she was as close to Asperger's as I've seen outside of my psych rotation), who had no idea what the patient's true prognosis was, and did not even explore the possibility of further treatment. Also, this student also knew full-well that we were NEVER to discuss the diagnosis before the attending had time to break the news to the patient first. I honestly don't know what came over her and made her decide to break the news to this poor, unfortunate woman.

This is one of the most difficult conversations a physician can have with his/her patient, one which requires a lot of experience, tact, and respect in order to be done properly. It's a conversation that patient will never, ever forget - so it's unbelievably important to do it right.

But the worst part of this story is the fact that Stage III Colon Cancer can be amendable to treatment. This diagnosis was not implicitly terminal; we do have treatment options available which may offer a significant prolongation of good-quality life with the possibility of a cure.

As a student, I've seen a few things happen that I don't quite agree with, but this was definitely the worst. I can't even imagine how furious the surgeon was when he discovered what had happened - luckily we moved on to the next service before he found out. I don't want to know what he would have done to Breanna...

Tuesday, October 16, 2012

Pathology: Days 4-17

Now that I'm nearly finished with my pathology clerkship, I suppose its time to give you all an update of what it's like "in the basement" of the hospital!

I spend most mornings in conferences with other specialties, showcasing the biopsies and cellular morphology of various surgical and cytological specimens and integrating that information in to the patients' care plans. From there, I have had different experiences, ranging from visiting each section of the lab (immunology, blood bank, microbiology, molecular genetics, chemistry, etc) to attending frozen sections to assisting in the gross lab (where we cut up the surgical specimens before examining under the microscope) to examining slides under the microscope for hours on end. The afternoons consist of either conferences, teaching sessions, or more time with the microscope. I'm surprised by how much I'm picking up, considering that there isn't too much teaching going on for the students (the residents get a very good education, but it is usually too intricate or detailed to be of much use for non-pathology physicians). 

I can't complain about the hours. They've been really nice. I only wish that I could learn more and utilize my time in work a little bit better. During third year, I would always have a book with me and I would study during any down time; since there aren't any shelf exams this year (and I don't have a good textbook on pathology), I'm not finding my time to be managed very well. But no complaints, I have had so much time to read for fun and socialize with my peers instead of always having my head in a book.

This week, I performed my first frozen section on a lung specimen - it was a lot of fun to do. You have to cut the specimen that you want to investigate, measure it (of course), then place it in a block to be "flash frozen" before slicing it into 4-8 micron thin slices and placing it on a slide - carefully - before finally staining it and examining it under the microscope. What we diagnose under the microscope directly influences how the surgery is continued, so the job is really important. For instance, if a patient is undergoing a lung resection for presumed squamous cell carcinoma but is found to have small cell, surgery is not going to be beneficial for this patient and the surgeon will end the surgery (but might have completed a lobectomy had it been squamous cell). So the job is vital - and the diagnosis is so crucial. It's also kind of fun because the surgery basically stops until a diagnosis is declared - brings a bit of excitement and a rush to the otherwise slow-paced world of pathology.
A frozen section:

I have a lot of respect for pathologists. The diagnoses they make directly impact patient care, and there is really no room for error (even though medicine can definitely be ambiguous). 

Wednesday, October 3, 2012

Happiness is a Fourth Year Med Student

This post is for anyone stuck in the preclinical years of medical school, thinking that those days will never end, studying 12+ hours every day, dreaming of one day being able to actually talk to a patient (nevermind actually help them!). It's a long road, but here are a list of things you have to look forward to during the first few months of your fourth and final year in medical school:

  • Determining and officially declaring your chosen specialty.
  • The moment you submit your application to residency programs after compiling the application and documents over several weeks/months.
  • Accepting your first interview offer.
  • Finishing the last exam of your medical school career.
  • Getting the results from your last exam of med school.
  • Reading through some really thoughtful and personalized evaluations from attendings you've worked with.
  • Seeing third years studying for the shelf exams, relishing in the fact that you've already taken them!
  • Having the weekends off (I haven't worked a weekend since I was on neuro back in April!)
  • Compiling a "Fourth Year Bucket List" (it's already a full page long)
    • Consisting of things such as: Enjoy a weekend in Chicago, Spend Christmas in England, but also some more mundane things like: Go To the Art Museum, Run A Half Marathon, Visit (a nearby city), Check Out the Casino, etc.

AND a few extras that have made me so happy in the past few weeks:

  • I became an auntie for the fourth time (reminding me of how much I love newborns, life is truly amazing!)

  • My little sister is engaged to a really great guy, making up a really perfect couple...!
  • Planning my wedding while my sister plans hers is really great! I love sharing this experience with her!
  • My eldest brother and his wife are pregnant with their third child! Due Date is a few weeks before my wedding! I love that our family keeps growing!
  • My fiance returned from a 17-day trip to England to visit family - so happy to have him back in my life!
  • I have time to do SO MUCH STUFF because I'm only working around 40 hours/week with WEEKENDS OFF!

Monday, October 1, 2012

Step 2 CK Results

I am beyond ecstatic!!!!! I am so happy that, after 7 weeks, I finally know my result - I exceeded my expectations and got a score higher than I had even hoped for on my Step 2 CK Exam!!!!

On Wednesday morning, I logged on to the NBME, started shaking like crazy, with my heart pounding out of my chest and hyperventilating. I downloaded my score report, opened it up, held my breath, and glanced at the word "pass". I decided I could breathe a little..! Then, after taking a big deep breath, I scrolled down the page, and I saw a number I totally didn't expect. I rubbed my eyes and re-checked it, to make sure I saw it correctly. I suddenly realized that I really did do that well, put on a huge goofy smile and started to tear up. Seriously, tears of pure joy started filling my eyes, and I just wanted to giggle & giggle. I cannot adequately describe how good it feels to have something you have worked so hard on come back with results that exceeded your highest expectations. I think I'm still in a bit of shock...!

I have had a lot of really great moments during my medical school career: white coat ceremony, humanism in medicine elections, connecting with patients, giving well-put together presentations, making friends, watching my knowledge base grow, getting pimped and knowing all the answers, and getting compliments from the attendings that I really look up to - but none of that even compares to finding out my results. THIS is the happiest moment of my medical school career!!!!!!!!!!

And you know what's even better? I bet there will be several things in the coming months which will surpass this - like matching into my residency program and graduation. Fourth year is pretty great...!