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The Last Question

Terminal patients’ search for meaning starts with you

The New Physician April 2010

Last ActsLittle of what medical students learn in school prepares them to answer this question from a dying patient: “What should I do with the time I have left?”

Dr. David J. Casarett draws on decades of clinical experience with the terminally ill to help patients answer that profound and humbling question, which is the heart of his book Last Acts: Discovering Possibility and Opportunity at the End of Life (Simon & Shuster, $26).

Casarett, an assistant professor at the University of Pennsylvania medical school, presents the radically different ways that patients find meaning near the end of their lives. Some attempt to leave a legacy. Some of them seek to make amends to those they had hurt. Others seek revenge.

While each patient ultimately finds his or her own path, Casarett strives to be nonjudgmental. He avoids labeling his patients’ final actions as “successes” or “failures,” seeking only to help them find the best path for themselves.

His examples are composites of different patients through several decades and together they provide an emotional journey of hope, despair, reconciliation, self-discovery and regret. Many have wishes that go unfulfilled. In one case, a patient in her 50s passes away, never realizing her dream of writing a novel.

Some of Casarett’s characters are hard to have empathy for, such as the alcoholic who stubbornly refuses to apologize to those he hurt.

Last Acts is not merely a rehashing of a carpe diem mantra, but an exposition of the tremendous challenge of taking full advantage of the time one has left.

The chapters tell of inspiring and moving acts, and somber tales remind the reader that life’s regrets and missed opportunities are all too common.

One patient spends her final days setting new priorities for herself, spending time with friends and seeking “small, simple pleasures.” In stark contrast, another spends his days drinking and gambling, growing increasingly distant from those around him.

Casarett tries to help patients who are grappling with death use their limited time in a productive and meaningful way. The author asks them to expand their horizons and think of what’s possible, but simultaneously figure out what is realistic and achievable. He asks patients to consider the people who matter to them the most and how they should figure in their final acts.

As medical students, as we make our way through exams and other hurdles in school, we might forget the bigger picture of why we chose medicine in the first place. Through the struggles and triumphs of those depicted in Casarett’s book, they may help us better know how to help terminally ill patients find meaning.

In one of the author’s most poignant observations, he writes that in the final days his patients face “excruciating reminders that they could have done more.”

Reading this book could transfer some meaning, and perhaps even urgency, into our own lives as we strive and make the most of every moment.

Andrea Wershof Schwartz is a fourth-year at the Mount Sinai School of Medicine.

Fear Doesn’t End With Residency

Doctors in TransitionBy Jason S. Fish, M.D.

The process of becoming a physician is full of transitions, many of which produce immense anxiety, and first-year attending physicians find no shortage of that. They often feel too inadequate to manage patients without supervision; they worry about making mistakes and being sued; and despite seven-plus years of training, they question their abilities as physicians.

The subjects in Doctors in Transition: The Socialization and Bioethics of the First-Year Attending (Victoria Press, $26) struggle with their new authority, from teaching interns to caring for patients, not to mention projecting confidence and a sense of competence to nurses, fellow doctors, patients and others.

Sociologist Alessia Minicozzi’s book asks the underlying questions: Why are these physicians struggling so much? Shouldn’t this transition be smoother, without these intense and pathologic fears? Why hadn’t medical education better trained these physicians for this transition?

Experienced nurses, perhaps resentful receiving instruction from a “baby doctor,” worsen the difficulties of the first-year attending through such condescending comments.

“Because they tend to be young, the attendings are often mistaken for residents—or if they are female, for nurses—by families, staff and even some colleagues,” Minicozzi writes.

Many physicians hide behind the white coat. Many first-year attendings struggle with their image of being a doctor, with ultimate responsibilities, and find the white coat as a kind of protective cloak, or “the equivalent of a superhero’s cape.”

And they need to project this competent image. Often treating severely ill patients, they need to instill confidence in those under the attending’s care that he has the knowledge, skill and maturity to treat the patient.

The difficulty can be in transitioning into an authoritative role, especially when collaborating in teams. “Being a new attending and not knowing what those lines are makes it really stressful, difficult and frustrating to know what I’m supposed to be doing,” the author quotes one attending. “Defining those lines has been really important to me over the first few weeks, so that I don’t just walk around being stressed and frustrated.”

Minicozzi writes that “because first-year attendings are just finding their footing while the nurse may be a senior clinician, the question ‘Who will lead?’ always hangs in the air, since I’m often not, by a long stretch, the most experienced clinician in the room.”

In transitioning to a teaching role for residents, there’s the frustration of taking interns and residents around on rotations with many openly displaying indifference to specialties in which they have little interest. Plus there is the additional pressure of residents looking to the attending for all the answers.

The attendings’ quotations are filled with so much angst that it is difficult to fathom why anyone would want a career in medicine. These new attendings also focus on the detrimental effects of this transition on their personal lives, from feelings of neglect and abandonment of their families to isolation and loneliness. The question is a sensation of inexperience and inadequacy.

But Minicozzi offers hope for physicians coming to grips with the process of becoming an attending: setting boundaries to preserve personal lives, and finding more constructive, less neurotic, approaches to the change.

The author takes us into the minds of first-year attending physicians, in which it is clear that this process of becoming the trainer, seasoned clinician and vital researcher, is not without immense pressure, fear and sacrifice.

The additional pressures come from having to obtain necessary research funding, finding appropriate mentors, producing important and valuable research, and maintaining an image among peers.

Minicozzi’s book is an important sociological account, and she ponders why undergraduate and graduate medical education seems to be inadequate to prepare them for life afterward. With more understanding of this transition and beyond, medical education can and will be strengthened to ease some of the difficulties in this transition, and help new attendings in the years ahead.

Dr. Jason S. Fish is a clinical instructor and director in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA.