pellicle
Professional Dingbat, Guru and Merkintologist
as patients we frequently see things from our side of the desk. I'm on a news letter where this came up and I thought it may be "helpful" (or at least informative) to read for some
The Long walk
I took the long walk today. The long walk from the operating room to the frozen section pathology suite to a consultation room in the surgical waiting area. The family of the patient whose operation I had just completed was waiting expectantly and fearfully in the room. I was out way too soon. I had started the operation less than an hour before.
The patient I operated on has a hilar cholangiocarcinoma, a tumor at the bifurcation of the right and left bile ducts joining into the single proper hepatic duct at the base of the liver. Bile drains out of these bile ducts into the common bile duct running through the pancreas to release bile into the first part of the small intestine, the duodenum
...
The pathologist called into the operating room and confirmed the presence of metastatic cancer in all of the peritoneal biopsy specimens. We closed the fascia and then the skin. The anesthesia and operating room staff were eerily silent as I pulled off my gown and gloves and began the long walk.
Informing the relatives
I first traipsed back to the pathology suite to look at the slides for myself. I took the Baylor College of Medicine third year medical student with me as we then trudged to the surgical waiting area. I walked into the consultation room with the medical student and we faced the upturned, concerned gazes from the patient's family seated in the small room. They knew from the warning conversation yesterday and from the look on my face the news was not good. I quietly and thoroughly explained what I found on my examination of the peritoneal cavity and the findings of the intra-operative ultrasound. The family, in the stunned and disbelieving early phase following delivery of such information, initially asked a few questions about next steps. I reported this was not a problem I could fix with an operation, and systemic chemotherapy delivered through an intravenous port would be the next treatment to consider. Predictably, I was asked about the success rate of such therapy and I dutifully and painfully informed them chemotherapy would possibly prolong his life by several months, but would have essentially no likelihood of curing him of this advanced stage IV cancer. I added the chemotherapy could be associated with significant side effects and toxicities affecting his quality of life. I delivered a hard, truthful, and delicate discourse on the truly unfortunate situation caused by this man's cancer.
Coping with the bad news
Disbelief and shock turned into tears. The third year medical student, who had asked me if he could accompany me to see how I delivered this difficult and heart-breaking news, quietly slipped out of the door and returned with a box of tissues. I noted with gratification he went from family member to family member and offered them a tissue and a comforting touch of his hand on their shoulders. We academic medical school faculty sometimes worry about the millennial generation being different, and possibly even indifferent. This young man offered me reassurance there is compassion, feeling, and care among our current generation of trainees and there is great hope for the future of medicine as a profession that attracts those who want to provide care and assistance for those in need.
I spent about 15 minutes in the room with the family and answered all questions. I reassured them several times I would be available later in the day and at any time in the future to provide assistance and further information. The family asked me if they could be present when I reported the findings to the patient, and I replied I would bring some of them with me after he was awake and alert enough from anesthesia to understand a conversation.
About an hour after taking the long walk, and after I had spent 10 minutes in quiet reflection sitting alone in a chair in the surgeons' locker room to gather my own thoughts and sort my own emotions, I went with one of the recovery room nurses and fetched three members of the family. We walked to the patient’s bedside in the recovery room where I repeated the explanation of the intra-operative findings to the patient. He was calm but appropriately disappointed. He asked several of the same questions the family had asked, and I reported we would obtain detailed pathologic and genetic studies from the tumor biopsies I performed to guide treatment decisions. At the end of our conversation, he took his right hand from under the blanket and stoically shook my hand saying, “Thank you for doing your best, Doctor.”
Providing medical and emotional support
I have taken the long walk numerous times every year for over 30 years now. Some weeks or months it seems there are more of the long walks, but I realize it is random probability and chance because at times we win more battles with cancer than at other times. It has not become any easier, and the walk does not seem any shorter. The feelings of sadness are no less raw. I am still amazed and impressed by the dignity, grace, and consideration demonstrated by patients and their family members after I deliver bad news and they recover from the initial overwhelming fear and grief. I know I will have colleagues who disagree, but I believe it is important to continue to feel and demonstrate genuine emotion and authentic concern. All of us dedicated to a career in medicine providing care for our fellow human beings must make the long walk on occasion. For those of us in oncology, the frequency may be greater, but it doesn’t mean we are any better at delivering tough information with heartfelt and thoughtful compassion.
In surgery, we may need to make the long walk when, like today, the cancer is unexpectedly widespread and not amenable to the planned surgical procedure. Other times, a complication or problem may occur during an operation for benign or malignant disease and we must dutifully, honestly, and transparently reveal and discuss the event and the implications. Not an easy task because surgeons never want a patient to suffer an unfortunate event or outcome during an operation, and the feelings we have of guilt, remorse, and self-doubt must be subdued temporarily to provide a thorough description and disclosure to the family and patient. In our hospital, the long walk is not very far if one actually measures the distance traversed, but it feels longer over the years as I steel myself for the onslaught of emotion I will face from distraught family and friends. They have the right, perhaps even the cleansing need, to express a full range of vigorous emotion, and our job as physicians and surgeons is to listen and to provide comfort, information, and support.
Final thoughts: Crucial physician-patient-relationship
In this era of rapid accumulation of data and technology impossible to digest and know completely, I feel an imperative to emphasize, teach, and model kindness, concern, and compassion for our patients and our colleagues in all disciplines. As patients, most of us have encountered the occasional physician who doesn’t make any more than cursory physical contact with us and whose eyes are glued to a computer screen while he or she mechanically asks questions typing responses and information into an electronic medical record. Such depersonalization leads to dissatisfaction and disruption of the crucial physician-patient relationship.
We should not forget or forego our humanity despite the pressures of too much information, too much time spent with the mandatory electronic medical record, and too much energy wasted with piles of paperwork, meetings, and insurance verification. If we accept mediocrity in the care we provide, we will have a 100% success rate. If we are willing to push the envelope, if we expect excellent, exceptional, and extraordinary effort at all times, we will have disappointments and failures, but we will also achieve spectacular successes.
I believe as we continue to learn more about preventing and effectively treating cancer, the long walks will become less frequent. Hopefully that will happen sooner rather than later, but cancer is an insidious opponent. We must fight on with our research and clinical colleagues to discover novel treatments and techniques to improve the lives and outcomes of our patients.
And we should provide hope and continued care tempered with earnest, honest, and realistic information and expectations every time we make the long walk.
The Long walk
I took the long walk today. The long walk from the operating room to the frozen section pathology suite to a consultation room in the surgical waiting area. The family of the patient whose operation I had just completed was waiting expectantly and fearfully in the room. I was out way too soon. I had started the operation less than an hour before.
The patient I operated on has a hilar cholangiocarcinoma, a tumor at the bifurcation of the right and left bile ducts joining into the single proper hepatic duct at the base of the liver. Bile drains out of these bile ducts into the common bile duct running through the pancreas to release bile into the first part of the small intestine, the duodenum
...
The pathologist called into the operating room and confirmed the presence of metastatic cancer in all of the peritoneal biopsy specimens. We closed the fascia and then the skin. The anesthesia and operating room staff were eerily silent as I pulled off my gown and gloves and began the long walk.
Informing the relatives
I first traipsed back to the pathology suite to look at the slides for myself. I took the Baylor College of Medicine third year medical student with me as we then trudged to the surgical waiting area. I walked into the consultation room with the medical student and we faced the upturned, concerned gazes from the patient's family seated in the small room. They knew from the warning conversation yesterday and from the look on my face the news was not good. I quietly and thoroughly explained what I found on my examination of the peritoneal cavity and the findings of the intra-operative ultrasound. The family, in the stunned and disbelieving early phase following delivery of such information, initially asked a few questions about next steps. I reported this was not a problem I could fix with an operation, and systemic chemotherapy delivered through an intravenous port would be the next treatment to consider. Predictably, I was asked about the success rate of such therapy and I dutifully and painfully informed them chemotherapy would possibly prolong his life by several months, but would have essentially no likelihood of curing him of this advanced stage IV cancer. I added the chemotherapy could be associated with significant side effects and toxicities affecting his quality of life. I delivered a hard, truthful, and delicate discourse on the truly unfortunate situation caused by this man's cancer.
Coping with the bad news
Disbelief and shock turned into tears. The third year medical student, who had asked me if he could accompany me to see how I delivered this difficult and heart-breaking news, quietly slipped out of the door and returned with a box of tissues. I noted with gratification he went from family member to family member and offered them a tissue and a comforting touch of his hand on their shoulders. We academic medical school faculty sometimes worry about the millennial generation being different, and possibly even indifferent. This young man offered me reassurance there is compassion, feeling, and care among our current generation of trainees and there is great hope for the future of medicine as a profession that attracts those who want to provide care and assistance for those in need.
I spent about 15 minutes in the room with the family and answered all questions. I reassured them several times I would be available later in the day and at any time in the future to provide assistance and further information. The family asked me if they could be present when I reported the findings to the patient, and I replied I would bring some of them with me after he was awake and alert enough from anesthesia to understand a conversation.
About an hour after taking the long walk, and after I had spent 10 minutes in quiet reflection sitting alone in a chair in the surgeons' locker room to gather my own thoughts and sort my own emotions, I went with one of the recovery room nurses and fetched three members of the family. We walked to the patient’s bedside in the recovery room where I repeated the explanation of the intra-operative findings to the patient. He was calm but appropriately disappointed. He asked several of the same questions the family had asked, and I reported we would obtain detailed pathologic and genetic studies from the tumor biopsies I performed to guide treatment decisions. At the end of our conversation, he took his right hand from under the blanket and stoically shook my hand saying, “Thank you for doing your best, Doctor.”
Providing medical and emotional support
I have taken the long walk numerous times every year for over 30 years now. Some weeks or months it seems there are more of the long walks, but I realize it is random probability and chance because at times we win more battles with cancer than at other times. It has not become any easier, and the walk does not seem any shorter. The feelings of sadness are no less raw. I am still amazed and impressed by the dignity, grace, and consideration demonstrated by patients and their family members after I deliver bad news and they recover from the initial overwhelming fear and grief. I know I will have colleagues who disagree, but I believe it is important to continue to feel and demonstrate genuine emotion and authentic concern. All of us dedicated to a career in medicine providing care for our fellow human beings must make the long walk on occasion. For those of us in oncology, the frequency may be greater, but it doesn’t mean we are any better at delivering tough information with heartfelt and thoughtful compassion.
In surgery, we may need to make the long walk when, like today, the cancer is unexpectedly widespread and not amenable to the planned surgical procedure. Other times, a complication or problem may occur during an operation for benign or malignant disease and we must dutifully, honestly, and transparently reveal and discuss the event and the implications. Not an easy task because surgeons never want a patient to suffer an unfortunate event or outcome during an operation, and the feelings we have of guilt, remorse, and self-doubt must be subdued temporarily to provide a thorough description and disclosure to the family and patient. In our hospital, the long walk is not very far if one actually measures the distance traversed, but it feels longer over the years as I steel myself for the onslaught of emotion I will face from distraught family and friends. They have the right, perhaps even the cleansing need, to express a full range of vigorous emotion, and our job as physicians and surgeons is to listen and to provide comfort, information, and support.
Final thoughts: Crucial physician-patient-relationship
In this era of rapid accumulation of data and technology impossible to digest and know completely, I feel an imperative to emphasize, teach, and model kindness, concern, and compassion for our patients and our colleagues in all disciplines. As patients, most of us have encountered the occasional physician who doesn’t make any more than cursory physical contact with us and whose eyes are glued to a computer screen while he or she mechanically asks questions typing responses and information into an electronic medical record. Such depersonalization leads to dissatisfaction and disruption of the crucial physician-patient relationship.
We should not forget or forego our humanity despite the pressures of too much information, too much time spent with the mandatory electronic medical record, and too much energy wasted with piles of paperwork, meetings, and insurance verification. If we accept mediocrity in the care we provide, we will have a 100% success rate. If we are willing to push the envelope, if we expect excellent, exceptional, and extraordinary effort at all times, we will have disappointments and failures, but we will also achieve spectacular successes.
I believe as we continue to learn more about preventing and effectively treating cancer, the long walks will become less frequent. Hopefully that will happen sooner rather than later, but cancer is an insidious opponent. We must fight on with our research and clinical colleagues to discover novel treatments and techniques to improve the lives and outcomes of our patients.
And we should provide hope and continued care tempered with earnest, honest, and realistic information and expectations every time we make the long walk.
