“We’re getting a transfer,” said my resident. “So far, all we know is that Dr. S. did some kind of surgery a year ago and now the patient is specifically wanting to see him. Why don’t you try to find his OP note on CAS? Be quick about your search. I’m going to the OR.”
I was able to pull up an operating note dated last year. As it turns out, the patient had a “hepaticojejunostomy” for “cholangiocarcinoma.” I sat back and tried to digest this information. I could not remember ever knowing what “cholangiocarcinoma” was.
Later that day, I went back to the floor to see if the patient had arrived. As I walked down the hall leading up to the nurse’s station, I ran into my intern. She walked toward me with a look of frustrated anger and said, “If you’re going to see our new patient, be careful. He’s pretty demanding and whiney. He does not look like he’ll warm up much to a medical student. I have spent the last hour trying to talk to him and his wife, but they keep telling me to just bring Dr. S.”
With that, she stormed past me and headed in the direction of the elevators. Her warning did make me a bit anxious. Then again, not many patients like to repeat conversations they’ve already had for the benefit of a medical student. I hardened my resolve and walked towards my new patient’s room. As I got closer, I saw that the door to his private room was closed. I knocked on the door and identified myself as the medical student. From the other side of the door I heard a gruff voice say, “Come in.”
When I entered the room I saw a tired, balding man with a large belly, lying propped up on pillows on the bed. He looked up at me with questioning eyes. On a high-backed chair to the right of his bed sat an equally tired woman who I assumed was my patient’s wife. She looked at me suspiciously.
During my initial interview, I learned that Mr. Ridder felt well after his last surgery, but only until a few weeks ago. He had begun to feel tired and to vomit. His wife anxiously noted that he had started to turn a shade of yellow and that he could not keep anything down. As they told me their story, they continued to ask for Dr. S. Mr. Ridder admitted that he admired Dr. S. He told me to learn from him, to learn a “good bedside manner.” He said this so adamantly that I sensed that he had not received what he called “a good bedside manner” at the other hospital. I figured part of his specific request for Dr. S stemmed from that fact.
After a day in the hospital, Mr. Ridder underwent a CT scan to find out why he was having so much trouble. From it, we learned that a mass was blocking the exit of his stomach.
As the days wore on, I continued to visit Mr. Ridder. His anxiety and fatigue were not improving. It was also clear that he was not cooperating with either the nursing staff, or the intern. They described him as “very demanding” and that his spouse was far more demanding. She would incessantly ask questions relating to why we did not know what the mass was. When asked, I tended to answer, “We do not know yet, but the team is working on finding out.” With that, Mr. Ridder’s face would contort into a look of anguish and frustration. Mrs. Ridder would fidget, asking when I thought we would know. I felt useless. Unlike the rest of the team who was angry with this uncooperative patient, I only wondered what I had to offer this couple.
The Ridder’s frustration and anger was understandable. They both worried about cancer. A week into Mr. Ridder’s stay, after a trip to interventional radiology, a trip to endoscopy with placement of a stent and getting bumped down many lists, a biopsy was scheduled.
On the day of the procedure, I entered Mr. Ridder’s room in the early morning, as I usually did. Looking exhausted, he lay in his bed. As I neared him, he said, “Today’s the day. I was not able to sleep last night. My wife stayed with me until late, but I told her to go to the hotel room. She has not slept well either, you know?”
“I see,” I answered.
“I’m a bit scared of what they’ll find,” he whispered. He turned away for a second then stared at me.
I looked at his wizened face and saw fear behind his eyes. I quickly looked at his large belly and placed my stethoscope on it and began to listen. It was a ploy, designed to prevent him from asking the next question. As I heard the occasional gurgle, I tried to think of how I could respond, but nothing was coming to mind. In an attempt to continue delaying a response, I removed my stethoscope and looked at his feet. “Do you think the swelling of your legs has improved?” I asked. Inside, I cringed at such a blatant and silly way of changing the subject. He looked at me and grinned sadly.
“No. I don’t think it has improved…Listen, I want to ask you something,” he finished in an imploring manner.
“That’s it,” I thought. “He’s going to ask me what I think they’ll find!” My heart began to race and my palms to sweat. “Sure, Mr. Ridder,” I replied in the steadiest voice I could muster, trying not to let my nervousness show.
“Are you going to be there…when they check to see what it is?” he pleaded.
”If that’s O.K. with you?” I replied.
“Yes,” he said grinning in a very reassuring way. “You’ve been coming to see me a couple of times a day. You’ve been patient with my wife and me in trying to answer our questions. We know that you may not have the answers, but it is nice that you try to answer anyway. We also appreciate you trying to explain what all these tests are. I think you’ll be a fine doctor someday.”
“Thanks, I appreciate that,” I answered, not knowing what else to say. The remainder of my daily exam was silent. Later that day, I sat in on his biopsy. A few days later, the biopsy confirmed what we all knew. His cancer recurred.
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Reprinted from Veritas, Volume 16, Spring 2004, with permission of the
Center for Humanism in Medicine.
© 2004 The Rector and Board of Visitors of the University of Virginia
Author Guillermo Solorzano, M.D. is a native of El Salvador who spent his early childhood traveling throughout Central and South America. He graduated from the University of Virginia School of Medicine in 2004, completed a preliminary year in Internal Medicine at UVa, and is now completing a residency in Neurology at the University of California at Los Angeles.