His email started out in a straightforward way, as most of the communications I receive from trainees do. He identified himself as being in his final year of medical school and asked about spending time rounding with me on our inpatient leukemia service. But then he went into territory I didn’t anticipate.
“I am going into surgery and feel underprepared in managing patients with terminal diagnoses,’” he wrote. “I was hoping to spend this elective learning about this as it would be useful to my career in the future.”
Medical students usually don’t enter surgical fields for a love of terminal illnesses. Most are attracted by an approach to medical conditions typified by the braggadocio-laced line, “A chance to cut is a chance to cure.” Surgery remains the most effective treatment for the majority of cancers. But leukemia, similar to other hematologic malignancies, is not a cancer for which surgery is a useful therapy, since its source, the bone marrow, can’t be removed with a scalpel.
I respected him for recognizing that his education was deficient, and also suspected that whatever event had occurred leading to his request must have been traumatizing. He was asking to spend some of his precious remaining time as a medical student taking care of patients who would never be a part of his future practice. I invited him to join me.
The following month, he stood nearby in the hospital’s hallway as my team and I discussed and visited our patients: younger and older people with new leukemia diagnoses, with leukemia that had relapsed, those just admitted to the hospital, and those who had been on our service for weeks. Some hopeful, some despondent, some resolved. Our medical student quietly scribbled information about each patient in a small notepad. After rounds, we walked toward the library together.
“What are you hoping to gain from this rotation?” I asked.
“I’d like to get better at giving bad news to patients,” he told me, pursing his lips afterward in such a way that I construed he didn’t want me to probe any further.
“Don’t take this the wrong way,” I said to him. “I hope we won’t have a lot of opportunities for you.” He gave me a brief smile. I sighed. “But unfortunately it’s almost inevitable that we have some difficult conversations. I’ll give you a task for tomorrow: See if you can learn at least one fact about each patient’s life outside of the hospital by what you observe in their rooms.”
He looked at me quizzically but nodded his agreement to the challenge.
Over the next few days, the medical student accompanied our team into each hospital room, listening intently to our conversations. After rounds, I asked him what he had discovered about one patient, a woman in her 30s who had just been diagnosed with leukemia.
“She has two young children,” he answered.
“Who’s taking care of them while she’s here?” I inquired. He told me he didn’t know. “What does she want to accomplish with her treatment?”
He thought about it. “She said she wanted to see her kids grow up. And she wanted to see her grandkids. Then she started crying. It sounded like she would do anything to be cured.”
I agreed and complimented him on his perception. Next, I asked him about a man in his late 70s who had received chemotherapy three weeks earlier. His eyes lit up.
“He worked as a machinist. And he has a girlfriend!”
“That’s right,” I said. “Have you seen her? Any photos of her in his room?” He shook his head no. “Does he have any children?”
“He has a daughter who lives in California,” he answered. “I haven’t seen her either.”
I nodded. “Sounds like we need to figure out who’s supporting him through this.”
Every couple of days, he and I would chat after rounds about our patients’ lives outside of the hospital, their families, and their goals. We reviewed scenarios of end-of-life discussions, and what our patients — or their families, in situations where our patients couldn’t speak for themselves — might consider in making difficult decisions about their own health.
And we did have this discussion with the daughter and girlfriend of the man in his 70s, who showed up when his leukemia stubbornly returned. He became quite ill, requiring a breathing machine in the intensive care unit. They decided to transition him to palliative care, and he died soon after.
At the end of our time together, my medical student opened up to me about what led to his discomfort with giving bad news.
“On my surgery rotation, we operated a few times on a man who had pancreatitis, and then recurrent infections in his abdomen. He was in the intensive care unit, and too sick to take to the operating room any more. He wouldn’t survive the surgery, and wouldn’t survive without it. When we told his family that he was dying, they got so angry with us.”
He paused, as if replaying the scene in his head. “We were really taken by surprise.” He hesitated, and the look in his eyes became almost revelatory. “But I guess we didn’t know anything about his expectations, or theirs. Come to think of it, we didn’t even know their names.”
Dr. Mikkael Sekeres (@MikkaelSekeres) is director of the leukemia program at the Cleveland Clinic.
