We learn early on in medical school that there are certain phrases that cause a great deal of anxiety within the minds of our patients. Once uttered, the mind will fall into an almost mystic ileus, unable to process anything further.
“Your son/daughter/brother/sister/father/mother is dead”
“You have cancer”
“You have genital warts”
and so on and so forth
This isn’t news to anyone. But what they didn’t teach us in medical school, was the wide variety of responses to crushing news, and the resultant effect it has on the psyche of the physicians in charge of the care of these patients.
Last week, I had the dreaded responsibilty of telling two of my patients they had cancer. Not just cancer, but the “you-have-months-to-live” cancer. Both situations were suboptimal. Both patients had been jerked around by the system, misdiagnosed, misinformed. When they finally were referred to our team, one had been diagnosed with pancreatic cancer (essentially a death sentence) with diffuse metastasis throughout his abdomen and secondary small bowel obstruction. The other had been diagnosed with colon cancer with metastasis to the liver (also a poor prognosis).
Patient 1 was an absolute delight to treat. Pleasant, optimistic and incredibly understanding despite the fact that the medical system had failed him. Patient 2 was the complete opposite. Abrasive, rude, arrogant and high maintenance. Pretty much the worst traits a human can possess. Also, his wife was an idiot and equally as abrasive.
I’ve always tried to treat my patients equally, no matter what their race, income, education or degree of malodorousness. I’m usually pretty good at that, leaving prejudice at the door that is. But the amount of counter-transference I experienced the past week was shocking.
I felt incredibly sympathetic (empathetic?) for patient 1. I felt genuine sadness for his wife, his kids, and for the man himself. And I believe it showed – through the tone of my voice, my body language, and the overall length of time i spent every morning with him at his bedside. On the other hand, patient 2 filled me with anger and resentment. And it showed too, I’m sure, despite my most earnest of efforts.
Often times, 4 of us would enter patient 2′s room. The moment he opened his mouth, the charge nurse would leave. Then his wife would speak and a resident would leave. Then 2 more minutes would pass and another resident would leave. Finally, I would have to excuse myself, lest the throbbing blood vessel on my forehead rupture. I would find my team exasperated, frustrated and insulted… fuming in the hallway at the injustice that they had just endured at the hands of such an ungrateful patient.
Both patients have since been transferred from our service, which has allowed me to think. And this is my shameful realization.
Disease chooses its patients. Patients never choose to be sick. Patients never choose to die. It is unfair, it is often abrupt and it is always life changing. So why SHOULDN’T they get to choose to be upset and rude and abrasive? They have just lost all the control they believed they once had over their own life. They WILL die and there isn’t a damn thing they can do about it. Who wouldn’t have a difficult time coping with that?
My cancer patients are important. They are not any more important than any of the other sick people, but they are important because many of them will die – soon. They can choose to be pleasant or they can choose to be pricks, I can’t control that. But for damn sure, I should be able to treat them with patience and compassion. Afterall, what do I really have to be angry about? This is what I signed up for and it should be an honor to be a part of their lives in the end stages. No, it is an honor.
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