Rewriting the Script
Adam B. Weiner
The word came unbidden into my head.
Oh, no. Here I was, only a few questions into Mr. Marlow's medical history, and the feeling had begun already.
I'd often experienced this when I was a pre-med student, spending so much time on labs and textbooks instead of with patients. When I'd begun my first year as a medical student, I'd hoped to leave all that behind. Medical school felt energizing: I was ready to see real patients and start helping them!
Fairly soon, though, I realized that I still couldn't do much for patients beyond taking a thorough history and giving a physical exam. Despite my growing clinical knowledge, I was nowhere near ready to offer clinical interpretations. Whenever a tough question came up, I had a surefire answer: "I'll be sure to mention that to my attending physician!"
Now the dreaded feeling was back. I was working with an attending physician in an oncology clinic, and Mr. Marlow had come seeking a second opinion about his newly diagnosed pancreatic cancer.
Mr. Marlow was visibly ill, breathing with the help of a portable oxygen tank. His muted "Hello" contrasted sharply with the bright, animated greetings of his wife, Catherine, and son, Jack.
Sitting down next to Mr. Marlow, I asked, "Would it be all right if I interview you?"
"Yes," he said faintly, his breathing labored. Then he grimaced and slumped into his chair, clearly exhausted by the effort of speaking.
Trying to hide my dismay, I looked at Catherine and Jack. Their animation had given way to dejection. Clearly, they knew that Mr. Marlow's prognosis was dismal.
Asking him to climb onto the table for a physical exam would be pointless; he was too fatigued to manage it. Besides, his swollen abdomen--probably the result of fluid build-up due to his metastatic disease--was apparent.
So I launched into my list of questions: "Past medical history?... Allergies?... Education?"
Quickly, these queries began to seem irrelevant. As Mr. Marlow grew wearier, Catherine and Jack began to answer on his behalf, but their replies got steadily briefer.
Again the word nagged at me: Useless....
I turned to Mr. Marlow's quality of life.
"Mr. Marlow, how has life at home been lately?"
All at once he looked straight at me. I knew that I'd finally asked the right question.
"Adam, I miss eating," he said. "I miss the taste of food, the feeling of satisfied appetite. Most of all, I miss sitting at a table with my family and sharing a meal together. Now the thought of food makes me feel nauseated. And I'm too tired even to sit with my family."
There was a pause. Then Catherine spoke.
"We know he's not in great shape," she said quietly. "We just don't want to see him suffer any more than he has to, before the end."
A soft, fleeting sound caught my attention. Mr. Marlow was weeping.
Instinctively, I reached out and put my hand on his.
In just a few words, he and his wife had helped me to get a better grasp of their family's situation than I'd obtained from the whole preceding interview.
I realized that they were grieving for much more than Mr. Marlow's impending death, as sad as that was; they were grieving, too, for the way his disease was robbing them of the chance to enjoy their remaining time together.
Now--finally--I felt that I could be helpful.
"I know you're going through a difficult time, but I believe I understand the situation a little better," I told Mr. Marlow. "After I talk to the attending physician, we can try do something to help you deal with the symptoms you're experiencing."
He relaxed into his chair, and Catherine reached for his other hand.
"That would be very good," she said.
Obviously relieved, all three family members smiled at me. Then I left to talk with the attending physician, feeling pretty relieved myself.
Still, I wasn't aware that our encounter had mattered all that much until later, when I bumped into Catherine on my way out of the clinic.
"Thank you," she said, then gave me a hug.
Walking away, I puzzled over both the thanks and the hug. Then I remembered Dr. William Osler's words: "Listen to your patient, he is telling you the diagnosis."
I realized that learning to diagnose and cure disease may not always be the only objective, or even the most important one. Sometimes, a patient's most urgent need is for comfort and consolation--and even a first-year medical student can provide those.
In fact, I thought, I can actually practice giving consolation.
Going forward, I'll try to offer my patients not only relief from illness but also consolation for the hardships that go with it. These are skills that can and should be practiced at any stage of medical training.
Which means that even a medical student doesn't have to feel useless.
About the author:
Adam B. Weiner is a third-year medical student at the University of Chicago Pritzker School of Medicine. "I began blogging (adambweiner.com) about my clinical experiences during medical school in an effort to remember and reflect on moments that have helped me to develop compassion as a caregiver. I am grateful to Dr. Kohar Jones and to Hannah Wenger for offering feedback on this piece and for encouraging me to do more writing, and to Dr. Mark Kozloff, my first clinical preceptor, for serving as a great example of compassion."