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Last Patient of the Day

Last patient of the day, and of the work week! I was finishing what felt like my Thursday Night Endurance Test, after which I could go home to my family, and eventually to bed.

As on so many Thursdays, I was running behind. My final appointment was with a new patient, Ann Miller. Before entering the exam room, I did some fact-finding.

Age: forty-two, a few years younger than me. (I categorize all patients as either Younger Than Me or Older Than Me.)

Chief complaint: Weight loss.

Ann had been seen recently at an outside facility, where she was evaluated for weight loss, abnormal bowel movements, poor appetite, fevers, abdominal pain. Her labs showed that she was anemic. She’d been diagnosed with a stomach flu.

I felt skeptical of this–she’d lost a good deal of weight, and her prior labs showed no anemia. An image from childhood flashed before me: a yellowing paper taped inside our bathroom medicine cabinet. It was a Reader’s Digest page entitled “Warning Signs of Cancer.” I read it daily while brushing my teeth.

During my medical training, I’d become all too familiar with those warning signs, and their significance. Now I ticked them off on my mental checklist as I considered Ann’s symptoms: Weight loss. A change in bowel movements. Fevers. A change in appetite. Check, check and check.

I need to ask her about night sweats, abnormal bloating and fatigue, I thought, with a growing sense of dread.

I entered the exam room and introduced myself. Ann, a trim, blonde woman, smiled warmly, and I felt an instant rapport with her. As we talked, my awareness of the hour’s lateness slowly slipped away.

In recent months, Ann had felt less and less like her energetic, active self. Her symptoms indeed included night sweats, abdominal bloating and profound fatigue.

Medical providers are taught to constantly sift through a patient’s history and physical findings to form and re-form a diagnosis. That night my brain screamed one thing: Cancer.

During the physical exam, we chitchatted about Ann’s life. She was raising several school-aged children with her life partner, had moved to Boston from Maine and loved the outdoors. She described her church’s progressive values–pro-diversity, pro-LGBTQ+, feminist–and how she worked to teach these values to her children.

As I palpated Ann’s abdomen, my body froze. Beneath my fingers, I felt a greatly enlarged, hard liver.

But the doctor at the other facility wrote that her abdomen was unremarkable! I thought, then recalled that physicians sometimes use a boilerplate exam form that lists everything as normal, unless the physician changes it. Did they use that form and forget to make changes? Or are my fingers mistaken?

I knew that my fingers had told the truth. They’d detected a likely tumor–and I was the first person in the world to know. This knowledge was bad enough, but it also raised a new question: When and how to share my concerns with Ann.

First, though, I needed a witness to what I’d discovered. Still chatting, I asked Ann if I could have a colleague examine her.

I found the only other doctor still at the clinic and brought him back with me.

“Hi, I’m Dr. Toms,” he told Ann. “I hear you haven’t been feeling well. Dr. Adelstein asked me to examine your belly. Okay?” His face carefully neutral, he palpated her abdomen.

Afterwards, we stepped out into the hallway, and he confirmed my findings. My heart sank.

How do you share your concerns about cancer (likely metastatic) with a patient whom you’ve just met? Especially knowing that she’ll go home to her loved ones and begin a painful wait. She’ll wait to get more blood work, a CT scan, a specialist referral. She’ll wait to get a biopsy appointment, wait for the results and finally wait for a plan of treatment. After this will come still more waiting, to see if that treatment works–a game of trial and error that could last months or even years.

I felt distressed and anxious at bearing such news, but I also felt determined to treat Ann as I’d want a physician to treat my own loved ones–to give her a caring, compassionate explanation, and enough time to ask questions and fully express her reactions.

We’ll both go home to our families tonight, but our conversations will be vastly different, I reflected sadly. Maybe neither of us will sleep…but for different reasons.

Reentering the exam room, I sat down with my back to the computer, so I could face Ann, still perched atop the exam table.

Slowly, I began: “Ann, your liver is enlarged, and given your weight loss, night sweats, low energy and bloating, I’m concerned that you may have a cancer. I don’t know what kind; we need to image your belly to get more information. I also want to check some blood work. Depending on the results, you may need a biopsy and further studies. It’s important that these be performed as soon as possible. Tomorrow morning, I’ll make phone calls to ensure this happens.”

Ann took the news surprisingly well. “I had a hunch that I might have cancer,” she confided. “I knew that something really is not right with my health.”

My heart went out to her as I pictured her quietly wrestling with this by herself. Uncharacteristically, I said, “I’m going to give you my email and cell-phone number. If you have questions, I don’t want you to worry alone. I’ll be here for you.”

I was doing my best to share the truth while also keeping hope alive–for us both.

At the visit’s end, we hugged.

“Thank you for taking the time to explain everything so honestly, but so kindly,” Ann said as she left.

The imaging and tests confirmed my suspicions: Ann had metastatic cancer. Over the next few months, she received treatment and evaluated her life goals with her family and religious community, receiving tremendous support from all. I saw her periodically in my acupuncture clinic, where our care helped to ease her treatment’s side effects. Eventually she and her family relocated to Maine, where she focused on healing and living and loving as her cancer inevitably progressed.

Some time later, I learned that Ann had died.

It was the moment I’d dreaded since her diagnosis. I desperately wished I could have given her more time, or cured her disease. I thought of all of the years unlived, the experiences not had, the children she would not see grow into adulthood. And I couldn’t help but think of my own hopes and dreams, adding a reflexive prayer for a long life well-lived, with close connections to my family and loved ones.

Beyond sadness, I felt a sense of shock at the taking away of a vibrant woman. I’d known Ann only during the “cancer phase” of her life. Had we met under different circumstances, I feel sure that we would have become friends.

I hope that I brought comfort–even joy–into her life. At the very least, every time we saw each other, I did everything I could to help her live the best life possible, and to foster our genuine connection.

Years later, I still think of Ann. While the details grow hazier in my mind’s eye, my heart remains grateful for the privilege of caring for her.

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Pamela Adelstein, a family physician, is the medical director of family medicine at the Codman Square Health Center in Dorchester, MA, and a clinical instructor at Boston Medical Center. Many years ago she developed an interest in integrative health, learned medical acupuncture and became the clinical champion of mind-body medicine at Codman. She has published essays in Pulse’s More Voices, WBUR’s Cognoscenti; Boston Globe Media’s STAT; Families, Systems, & Health and elsewhere. “My desire to understand and express the humanity at the heart of the doctor-patient relationship feeds my passion for narrative writing.”

Comments

9 thoughts on “Last Patient of the Day”

  1. Harvey Adelstein

    Pam, your article was fantastic. It was very heartwarming. We`re very proud of you. Love, Mom & Dad

  2. Yes, Dr. Adestein “practiced medicine as it should be
    practiced.”

    But why do readers skip over this paragraph:
    “But the doctor at the other facility wrote that her abdomen was unremarkable! I thought, then recalled that physicians sometimes use a boilerplate exam form that lists everything as normal, unless the physician changes it. Did they use that form and forget to make changes?”

    Yes, almost certainly, that is exactly what happened

    We (patients and doctors) all need to recognize that today,
    a great many doctors do not practice medicine as it should
    be practiced.

    It is not the they lack the skill, or the knowledge (though, of course, sometimes that it is the case.)

    But too often, they simply are careless: they are in a hurry;
    they feel they won’t be paid enough for the extra 10 or 15
    minutes to do the job as they should.

    Let me correct myself: they are not simply “careless”.
    They Care Less than any healer ever should.

  3. You write so beautifully .I felt as if i was there with you .In part because I have been in your shoes and have known that feeling .Also, because of the harsh reality that some day I may be at the receiving end of the conversation and hope that a physician with your sensibilities will be at the other side. Thank you for sharing

  4. Dr. Louis Verardo

    Dr. Adelstein, you did exactly what we are all taught to do when seeing a patient like Ann at the end of a busy day: you slowed down, you did not rush her, and you were truly present to her. And this is not just empathy; you made the correct diagnosis.
    You were a true professional to this woman, and you treated her very well.

  5. Beautiful actions remembered and written with sensitivity and grace. Thank you – and I wish all our physicians were able to connect like you do.

  6. Pris Campbell

    I wish all doctors were as thorough and compassionate as you. Giving your cell phone number was a double act of generosity,

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