The Good Patient

Saturday, June 27, 2009

 

From Academic Medicine

Evan J. Zucker MD
Published: 06/11/2009

Before medical school, I had taken it for granted that doctors treated all patients equally. My experience caring for a patient on my third-year surgical rotation taught me otherwise.
My patient was a young man, just a few years older than myself. He was a good kid-from the suburbs, a law school student, with two devoted parents. He was tall with an athletic build, dark blond hair, light brown eyes, the kind of guy nurses doted over, someone whose path I might have crossed in other circumstances.
He was otherwise healthy, but he had a problem. Some vague fatigue, a hematocrit in the low 20s, and then the CT, which revealed a massive gastric sarcoma. I was there for his debulking surgery; the morale in the OR was high that day. Nurses played Guess how much the tumor weighs as the surgeon scooped out the bowling-ball-sized cancer in record time. And what an interesting case! A brother with Wilms tumor, aunts with early-onset breast cancer-could it be Li-Fraumeni, we wondered?
And then the surgery was done, and he was my patient. I was the first one to see him each morning, to turn on the light just hours after the previous night's blood draw. From the team's perspective, he was one of our healthiest patients and did not require much attention.
Early on, he complained of some throat irritation and pain with swallowing, likely related to his nasogastric tube, which I faithfully reported back to the team. We spent a few minutes with him and gave him some numbing spray for his throat, but he still complained daily. The team teased, We'll just have to make him your personal patient, now won't we? I could take the hint-in bringing up my patient's throat, I was also wasting precious time on rounds, and so I learned to keep quiet about his complaints.
Yet, the following week, in taking signout with my intern, I found there was page after page about my patient's throat but that the nightfloat had decided not to check on him. While I knew this probably wasn't crucial and didn't want anyone to be blamed, I kept thinking-he was so young, my age. If our positions had been reversed, who would speak up for me if no one would hear me? I broke my silence and brought up my patient's throat again on rounds.
This time, the intern was chastised on the spot for not taking care of things sooner. Yet, when we got to my patient's room, the reminder of our 25-patient list soon caught up to us, and the patient was simply handed the stern Okay, yes ... someone will come back to see you line. The next day, nothing had changed-neither his discomfort nor the lack of attention to it-and yet he had no complaints and tried to crack a smile. I remember looking at him that day. He seemed dirty and disheveled; his hair was now matted and frazzled. A good patient today-no complaints, right on schedule. Today he had given up. Just like everyone on the team, he had learned his place, too.
My patient was discharged shortly thereafter, only to return the following weekend with an intraabdominal abscess almost as large as his original tumor. Probably, there was no way our team could have prevented this. At least his throat didn't hurt anymore.
During my clinical years, I learned more and more to think and act like a doctor. In caring for this patient, I also learned that it is important to continue to take a step back and think about what kind of doctor I want to become. Acknowledging and alleviating what seems like a minor complaint may not be as medically necessary as, say, tumor removal, but such acts recognize and dignify patients' humanity. Doctors may not always get good patients, but we must always be good to our patients.
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