While on my solid oncology rotation during clerkship year, I was assigned to work with a 23 year-old patient “John,” who was being admitted for a new diagnosis of a rare sarcoma. John told me that he had assumed his back pain which began a few months ago was from lifting weights, but then he started to have trouble breathing. When he went to the emergency room, he was shocked to learn that his test results were suspicious for cancer.
John shared that he was a very healthy person. He didn’t smoke or use drugs, he was extremely active – how could he have cancer? He had recently graduated college and loved his job. He said with a smile, “I’m going to beat this.” I remember being relieved that John was so hopeful and positive – it made our conversation much easier. As a chronic people-pleaser, I tend to be overly positive towards patients. I replied in my never-not-nervous medical student voice, “You’re in great hands here. We have the best experts working on your treatment plan.” And I really believed it. In the brand new HUP Pavilion, John’s hospital room was stunningly modern, with its floor-to-ceiling windows and giant TV. The doctors there saw rare diseases all the time; they would surely figure out how to cure this young, otherwise healthy person.
Over the course of my two-week rotation, John seemed to become sicker every day. Still, he remained remarkably positive and hopeful. Each morning when I said hello for my pre-rounding, he greeted me with a smile and reassurance that he was doing okay. It was obvious that he was in a lot of pain, but it was as if he didn’t want to disappoint us. After listening to his lungs under his damp gown, I asked him about his night sweats. “I’m just a sweaty guy, always have been,” he said with a laugh. The cancer had spread to his lungs, and he had to get a chest tube to drain the fluid. I can’t imagine how awful that must have been, but you wouldn’t have known that from talking to him. He was always grateful for our care.
The attending on our oncology service, “Dr. D,” is one of the most memorable people I’ve worked with in medical school. She has an exceptional gift for saying the exact right thing to patients and their grieving families. To the daughter of an elderly woman dying of metastatic breast cancer, Dr. D said, “I’ve been in your shoes, and I know how awful this is. Our moms are everything to us.” Then there was the man in his 60s who was rapidly decompensating from metastatic esophageal cancer. While our team was talking to this man’s wife about his poor prognosis, I was holding back tears – I have that awful trait where I cry when I see other people cry. I inched towards the door, as I thought it was time for us to let this poor woman grieve in peace, when Dr. D paused and asked, “Can you tell me the story of how you two met?” Thinking this would only bring on more tears, I was surprised when the woman lit up and happily told us about how they met while she was working as a waitress in their 20s. I was in awe of Dr. D and her end-of-life conversational superpower. If she was that great of an oncologist, I was certain that she could save John.
Dr. D had been consulting sarcoma experts and crafting John’s chemotherapy plan. While the nuances of his medical treatment went over my head, I felt frustrated that John had been admitted for multiple days and was still waiting to start this allegedly life-saving intervention. Occasionally John’s mother, who was equally as kind and grateful as her son, would ask me questions during my visits alone to his room. I felt like she specifically wanted to talk to someone who was not a doctor. Less jargon, simpler explanations, and certainly no dumb questions. I didn’t have a great answer for why John’s chemo plan was taking so long, only that these decisions are complicated, his cancer was rare, and the chemo had severe side effects, so we wanted to make sure we had it right before starting. I remember feeling annoyed at my own positive tone – the urge to say “everything will be ok!” even when I’m not sure it will be. I definitely do not share Dr. D’s superpower.
One day I walked into John’s room, and the walls were covered in sticky notes. There must have been a hundred of them – all with sweet, encouraging messages like “Stay strong, John!” He told me his friends came by to see him the night before. I mentioned this on rounds and our senior resident remarked, “It’s a reminder of how young he is.” When I finished my presentation discussing John’s case, I looked up at my team to fill in the inevitable gaps. Dr. D said, “I stopped by John’s room and told his family that he likely has only months to live… It could be 8 months or so.” Shock and anger rippled through me. I thought, “How could she?” I couldn’t believe that she had the audacity to tell this family that he only had months to live, when we hadn’t even started his chemotherapy. How could she crush their hope like that? I know now that she was just doing her job well, but in that moment, I felt like everyone on John’s team – from the palliative care consultants to the residents – were in on a secret that I hadn’t realized. They knew that in the end it didn’t matter that he hadn’t started chemotherapy yet, because the cancer would take his life anyway.
On the last day of my rotation, I stopped by John’s room to do my final pre-rounding exam and to say goodbye. I was nervous to walk into his room because I thought I might cry, but I had thought about what I wanted to say before entering. I told John and his family, “This is my last day on this rotation, so you’ll meet new residents and students tomorrow. I just wanted to say that I admire how strong and positive you are. We all loved working with you, and I’m rooting for your recovery.” A quiet sob came from John’s dad, who was sitting in a chair next to the bed. John looked genuinely disappointed by my news. He said, “You’ll be a great doctor,” and held up his fist for a fist bump. By that point, John had finally begun his chemotherapy infusions. The pharmacist on our team warned me to take precautions while examining John because even touching his sweat could be toxic to me. I hadn’t put gloves on yet and thought back to what the pharmacist said, but then decided it didn’t matter and touched my fist to his. I’m still in awe of John’s thoughtfulness and kindness, even through all of his suffering.
Three months later, I was across the city at Pennsylvania Hospital on my neurology rotation. One morning, I had finished my pre-rounding early, so I decided to check in on John’s chart. I thought, I hope he’s getting better – maybe I’ll stop by and say hello if he’s at HUP during my next rotation. I clicked on his name and a message popped up: “This patient is deceased.” My heart sank and I blinked away tears. I couldn’t believe it – only 3 months? That’s the best we could do? I searched his name online and found a website with his obituary. It showed a nice picture of him, healthy and smiling, not in a sweaty hospital gown. I typed up a text to the wonderful residents who I had worked with during that rotation. “I can’t believe John died…”
Then came a wave of embarrassment. I barely even knew John. In fact, I knew him for less than two weeks. I must have only spoken with him for a maximum of 30 minutes a day during that time. I deleted the text, thinking the residents would think I’m overly emotional. They had long moved on from that rotation; they might not even remember John. I was left with my own emotions, that day in the neurology workroom, and still now as I’m writing this. I am disappointed that we weren’t able to give John more time, but I understand that medicine has its limits. I know there was a lot of noble work that went into making the end of his life comfortable and meaningful. Above all, I am surprised by how deeply I mourned someone that I barely knew. My short two weeks with John led me to realize the limits of what we can do for our patients medically, but also that some patients will leave an enormous impact on us. I know John will stay with me throughout my career as a physician, and I can only hope that even though we were not able to cure his cancer, we offered him accompaniment, companionship, and a human connection.
Kaley Ricciardelli is an MS4 at the Perelman School of Medicine.
