Esophageal Cancer

The phrase immediately makes me uneasy, as my thoughts gravitate to my first "patient", Mrs. B.

I was a ball of nerves, as I always am before doing something for the first time. But when I walked in I had gathered myself and I was all smiles. Other than some ugly tubes coming out of her neck, she was a calming presence. White hair slightly matted by days in a hospital bed, skin worn by hard work and a nasty cigarette habit, she looked frail. But she came alive when she saw me, the power of her spirit seemingly transforming her. We hit it off immediately, and talked like old friends about what had brought her to the hospital, and all the details of her harrowing past year.

It started with trouble swallowing. Food and eventually some liquids would just "stick" in her throat, and she wouldn't be able to swallow them. It started gradually, but after a couple weeks she knew this was no fluke. Something was seriously wrong.

The rest of the year was test after test, and liquid nutrition drinks - the only thing keeping her from wasting away - then the treatment (radiation+chemo). At first it wasn't too bad, but her long course of treatment quickly drained what little life she was pulling out of her Ensure cans. During the interview she made it clear she never wanted to go through that again. One more test. The tumor is still there, but smaller....a good sign.

Fours days after a complicated surgery and recovery, she was feeling great, swallowing most liquids and preparing to leave. i was smiling too. My first patient, an affable lady with a coherent story of her illness (most patients benefit from a little guidance I am learning), was a cancer survivor. How wonderful!

I proudly presented my ideal first patient - my success story - to the group. The attending gently but pointedly asked the group what we knew about esophageal cancer (nothing).

As I researched her illness that night, pride gave way to the icy truth. Esophageal cancer progresses especially quickly and silently, easily passing into nearby tissues and taking up residence in distant lymph nodes - gathering strength off the oblivious patient. By the time symptoms arise, most esophageal cancers have progressed substantially, resulting in an overall 5-year survival rate of only 10% - nine out of ten patients die within five years, treated or no.

Mrs. B was dying in front of my eyes, passing from living breathing companion to a ghost. My research for the following session became a form of grieving...figuring out what could be done, and what her chances really were. I was fighting - if only metaphorically - for a breakthrough to "save" her.

True, all of this was mental exercise, dealing with the newfound possibility of patients dying. I was supposed to be practicing the medical interview. I have years until I actually provide medical care to anyone. But it became real when I learned her story and took on her struggle.

I still think of her sometimes when I'm trying to sleep...never certain of whether I am recalling a survival story or a eulogy.

On the Horizon: MicroPractices

The good Doctor (Charles) says it best.....Click me!

The idea is that doctors use technology and unique business models to keep their costs super-low. This allows them to see fewer people per days -----thus see people for longer than, say, 10 minutes per visit.

A round of emails passed through the med school a couple months ago. Its very interesting stuff for most docs who - just like their patients - are really frustrated with the current doctor-patient relationship.

An article in USAToday...
and one in the Wall Street Journal (via DrCharles)....

This is something that makes me excited about medicine in my time. Yeah, yeah healthcare is broken and it'll only be worse in "my day". But unique and innovative approaches are going to turn medicine on its face, and maybe even "fix" healthcare in the process.

Playing Doctor

I gotta tell ya, I looked the part: dress clothes - no tie for hygiene and a little for rebellion (my dad understands); and white coat - pockets filled with instruments, reflex hammer, tuning forks, and whatever other crap might make me look legit.

Now I had to play the part: this was my first "solo flight" into a complete medical history and physical exam. We've been doing histories for months now, and I feel pretty comfortable with asking open-ended questions, letting the patient tell their story until they stop or their story starts "swerving around", asking some follow-ups or retelling the story as I know it, and being generally charming - side note: old people coincidentally LOVE me.

But today I have to poke, drum on, listen to, and occasionally whack (CVA tenderness) someone in just the right way, step back and look thoughtful, then do it some more. And further, my first time is on a fourth year med student, assigned to (quite convincingly) play a guy who has knee pain. He knows when I don't know what I'm doing.

"Where's it hurt, when, how bad, whens it worse or better, and who are you having sex with?" Of course that's not the exact progression! But it turns out, that last question was key...the kid had the Clap! (gonorrhea). For good form I did every exam there was - its supposed to be a learning exercise for me - but I saved the best for last, yanking back and forth on his knee while he winced and sighed. This guys was good at making me feel like a monster for hurting him, but that's part of the MD stamp I guess.

It was all completely pretend, and at times we'd break role and talk about techniques etc, but for about an hour it felt quite real. I felt both knowledgeable and like a complete fraud simultaneously. Afterwards I was completely drained. How am I going to do this every day, all the time?

The more I reflect on the experiences related to my professional development class (learning histories and physicals), the more I feel exactly the opposite from the above paragraph though. Only months ago, I was completely oblivious to the intricate art of Doctoring....how exacting the interaction is, extracting clues from the words a patient uses to describe their symptoms, and the subtle signs their bodies give up to betray the disease within. I feel like Encyclopedia Brown, my childhood hero.

I had a talk with a family doc at my church about the actual use of history and physical exam in diagnosing disease in these days of billions of lab tests and imaging techniques (ie x-rays, CT, MRI). While "seeing" the problem physically (imaging) or chemically (labs) appeals in its simplicity and covering your @$ from getting sued, what is truly gained other than a much larger doctor's bill?....seriously, that stuff is pricey.

Maybe talking to your doctor and having him drum on your liver is old-fashioned. Now are the days of full-body MRI's and Comprehensive Metabolic Panels.