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The Patient-Student

An unexpected lesson challenges everything about a future physician’s training and career

The New Physician October 2013

Dr. Joshua Gaines at graduation ceremony“It’s cancer,” said the ER doc. In one second, I had gone from perfectly healthy to very, very sick. None of the emotional impact was tempered by the fact that I had seen similar cases myself while on the wards or in clinic. It’s so cliché to say that you never expect these things to happen to you, but when you’re a fourth-year medical student who just learned where you matched a week prior, to have something like this occur definitely puts a significant stress on your conception of self.

So, hang on a second. I’ve got metastatic colorectal cancer at age 30. Median survival time is 29 months and five-year survival rates hover between 8 and 10 percent. Where am I supposed to fit the remainder of my medical education if I probably won’t survive to see the end of it? Is there any point to anything anymore? What if I adopt such a nihilistic view and then recover? What will I do then?

To even get to med school, you have to be a long-term planner: always estimating probabilities and planning for contingencies. Cancer does not respect that character trait. In the five months since my diagnosis, I’ve come to the conclusion that it is very unlikely I will ever enter practice. I think that I would have significant anxiety during residency, to the point of interfering with my work. Would the stress of residency cause me to relapse? Would I even be able to tell the difference between a relapse and the normal stress of residency? I don’t think I could work with those thoughts in the back of my mind. The only way I can imagine myself entering practice would be if some significant medical advance occurs before my cancer becomes too resistant to maintenance chemotherapy. I finished my 12th and final chemo cycle in September and I expect to have my colostomy reversed before the end of the month. I’m actually feeling very good at the moment and anyone looking at me would not suspect I’m sick. I’m to begin doing research with the oncology department that is responsible for my treatment very soon. My hope is to learn enough about lab techniques to become a clinical researcher. It still pains me that I will likely never be able to take the final steps necessary to actually practice as a physician, but I hope that my education and training will not prove to have been without some wider benefit to society.

It was around October that I started to feel bad, though it happened so gradually that I didn’t fully realize how bad it had gotten until Match Day. I was still able to handle the interview trail and enjoyed seeing the different cities of my interviews. My symptoms since October were vague rectal pain, constipation resistant to fiber therapy, very slight rectal bleeding, and abdominal distention. I hadn’t lost any weight, so I never once thought cancer. From my research, the only thing I could come up with was levator ani spasm or chronic anal fissure. Trips to the physician and a referral to a surgeon never resulted in a definitive diagnosis. After all, common things are common. Mucinous adenocarcinoma of the colon is not something you think of right off the bat in a 30-year-old with my symptoms. Given my many trips to physicians and the lack of any response to their treatments, I was eventually referred to a gastroenterologist. The gastroenterologist I was referred to had been booked up for a month in advance, so my appointment was to occur after the Match. The morning before Match Day, I had vomiting and PO intolerance. I wasn’t even able to keep down water. I was, however, able to make it to the envelope opening ceremony, but I was too sick to make it to the festivities afterward. I had tried to move my appointment with the GI physician earlier, but was unsuccessful. The week after Match, I was noticeably ill, but when I experienced satiety after only two bites of food and my abdominal distention became obvious to the people around me, I decided it was time to head to the ER, since I couldn’t get in with the GI doc until the day of my appointment.

So I went to the ER and explained my symptoms. The physician there thought I showed evidence of cachexia even though I hadn’t lost any weight. Even though all my lab values were normal, as was the X-ray, he ordered the CT, which revealed extensive metastatic disease in the liver. Turns out that I had lost weight, but the mass of my liver and the slight ascites from the pressure of a tumor on my portal vein had balanced that out.

In a puff of smoke, all of the plans I had made before I was to start residency evaporated. The next day, I had an appointment with the oncologist who, given my near-status as a physician, told me the raw statistics and assessed my rather grim prognosis with no sugar-coating. He stated that I needed to receive chemotherapy urgently. So urgently, in fact, that resection of the primary tumor would have to wait until the end of the chemo regimen. Instead of resection, I had a colostomy operation to bypass the obstruction, with the expectation that, at the end of chemo, I would have a colostomy reversal and resection at the same time.

The days in the hospital after that are an uncomfortable blur. I received my chemotherapy port and the colostomy and spent several days recovering from both. I had never experienced discomfort like that before.

Given that just a few weeks prior, I was as healthy as any 30-year-old, and now I was experiencing what so many of my patients had gone through, I was shocked at how difficult it was to process. Being the patient is practically like living on another planet from the physicians. Despite the fact that the doctors spoke to me as they would a colleague and that in another circumstance I could even be rounding with them, the time I spent in the hospital wasn’t in any way familiar. I definitely developed a new appreciation for how hard nurses work and how different their work is than physicians.’

While in the hospital, I began to send out e-mails to people apprising them of my situation. I had matched at the Cleveland Clinic Foundation for anesthesiology and the program director was kind enough to hold my spot for me so I could start at any point up until July 2014. That was encouraging, but the fact remains that my chances of merely surviving to the end of residency were less than 50 percent and that’s assuming I would ever be healthy enough to work a resident’s schedule. Fortunately, I had finished all of my rotations by the end of February, so my school obligations were practically nil.

Will I be able to even start residency? Only time will tell. The PET scan after my sixth chemo treatment showed complete regression of the primary tumor, but still lots of metabolic activity in the liver and around the portal system.

If I make it through treatment, my experiences will have endowed me with the ability to empathize with my patients far better than physicians who have not personally faced a life-threatening illness, but the odds of that occurring are obviously less than encouraging. I know what it feels like to be confused and helpless. Having a medical education did not in any way mitigate that. I can, on an extremely personal level, appreciate how valuable and fragile life is, but is that something that any 30-year-old really needs to know, even a physician?

Ironically, the answer may be “yes.” While the time since my diagnosis has been the most difficult experience of my life, I’ve also been richly rewarded with unexpected blessings. On some level, I have to say that if getting my diagnosis was the price of growing as a person, it may actually have been worth it. I’m not saying that I want to die or that I don’t intend to keep fighting, but I can’t ignore that my horrendous trial has actually had significant benefits. For example, I recently began reading Ernest Becker’s The Denial of Death. It’s been extremely thought-provoking and I think I understand it in a way that would have been impossible for me before my diagnosis. Since I’ve been forced to look death in the eye, so to speak, I’ve become more aware of the illusions under which I was operating. That is, before my diagnosis, I looked at life as little more than a series of “must-dos” that should be checked off and would eventually lead to some ill-defined deeper satisfaction. I now realize that I was attempting to find meaning in a life that was built around what I thought were society’s expectations of me. As I see it now, there’s no satisfaction at the end of that path.

In The Myth of Sisyphus, Albert Camus argues that you have to realize and embrace the impossibility of finding absolute meaning in existence before you can be free to construct your own meaning within that vacuum. For me, that meaning isn’t found in one’s career, but rather in one’s relationships with other people. Since I’ve come to that realization, I actually feel happier and more content than I have ever felt before, even before I began to feel sick.