It seems to me that sometimes the practice of medicine is in desperate need of common sense. I understand about data, testing, pathology, and the need to document everything we do. Nonetheless, despite the beauty of the science of medicine, perhaps we are in need of a little art.
I saw Phil a few weeks ago for an opinion about his lung cancer. It was a “routine” new patient consult. He arrived at the office with his daughter, a pile of CDs and paper in her hands, exhaustion and fear in her eyes. I reviewed the records carefully before I entered the exam room.
Phil, an 82-year-old gentleman, had undergone a thorough medical workup in the prior month, including labs, three chest x-rays, pulmonary function testing, CT scan of the chest, abdomen and pelvis, MRI of his brain, nuclear bone scan, entire body Positron Emission Tomography, bronchoscopy with ultrasound guided transbronchial biopsy and, finally, a CT guided core biopsy of the dominant lung mass. This analysis had proven the presence of widely metastatic non-small-cell-lung cancer, involving liver, bone, lymph nodes and opposite lung. As I pondered the results, I began to construct a tentative plan for palliative radiation and chemotherapy. I entered the room.
Phil sat collapsed in a wheelchair, daughter grasping his wasted arm. He weighed perhaps 115lbs, bones protruding from his skull and jaw such that his ears were as broad antennas from the sides of his head. He was short of breath with a modestly accelerated respiratory rate. Phil was so weak I imagined him falling from his perch. Worst of all, to my deep consternation, Phil was in pain.
There is a change in the eyes when someone has been in pain for a long time, a combination of squint and exhaustion, like a bull almost beaten in the ring. Those eyes do not focus no matter how hard the patient tries to pay attention. Patients shift in their seat, occasionally grimace and project depressed agony. Phil was a nightmare advanced cancer patient, with uncontrollable pain, anxiety and shortness of breath. From five feet away and in less than five seconds I knew Phil had very little time to live.
My job was straightforward. Build a relationship with Phil and his daughter despite their pain and fear, confirming what they had already knew, that he was dying. Reassure them that the suffering was over. Prescribe medicine to get his symptoms under control, order oxygen and figure out where he wanted to spend his final days.
In 30 minutes Phil was headed home, narcotics were on the way and a hospice worker was driving to meet them at his house. I never saw Phil again; he died in his own bed in his own home eight days later.
What astonished me was that it took six weeks and innumerable tests to get to this point in care to which Phil was headed from the start. This man had advanced cancer and had been wasting away for months, which was literally obvious from across the room. It did not require an oncologist, nor maybe even a doctor to make that diagnosis. Why had there been such procrastination in stating the obvious and offering help? A good physical exam and an honest conversation were all that were needed to guide Phil and his family, and most importantly to bring his suffering under control. A little bit of common sense.
This pattern of “care” oncologists see often. Physicians order tests instead of making decisions based on clinical judgment, substituting detailed “workups” for honest conversation. It seems to me that this approach is a failure to confront the patient with basic difficult truths, a tendency of physicians to mask emotional trauma with medical dogma. In Phil’s case that meant more than a month of tests and pain, rather than up front discussion and planning. Sadly, this denied Phil precious weeks that he could have shared with his family and perhaps a few moments of joy.
If we are going to solve the problems in health care and provide compassionate support of our patients, we need to do better. If a test is not going to change therapy or outcome, do not do it. Give patients real choice by giving them realistic expectations. Use basic clinical skills and direct honest communication, rather than a cookbook list of tests and treatments. Open our eyes and hearts, take a moment to consider, and, for God’s sake, use a little common sense.
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