I will never forget the man who lay in room 1219. I met him in the emergency room on a Friday evening to admit him for severe anemia and he was not excited to see or talk to a medical student. After introducing myself, he said “I’m sorry, it’s nothing personal, but you are just a student. I have to tell you the story. Then I have to tell the story to the doctor and then probably another doctor. I want to talk to the person who is going to make the decisions. I am too tired to repeat myself.” His wife looked very emphatically at her husband laying on the gurney. The frustration in the room was palpable.
After a bout of pancreatitis, he had endured an extensive workup over the past two months for lingering jaundice and worsening fatigue. He was fed up with people telling him that he would be fine and that more time was needed for a full recovery. He knew something was not right. There is a phrase one hears in medicine, “if it looks like a duck, walks like a duck, quacks like a duck, it’s a duck.” The clinical symptoms this gentleman presented with–painless jaundice, severe anemia, chills, and a 60-pound weight loss–clearly suggested to me that he had pancreatic cancer. However, multiple imaging studies failed to identify a pancreatic mass to support this diagnosis.
Instead of apologizing for being just a student, I asked him if I can take a look at the tests he has done up to this point. His wife handed me a stack of papers. I took a few minutes to read over the labs, imaging, and biopsy results and then turned to him and his wife and asked what they understood about this stack of papers. It was very apparent from what they were telling me they had Dr. Googled the crap out of this stack of papers. Dr. Google is dangerous, but it is also empowering. In their case, they knew that his hemoglobin—the test we use to track anemia—was half of what it should be and is half of what it was five months earlier. They didn’t understand why no doctor cared that it had been steadily dropping over the past two months. They also didn’t understand why now was the time he qualified for a blood transfusion. So we discussed hemoglobin and why now was the time he needed to get a blood transfusion. This went on for about an hour. I took test after test and answered their questions about how these were all related.
Deep down I felt very confident he had pancreatic cancer, but there is no way I could tell him and his wife. Being a student that is not my place. What I did tell him is we are missing one piece of information to put this all together, all the abnormal results, and we just need to find it. That piece of information will put this all in perspective and we will be able to get on a path to treating him appropriately. He had more imaging done that evening that was inconclusive, but looked abnormal. He had a scope done and a biopsy of his intestines just past his stomach which per the gastroenterologist did not look right. He sat in his hospital bed over the weekend while we waited for the pathology report to be generated. Sunday I visited him and he told me he needed to apologize for the way he treated me on Friday. He told me something I said to him on Friday really resonated with him. My comment of missing one piece of information changed the way he thought of me entirely. He felt a sense of confidence and sincerity in my delivery that he actually felt I was going to find him the answer.
Monday morning I tracked down the pathologist. Standing in the doorway of his office, he just finished discussing my patient with the gastroenterologist. He turned to me and I asked if we could discuss my patient. He says somewhat dismissively, “Oh yeah, he has pancreatic cancer. I just talked with Dr. Johnson.” I hung my head and wanted to cry a little bit because my patient is 46 years old. He has teenage kids. Just before all this started he was taking deliberate steps to improve his life, exercising more, eating better. Sitting there with the pathologist as he used a green arrow to point out the cancer on the tissue slides, I thought to myself he is going to die before Christmas. It was a heartbreaking reality.
I left the pathologist’s office and had to cry over my patient. I have come to realize there is about one patient per rotation that really hits me hard emotionally and this month it was him. I spent about 10 minutes by myself thinking about how I wanted to walk into his room. I made my way to his room and walked in and said kind of sheepishly, “Hey.” I could tell by the way he reacted someone had already come by to tell him the news. He says, “Well you were right. You found that missing piece.” He felt I was the reason he had the appropriate testing done this time. He felt I was the reason the doctors took him seriously this time. He felt I was his hero. I didn’t feel that way. I felt like a student who had enough time to make him and his wife feel heard. He probably would have gotten the same tests regardless of my presence, but his perception was very different.
My encounter with him and his wife made me realize how important it is to educate our patients, to slow down and make sure it is clear they understand the test results and how it all fits together. We need to tell patients why abnormal values are not always abnormal enough to be acted upon and sometimes we need to be the punching bag for patients unfortunately because they have just reached that level of frustration. Being sick is scary and we as health care providers are the interpreters and need to make sure we do what we can to interpret for people. People know when something is off, but they don’t always know what it means. We as physicians cannot dismiss patients complaints just because it doesn’t fit our mindset or what we feel is a possible conclusion. We need to strive to always be openminded, never put your blinders on too early as one of my preceptor’s would always say. This man may have had a different course if the doctor’s treating him before thought cancer was a possible cause of his symptoms, but it’s clear they were not thinking that at the time. So to my patient in room 1219 you have forever changed the way I interact with patients, peers, and mentees. For my future patients, I hope to always be the interpreter you are looking for and provide the support you seek.