More than the body physick

Rasha Ali, University of Illinois at Chicago, MS4

Thursday, 11:32 pm. The harried young doctor stepped into the isolation room and cleared his throat, trying to rouse the two people sitting by the elderly woman's bedside. Two expectant faces swung upwards to the silhouette of the lanky physician standing by the door. Their mother--the frail inhabitant of the hospital bed--did not stir, sleeping on a sea of morphine kindness.

"Anything new, Dr. Arden?" the adult man ventured with trepidation.

"Well, the lab finally found Streptococcus G growing in her blood. I've never seen that before. Frankly, with this septicemia and her failure to respond to antibiotics, the surgical team and I don't see any other option for her foot but amputation." He spoke quickly and brusquely, arms crossed as if to ward off a chill or any dissent. "Above the knee." He motioned to his own leg with a hand-chopping gesture.

"Amputation?!" The older woman said. "Isn't there anything else we can try? Can't you switch the medicine?" She glanced at her mother's mottled, purple and swollen foot poking out from beneath pristine sheets. "How can she survive an amputation? She's already so weak!"

"Yes, we know she's not the best surgical candidate. She hasn't been eating and her low protein doesn't bode well for surgery. Regardless, things don't look good if we wait longer either. She has no other options. I'm going to have to awaken her to obtain consent for the procedure."

"No! Wait!" the son interrupted. "Please, don't share this with her right now, she's already been through so much and I'm afraid she will lose all hope!"

"I can't withhold information from her," Dr. Arden said. Impatience crept into his voice. "It's unethical. She needs to know--otherwise her chances of survival are very slim." He spoke deliberately, as if addressing a recalcitrant child. "I'm sure you understand the seriousness of her condition. You're not doing her any good by hiding the facts." He glanced at his watch. "If you excuse me, we can talk more tomorrow."

"No please, talk to my daughter first," said the woman. "She is in medicine; she'll understand the details. Here's her number." She scribbled and held the note for him.

They watched helplessly as the hospitalist shed his blue isolation gown, stripped off his gloves, took the note, and fled. He was finishing his 18 hour work shift and could take this family no more. Too many questions. Very high maintenance. Both brother and sister stared after him for a moment. Their oblivious mother lay with her eyes half-closed, her labored breathing grating against the silence. Her chest shook loose under the blankets, like a fragile balloon caught in tree branches trying to free itself with the wind. Delicate paper thin eyelids laced with tiny veins and hollowed features could shatter under the slightest impact. Yet this exterior belied her indomitable inner strength, borne of years of adversity: widowed at twenty five with two small children and a third on the way, struggling to eke out a living as a single woman in a patriarchal Indian society, and battling lymphoma at age 35. Having dealt with decades of chronic lymphedema and intestinal adhesions secondary to the life-saving radiation treatment back then, she was now fighting a malignant pleural mesothelioma caused the radiation. At age sixty-four, there had been no respite.

Her son and daughter had recently witnessed how the latest round of chemotherapy succeeded in burning the shrunken veins of her hands and arms leaving snaking black tracks that served as ghastly reminders of the undiluted chemotherapy's painful effects. The chemotherapy had been misadministered, but the family had not blamed the oncologists and kept their faith in the system. It was through these same burn entry scars that exotic bacteria had entered her system. The septic shock lowered her blood pressure enough to turn her lower extremities blue. Her right foot was particularly bad, with patches of necrotic tissue and no discernable pulses. Despite her patience and fortitude, her son worried that his mother might lose the will to live. The loss of her foot signaled the last blow. None of this was known to Dr. Arden.

Outside at the nurses' station, Dr. Arden was on the phone with me. "I'm done my shift and the morning team will re-evaluate," he said. "But you know how these things go-you'll have to talk to your mother and uncle and give them realistic expectations. I don't think they get it. In fact, if her blood pressure had been lower, I would've been talking to them tonight after we had taken your grandmother to the OR. Given your medical background, it's your job to prepare them for that eventuality. The leg has to go, don't you agree?"

He wanted my medical opinion. And he wants me to take on his responsibility for explaining the situation to my family. Whose side was I on? "Can we try a higher order antibiotic regimen first, empirically? An amputation seems so drastic," I meekly submitted.

"Hmm. I suppose it's worth a try. If you say so. But what's the point? The overall picture is--she has a fatal cancer too-she's got months to live." The words, put so bluntly, burned in my ear. I swallowed a lump and said nothing. He hung up.

Everything he had said to me was true. The language of medicine he chose to communicate himself in was perfectly lucid to me. Yet, somehow, he was unable to grasp the language of humanism, asking me to translate his technical message to my family instead. Due to his unwillingness to address the situation in a manner comprehensible to his patients or their families, the doctor had lost the very element so crucial to establishing doctor-patient rapport. Communication is the foundation for any relationship, and like any medication, the carefully chosen word has the power to heal. If spoken injudiciously, there are lasting side-effects.

When I went in to see my grandmother the next day, she seemed slightly better on the new antibiotic: the leg was less cyanotic and her blood pressure was a bit higher. "There's a saying in our religion," she told me in one of her waking moments as I sat by her bedside, "'verily, for every disease there is a cure. Have trust in God.'"

A few hours later, I approached Dr. Arden as he was rounding to ask about the team's next decision. He was surprised that I was so young in person. "I'm a third-year medical student," I admitted. Of course, I had not intentionally misled him, but he must have assumed I was older on the phone. "I think the medication change is helping," I told him.

Did he suspect that I was questioning his judgment in handling this patient? Would that make him irritated and less inclined to consider my opinion? "Hmm. We'll have to see," he said in a more dismissive tone of voice. Suddenly, I had lost all my credibility.

Caught between the medical facts as he presented them to me and my own half-baked education, I struggled to respond. Not a full-fledged member of the medical community but with inner aspirations to be seen as an equal colleague, maybe I should agree with him. Was I (like my family) pushing for more aggressive measures because I could not be objective like Dr. Arden? Or was Dr. Arden being pushy and blinded by his own agenda to not consider the other aspects of his patient's care?

Granted, Dr. Arden worked under strained conditions as a busy hospitalist, catering to the needs of many ill individuals. He had an intensive, demanding job that, under the auspices of managed care, required treating a vast number of people. Still, did his taxing work drain him of all empathy? Did a busy schedule simply preempt the possibility of exercising compassion or developing a proper rapport with the patient and family?

Had he asked, there is much he could have discovered about my family. My grandmother has deep spiritual roots and a complicated life story. She had hope in the future, and yet she had been tiring in recent months. The loss of her leg signaled more than a physical disability-she would never be whole again emotionally. Giving up on his patient under the guise of supreme pragmatism, Dr. Arden had amputated her entire soul before he had even addressed the issue of her leg. As he stood in the distant doorframe to accost my family, I realized how much more trusting we would have felt if he had pulled up a chair and spoken to my mother and uncle by the bedside, at eye level. He had seen us sitting in the room with her, reading religious scriptures and praying for her. Instead of brusquely explaining details of the operation, he may have had a different effect on us if he had sat with us and gently assured my mother and uncle that things would be okay.

I know that my grandmother did not hold high hopes about her overall condition, and my uncle and mother did not want to simply shield her from the truth. But, there is a balance between giving false hope and crushing one's motivation to live. In an essay called "The Faith That Heals" by Sir William Osler, he quotes Galen as saying, "confidence and hope do more than physick-'he cures most in whom most are confident.'" [Osler W. The faith that heals. BMJ. 1910; 1470-2]. While Dr. Arden himself may not be religiously or spiritually motivated, his approach to our family's wellness would have been better approached from this holistic framework. Instead, his contrastingly scientific manner in this sensitive issue only enhanced a sense of coldness and calculation. The result was a sense of alienation.

These days, a physician is told to present the alternative treatment possibilities and provide consent for the risks and benefits of each decision tree. The patient, as a consumer, is told to make the ultimate decision they feel most comfortable with. Of course a physician can lead a patient towards a decision he thinks is best, but he or she must do so without being paternalistic. Dr. Arden clearly felt that amputation was the only answer and that it would be unethical to not inform his patient despite the objections of her family. Perhaps he was less willing to consider the alternatives out of the inconvenience of dealing with us. Rather, I would argue that it is the ethical obligation for a physician to uncover the patient's belief system and incorporate those parameters when making a medical decision. Investing more time in patients and their families to develop a relationship of mutual respect may have given him a different perspective.

As I progress through medical school, this ethical lesson has not been lost upon me as I take care of my own patients. My grandmother eventually recovered from her septicemia and came home a week later with her leg healed and intact. In essence, she was saved from a needless amputation. She passed away six months later from her abdominal cancer, lasting a few months longer than our physicians had predicted. My mother, uncle and I had known her disease was incurable and that she had been suffering long enough. But, she passed away with intact dignity and peace, and those extra months of closure for our family made all the world of a difference.