Happy Holidays, You Might Have Cancer

It was the day before Thanksgiving. The menu was planned, the shopping done. I planned on baking pies and chopping vegetables once I got home. Only a few patients to see that day, one a new patient. Usually my NP doesn’t see new patients, as initial evaluation is left to the physician.

She was flustered about seeing this patient she’s never met. Rushing into clinic to see the NP usually means something is urgent. This particular patient was highly symptomatic following a procedure by another provider. Unable to provide an explanation for her sudden shortness of breath, that provider referred her to our clinic.

The sudden onset and change in her symptoms frightened the patient and her husband. A young woman who enjoyed exercising was panting after walking less than 10 feet. Looking over the results from labwork, procedures, and imaging didn’t reveal a clear picture. She looked at us, pleading for answers with big, round eyes. She held her hand tight as her husband helped answer questions so she could catch her breath.

Imaging showed an abnormality, not explained by the most common diagnosis. The suspicion arose for cancer, though more testing would be needed. By the way her face fell, she had obviously not considered such a disastrous possibility. Her procedure was supposed to be simple and easy. From a cardiac perspective, it had been successful. Now she and her healthcare providers were forced to contemplate more malignant causes.

Despite working in a medical clinic, I’m not accustomed to seeing my patients die. We primarily see patients with atrial fibrillation, a treatable and manageable disease not likely to be the sole cause of death. The interventional team has to worry about death from heart attacks, while the heart failure team deals with high risk transplant candidates or LVAD patients. Cancer is usually handled by outside physicians specializing in other bodily systems and/or oncologists.

Right before the holidays, even the most remote possibility of cancer seemed devastating. It was difficult to hold myself together for the patient’s sake.

One of the research physicians suggested that I begin hospice volunteering. Despite all my research and reading book after book about death, I have little experience with confronting the ultimate partner to medicine. Perhaps it’s best I heed his advice.

Shadowing: MS Clinic

I’ve probably only spent 6-9 hours scribing for the neurology clinic. The provider I worked with is older than the average physician. His expertise lies in the treatment of multiple sclerosis (MS). MS is an auto-immune disease in which the body attacks the myelinating sheaths over the nerves of the nervous system. It can be diagnosed with lesions apparent on brain imaging, but symptoms vary. Usually there is some component of chronic pain, disability due to lack of coordination or difficulty with motor movement, and fatigue.

MS is often confused with fibromyalgia (which is a clinical diagnosis not based on brain imaging). Patients with chronic pain are often over-diagnosed with MS. Though the reasoning may be unclear, it may be a last-ditch effort to diagnose a patient with something, anything that could lead to a treatment plan. Extensive work by Dr. Andrew Solomon has explored how often MS is incorrectly attributed to patients and how to improve diagnosis (as well as how to address the misdiagnosis with patients).

Chronic pain patients get a bad reputation. Some of the negative labels attributed to them are “crazy,” “attention-seeking,” or even “drug-seeking.” I have an aversion to treating chronic pain, which I suspect many pre-meds may have as well. Chronic pain is difficult to attribute to a diagnosis, difficult to treat, and nearly impossible to cure. I’m sure this aversion will resolve with more extensive shadowing and understanding of the physical factors at play.

The provider I worked with is one of the greatest people I’ve ever met, especially as a physician. There are very few people who can make such a strong, empathetic connection with patients. Clinic with him is not like a doctor’s visit, but an engaging conversation in which he and the patient discuss health and treatment options. He is first and foremost a teacher, to patients and staff.

He does not flinch in the face of complicated medical histories, patient pain and emotional struggles, or patient non-compliance. He and his patient come to a truly mutual decision regarding their health and treatment.  He does not shame patients for refusing a certain medication or procedure. The patient only has to explain their reasoning. Whatever it is, he will accept it, as long as they are willing to explain their refusal. The patient feels like they are the one deciding, not the doctor.

I wish I could properly convey the experience of his clinic. He openly admitted to treating me like a resident. In exchange for scribing, he felt he should offer me an opportunity for education. He asked questions and encouraged me to ask questions. All my fear about the lack of neurology knowledge went away. I left more confident and energized. My only disappointment is that I haven’t been able to return for more shadowing.

Have you shadowed in neurology clinic? How was your experience?