December is not a good month to be a family doctor, or any doctor for that matter. I have lost count the number of bad diagnoses I have had to give before Christmas. What an incredibly shitty way to end a year.
“I’m so sorry to have to tell you this, but that lump in your groin is lymphoma.”
“The biopsy has confirmed it’s malignant melanoma.
“Unfortunately, your baby stopped growing around 9 weeks of pregnancy.”
“The lump in your breast is suspicious for cancer.”
January is sometimes even worse. Who wants to start a new year with bad news?
Every year I feel like I’m back here lamenting the fact that it’s supposed to be a magical time of year, these “holidays”, and I’m forced to give more people more bad news. Can’t I just have one year where everyone is healthy? Is that really too much to ask for?
Day 28. National Blog Posting Month
I am actually looking forward to the weekend. It has been a hellish week at work (see my earlier posts). I’ve been insanely busy with appointments and double bookings and it seems like everyone’s lab tests are abnormal. I was supposed to have a meeting with my colleagues at dinner last night but I felt unwell all day and had to cancel. I thought the stomach virus was coming back but I think I just needed some sleep. So this colleague and I have not actually spoken about the issue that came up this week and rather than hang around this afternoon to do so, I am going to get the hell out of here while I still can. I have no one booked this afternoon, so I am finally going to get home before 6pm which is so nice for a change.
I got to work this morning thrilled that no one was booked after 1 pm and dug in to clear my inbox. And that’s when I found out a patient (60 years old) has had a 20+ point drop in their hemoglobin over the past six months. This patient has other serious problems, a degenerative neurological disease, and really doesn’t need me to call and tell him he’s now anemic and we have to find out why.
For those not in the know – a significant drop in hemoglobin, the molecule in the blood that carries oxygen and is a marker of the bleeding status of a patient, in an individual over the age of 50 is a red flag for a gastrointestinal malignancy until proven otherwise. This patient has not had any overt bleeding events in the past 6 months. The bowel pattern has changed but was being blamed by the medications used to treat his neurological condition. This patient has been declining rapidly with respect to his neurological status but now I can’t help but think there was something going on all along this past year that we are only just now seeing. Could this patient have cancer? I fear the answer may very well be yes.
And why the hell does this have to happen on a Friday and a month before Christmas?
Really? What the F—!?
I saw my colleague’s patient the other day as I was covering her practice for a few days. It’s haunted me ever since. She was diagnosed with a bladder infection last week and I got the culture report back just before the weekend. I had to change her antibiotics. I spoke to the patient on the phone and told her if she still wasn’t better after the weekend to come to see me.
Well she did. While the bladder symptoms appeared to be improving she also mentioned how light-headed and dizzy she was and “oh yeah, by the way, I’ve lost about 10 lbs in the past month.”
I looked through her chart at her recent blood tests. Hemoglobin was normal but compared to 2 years ago, there’s been a 20+ point drop.
Upon further review of her chart, I noted a family history of colon cancer in her mother and stomach cancer in her father. Both deceased.
Oh and she repeatedly refused to be screened with colonoscopy or fecal occult blood testing.
You get the drift.
She’s got cancer and it could have been caught early with a simple screening test.
Yesterday, a news story came up on my FB feed. I’m still thinking about it and trying to figure out how I feel about it. I decided to write about it, hoping it might help me process my thoughts. It’s about a 29-year-old woman with stage 4 brain cancer (glioblastoma, the same kind of tumor that Dr. Greene (Anthony Edwards) on ER had) and she is going to die on November 1. She lives in the U.S., in a state where, apparently, there are laws in place that allow patients to take their own life when terminally ill. She states she’s not committing suicide, rather, she is taking control of her illness and deciding when and how she will succumb to it, not the other way around. Most of the comments posted after the article are all like, “Wow, what a brave woman”, “Good for her”, “I’d do the same”.
Really? I was kind of surprised that no one seemed to question the ethics here.
I can’t even begin to imagine what this woman is going through. To be diagnosed at such a young age with terminal cancer, it’s truly heartbreaking and tragic. One of my colleagues said she’d probably do the same if she were in that situation. I’m really not sure I would, to be honest. Or maybe I would? How can one ever know until faced with the reality?
I have three children. This young woman has none. Would her decision change if she had kids? How would you explain to your children that you are going to end your own life before the cancer gets a chance to?
Death is a natural part of life – granted, dying at 29 doesn’t seem all that natural. Dying at 90 on the other hand, does. Still, we are all going to die, none of us can ever know when or how, that is, unless we are diagnosed with a terminal illness and even then, no one really knows how long we have. Last spring, I visited a patient dying of prostate cancer. I saw him about 12 hours before he passed, peacefully, at home, surrounded by his family. When I spoke to his wife the following morning, she struggled with the fact that she was asleep when he died. I wondered if it would have been easier for her to witness his death? I’m sure it would have been difficult regardless. To the very end, my patient hoped and prayed for a miracle. It was never stated, but you could see it in his eyes. He didn’t want to die; he didn’t want to leave his wife and children. He should have had more time. He kept fighting to the very end. I admired him for that.
I have a hard time knowing that this young woman is going to actively end her life. That she picked the day she was going to do it, much like one picks a wedding day. It’s two days after her husband’s birthday. She has been told there is no cure, that her final days will be spent in pain, perhaps with multiple seizures and it’s not something she wants her family to witness. I understand that, I really do, but there are ways of helping dying patients be more comfortable in the final stages of life. It’s the whole reason Palliative care exists. The process of dying has to remain a natural part of life, once we start helping patients to die, we no longer adhere to the Hippocratic Oath, in my opinion.
First, do no harm. A physician, in good conscience, cannot be a party to the death of another human being. I can already hear those on the other side of the argument – NOT assisting a patient to “die with dignity”, causes harm. I don’t believe it does and I don’t think this is what Hippocrates had in mind when he wrote the Oath. I don’t wish for any individual to suffer on their deathbed, far from it. Medicine has come a long way in the past 150 years – expected death can be painless for the vast majority of patients. I think we are actually inviting more harm to patients, their family, and society as a whole if we decide that assisted suicide, euthanasia, dying with dignity – whatever you want to call it – is okay.
It’s just not.
In the next few days, a family is going to lose a parent, a sibling, a friend, a partner, a lover. This is a family who has come together at the end, in grief and in love.
I witnessed a small piece of this today.
With a heavy heart I knocked softly at the front door, taking note of the “No Smoking, Oxygen in Use” sign.
Upon entrance into the home, the sound of the oxygen tank was heavy in the air. A hospital bed could be seen down the hallway in the living room, and lying in it, my patient. I forgot how one looks during the final hours of life. It caught me by surprise and a lump formed in my throat. I approached the bed and touched my patient’s hand. I said hello, as the personal support worker washed my patient’s feet. I am not religious but was instantly reminded of Mary Magdalene washing the feet of Jesus as he hung on the cross dying. The living room was transformed into a makeshift hospital room. Bedpans, sheets, syringes, bottles of medications, all visible on the bookshelf and lined up meticulously, within easy reach. But this was someone’s home – unopened mail on the coffee table, hospital brochures on dying at home scattered underneath. Half-read books on the couch, an afghan and pillow rested in the corner.
Surreal doesn’t even begin to describe it. The family and I talked, mostly about their loved one and the events of the past few weeks, but also about their plans after the funeral; the trip they will take this summer, to scatter the ashes; the arrangements for the funeral.
I walked for a while after the visit. Trying to clear my head. Trying to imagine what that family is going through, watching their loved one dying in front of them. I wished, for just a moment, that I was religious. Maybe believing in God would help me understand this process of death, what it means and what it leaves behind.
Yea, though I walk through the valley of the shadow of death, I will fear no evil: for thou art with me; thy rod and thy staff they comfort me.
There’s an aspect of being a doctor that never gets easy and that is delivering bad news.
In medical school we take a course called “Breaking Bad News“, but nothing prepares you for actually having to do it.
I’ve had my family practice for 7 years and have been practicing medicine for almost 10. I can still remember every single time I’ve had to give bad news.
- While working at a walk-in clinic, over the Christmas holidays, I had to tell a woman she had pancreatic cancer.
- In my first year of family practice, I told a woman she had cervical cancer.
- In my second year of family practice, I felt a pancreatic mass in a 55-year-old woman; she lived for 4 years after that. I attended her funeral.
- Three years ago, I felt a very abnormal prostate gland and new instantly the patient had prostate cancer.
- A young woman, believed to be about 3 months pregnant came in for an unrelated matter and asked if we could listen to the heartbeat. She’d seen her midwife the previous week and they couldn’t find it. Neither could I. An ultrasound a few hours later confirmed what I already knew. She’d suffered a miscarriage but didn’t know it.
- There was an older woman who came to see me for chest pain. She had been coughing from a cold and had a lot of chest wall pain. An x-ray showed multiple rib fractures. Spontaneous rib fractures. A week later, after sending her for a series of blood tests, I diagnosed Mulitple Myeloma.
- Sometimes a diagnosis of chlamydia can be devastating. It certainly was in the 31-year-old married woman who came in for a routine Pap. Sadly, my bad news was instrumental in her later ending her marriage.
- My first week back to work, I told a man he most likely had kidney cancer. Welcome back!
Every time I have to deliver bad news I am reminded how fortunate I am and how fortunate my patients are for living in a country where, when its required, they have access to timely health care. None of the above patients waited for more than a week or two to see a specialist. Sadly, not everyone survives after being given bad news. I haven’t had to do it very often, but when I do, it affects me personally. Often I can’t sleep for a few days. Sometimes I worry (often unnecessarily) that I missed the boat and should have caught the illness at an earlier stage. Anything else going on in my life suddenly seems not to matter for a while.
Bad news bear.
Sometimes that’s me.
From the time of antiquity, healers, physicians, medicine men have treated their patients in the home. In the United States, up until a century ago, a visit to the home was the standard way of delivering medical care. Today, things are much different. A study published in the New England Journal of Medicine in 1997 looked at the frequency of house calls to the elderly. Shockingly, less than 1% of Medicare patients received house calls from physicians. I suspect that this remains the case.
And let me be clear, what I am addressing here are the home visits by a patient’s primary care physician, not the walk-in clinic doctor opening up a house call business.
The days of your family doctor coming to your home instead of you going to their office, are largely over, I think. Although my colleagues still make house calls, mostly for their elderly and housebound patients, as well as those dying at home, it’s not very often, and I can usually hear them grumbling about it. “Ugh, I have to make a house call.”
I am proud to say that I have made a few house calls, albeit not many, but when I feel it would benefit my patient, I make the effort. Granted, I have a much younger patient population than my colleagues, so the opportunities for home visits are few and far between. I expect this to change as my patients age. I was interested to find out what the state of house calls is in this country, so I looked it up.
In 2010, family physicians in British Columbia were surveyed about house calls. The sample size of physicians who completed the survey was small. After all, who has time in their busy practice to fill out a survey among all the other paperwork? In this study, 73 surveys were completed (250 were sent out). Of those completed, 87.7% stated they had done at least 1 house call in the past year; 31.5% did house calls at least once a month and 16.4% did them at least once a week. What I found interesting was that when the study authors looked at the physicians in two groups – those who graduated from medical school before 1990 and compared responses to those who graduated in 1990 and after, they found:
The 49 physicians (67.1%) who graduated from medical school before 1990 were no more or less likely to have done at least 1 housecall [sic] in the past year than the 24 physicians (32.9%) who graduated in 1990 or later (n = 42, 85.7% vs n = 22, 91.7%; χ2 = 0.53, P = .47). However, 11 (22.4%) physicians who trained before 1990 did housecalls at least once a week compared with only 1 (4.2%) physician who trained in 1990 or later (χ2 = 3.92, P = .048).
Younger physicians are doing about half the house calls their older counterparts are doing and even less are doing them once a week. The tide is turning, indeed. Even more interesting, is the report from the National Physician Survey:
The National Physician Survey reported that, in 2010, only 47.8% of British Columbia (BC) family physicians offered their patients housecalls and 0.9% described housecalls as a specific area of focus in their practices.2
Family doctors seem to prefer to see their patients in the office, not in their patients’ homes. I can understand why – it’s more convenient to stay in the office, travel time in the city can be a nightmare, and remuneration may leave something to be desired. After all, in the time it would take to travel to visit one patient, a physician could see 5 – 10 patients in the office.
A lot can be learned from visiting a patient at home. For example, an 85-year-old woman who has had multiple falls in recent months; she can’t come to the office because she’s in a cast after having broken her ankle. You, as her physician, decide to take the visit to her home. Upon walking in the door, it’s quite evident why she’s falling a lot – the floors are lined with ratty carpets, even you almost trip on your way in!! The patient’s daughter is also present for the visit and instead of discussing the fracture, the visit is spent discussing removal of the carpets!
I made a home visit this week to a patient who is dying of cancer. I called her husband last week and asked if she was well enough to come into the office. She has a team of doctors looking after her, one of whom is a palliative care physician who makes home visits every few weeks. A visit with me at this point is purely supportive in nature as her palliation is being tended to by the specialists. Her husband said that, while they do make it to chemotherapy appointments, and other specialist appointments, it takes a tremendous toll on his wife and he didn’t think she’d be up for an office visit in addition to their weekly outings. I knew he wouldn’t suggest a home visit – most of the time the last thing a patient wants is to impose on their physician. So, I gently asked if she wouldn’t mind a house call. The pause on the phone was telling. “That would be wonderful for her,” he said. “She would enjoy that so much.” He sounded a little bit surprised that I would offer.
Seeing a patient in their home environment is one privilege of family medicine I didn’t expect. Once you step foot into their home, they cease to be “just a patient”. You bear witness to their real life, to the home they have made, to their hopes and dreams, to their sorrow and sadness. My patient and her husband welcomed me into their home, offered me a delicious cup of coffee and we talked. We talked about her cancer and her pain; we talked about how chemotherapy was going; we talked about the cat I saw roaming in the backyard; they told me how they met in Spain thirty-five years ago; and we talked about their four children. I saw the hope flicker in her eyes when she talked about the chemotherapy that helped her pain and maybe, just maybe, is shrinking the tumors. I saw the courage in her husband’s eyes as he tended to her needs and fluffed the pillow she had behind her back. I saw the profound sadness in her eyes as she struggled to find the words to describe what it’s like to plan her own funeral.
Most family physicians don’t do house calls anymore.
I am not one of them.
Prior to my maternity leave, one of my patients had been diagnosed with pancreatic cancer. She was set up with specialists, I reassured both her and her husband that they were in excellent hands with my locum and promised to be in touch with them as soon as I could. My locum has been keeping me up to date on this particular patient as well as a few others. This patient had major surgery a few weeks ago to remove the tumor and reportedly has been doing well. I read the operative report today. She had a procedure known as the Whipple.
The Whipple is a complicated procedure. I saw one performed once as a medical student and all I remember is holding a retractor for a very, very long time. Generally speaking, pancreatic cancer is not a good cancer to be diagnosed with – I mean, no cancer is, but this one in particular can kill a patient very quickly if it’s not caught early. Thankfully, I believe my patient’s tumor was found early and according to the operative report, the Whipple procedure was considered curative. Curative!! If I believed in God and Angels, I would say she definitely has an Angel looking after her.
Cancer is one of those illnesses that, I believe, touches all of us in one way or another. My mother had breast cancer, diagnosed 12 years ago while I was still in medical school. My mom was one of those women who always did self-breast examinations because she was prone to developing cysts. I remember when I was a lot younger, she went in for day surgery to have a lump removed. It was benign, but ever since then I always remember her feeling her breasts, always checking for something. Well, on one of those checks, she felt something different. Her family doctor couldn’t feel it; the radiologist couldn’t feel it; the breast surgeon couldn’t feel it. But my mom did and the mammogram proved it. She had a lumpectomy about a month later and it was proven to be contained within the breast with no evidence of spread to the lymph nodes. She had 5 weeks of radiation therapy, took Tamoxifen for five years and is considered cured. Her having breast cancer does not necessarily increase my risk as she was post-menopausal at the time of diagnosis, but I still plan on being vigilant and likely will get my first mammogram next year when I turn 40.
Husband’s father was diagnosed with bladder cancer at the age of 62. Like most individuals diagnosed with bladder cancer, he presented to his doctor with gross hematuria (frank blood in the urine). His tumor was small, localized and initially treated with an immune-stimulating drug called BCG (made of the bacteria that causes Tuberculosis). It seemed to work at first but several months, maybe a year later, he developed acute renal failure and it was discovered that the tumor had spread outside the bladder wall and was blocking one of the ureters that drains the kidney. I believe he underwent chemotherapy at that time, as surgery was no longer an option due to local spread. Sadly, he died about a year and a half after the initial diagnosis. His risk factors were his age (>40) and his sex (male). He never smoked, but he did work in the pharmaceutical industry as a pharmacist for many years back in Scotland, so it’s possible he was exposed to some chemicals back then. We’ll never know. As husband has just turned 40, I remind him periodically that he needs to go for his check up.
I remember a particularly difficult case I worked on during my family medicine training. I spent two months on the Palliative Care unit. Palliative care is end of life care. More than that, it is medical care and treatment during the process of death and dying, not only for the patient, but for the family as well. Difficult under any circumstances, but brutally awful in this particular case,which was a 44-year-old mother of two children, dying of colon cancer.
Colon cancer is one of those illnesses you think happens to a man in his sixties. At least it was for me, as a medical student and resident. But those two months on the Palliative care ward taught me otherwise. Almost 10 years later, I don’t remember the details of the case, but what I do remember is that cancer can strike anyone, at any age. My job as a family physician is to be suspicious and cognizant of that fact. Anyone with symptoms of anemia, weight loss, change in bowel habit, vague abdominal pain/cramping, night sweats, regardless of their age – these are all red flags that need to be paid attention to. Sadly for this woman, her physician lacked a certain amount of imagination and her tumor wasn’t discovered until it was too late.
I recently visited the RateMyMD website and looked myself up. I was pleasantly surprised to see several new comments, and yes, they were all positive. (Giving myself a pat on the back right now!) One in particular stood out. This patient was new to my practice, having seen her husband’s physician for many years. This physician was retiring and she sought out a younger, female doctor. She got me. Apparently, at her first annual physical exam with me, I asked her about colorectal cancer screening. She had never had a colonoscopy – it was never brought up by her previous doctor. She had the “home testing kit” done every few years. These fecal occult blood tests (FOBT) are designed to detect microscopic blood – blood not visible to the naked eye. The thing is, not all tumors bleed, so the test might miss one. Colonoscopy is the gold standard test for detecting colon cancer. Guidelines for screening state that all patients > 50 years of age should have one every ten years. However, this usually doesn’t happen because of wait times and cost to the healthcare system. Thus, the FOBT became a test to do in between colonoscopy. Despite the guidelines, most physician will still recommend for all of their patients to have at least one colonoscopy. Apparently, I talked about it enough at this woman’s appointment that she agreed to have one. Turns out, I saved her life. She had several precancerous polyps which were removed during her colonoscopy.
It’s a no-brainer, folks. Screening tests work, be it mammography for breast cancer or Pap smears for cervical cancer. If anyone reading this has a family history of cancer, or is of the age that a screening test is recommended, please get your screening done. It really might just save your life.
A while ago, I posted about how it sucked that every time I go on maternity leave, one or more of my patients gets seriously ill right before I go. I know it’s just part of the job, some of my patients are going to get sick and some are going to die. It just feels worse when it happens and I’m not physically present in the office to get the news.
Well, one of the three patients I was worried about dying while I am off, has died. I got the news the other day that a lovely woman, a patient of mine for 6 years, has succumbed to her blood cancer. I knew it was coming based on reports I had been receiving from her specialists over the summer. I just didn’t think it would happen 2 weeks into my leave. I see most of her family but hadn’t seen them in quite some time. Either they are relatively healthy, or more likely the case, they were busy with caring for their wife and mother. In any case, I am now faced with the question: Do I reach out to the family?
Normally, I wouldn’t hesitate to call the family upon hearing the news that a family member passed away. But I am not working and I haven’t seen the family in almost a year. A part of me wants to reach out, but I worry I may be intruding and perhaps it’s best to just let it go and address it when I see the family again.
And I have to ask myself, am I reaching out for their sake, or my own?