Peter Cho and his wife Shirley
gave me a comprehensive medical history of his hepatitis
B and hepatocellular carcinoma, including treatments
with antivirals and chemoembolization, and imaging results.
Over the last two weeks, Peter had gradually become
worryingly jaundiced. He had no other health problems
and had been doing so well that they were considering
looking into liver transplantation despite him not meeting
the Milan criteria.
After I reviewed Peter with the
fellow, Shirley asked, "Would it be ok if he had a good
night's sleep at home and came back in the morning?"
Usually patients in emergency were too sick to return
home, but as far as I could tell Peter would be fine
for the next six hours and uninterrupted sleep would
be better than a night of ER drama. The Chos continued
to insist, so I arranged for them to return in the morning.
No sooner had they stepped out
the door, I got a stern talking to from the fellow about
sending patients home. "If they can just go, then perhaps
they shouldn't be in the emergency in the first place,"
he shouted. He pointed out that if something were to
happen to the patient, it could be argued that we were
responsible. It would have been a particularly awkward
situation since the staff physician hadn't even physically
seen the patient yet.
Ironically my behind-the-scenes
blunder scored me points with Peter, who said it made
me a "very good doctor." He was the first patient I
ever got a thank-you card from.
QUESTION
PERIOD
The Chos were extremely involved in their medical care,
asking about treatments from the internet, making their
own suggestions, asking a lot of questions.
"What's my bilirubin today? Oh,
it went up from 148 to 151. That's bad, right?" Peter
would ask each morning. With forced enthusiasm, I reported
his lab results twice a day, each time explaining that
a small transaminase rise of 4-5 points was not the
problem he and his wife should be focusing on.
They seemed to hope if they asked
the right question, the right way, then we'd say yes
he could go on the transplant list, or yes that the
ERCP was successful and that his jaundice would disappear.
I was often tempted to skip rounding
on the Chos. I fantasized about a more paternalistic
system where I could just do my work, run tests and
procedures, and not explain or even talk to the patient
until everything was finished and I had all the results.
Yet every day I'd go see the Chos
and patiently answer all their questions all over again.
I spent more time with them than with anyone else on
the ward. Instead of catching up on sleep on-call, I
felt a duty — sometimes a frustrating one —
to drop in just to talk.
HUMAN
TOUCH
Certainly patients want medical competency, but I wonder
if what they truly crave is our time. If presented with
either strictly medical treatment or psychological counselling,
which would they choose? Sometimes it seems like I'm
offering much more of the latter, but do my patients
realize this?
"I try to see all my patients twice
a day or more," my preceptor told me. "They sit around
in their rooms all day doing nothing but waiting for
you to talk with them."
Medicine demands so much humanism
but the system did not provide for it. My schedule was
packed with OSCEs, exams and research, academic half-day,
subspecialty rounds and interdisciplinary meetings.
But no time slot for "speak with patients," even though
it was probably the most important thing for them. Physicians
can't bill more for being more effective communicators.
There are no awards for compassionate medical students
and no heading under which to emphasize the quality
of our patient relationships on our CVs.
When Peter was finally discharged,
I felt I hadn't really done anything. Someone else did
the ERCPs and all I had done was read the lab values
and explain them.
And for that, Peter and his wife
thought the world of me.
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