#thatawkwardmoment

...when it is 3am on call and you are assisted by 2 senior staff nurses having difficulty catheterizing a precious transplant patient having gross hematuria in an isolation room where there is pindrop silence...

...and your stomach decides to announce that you skipped dinner.

D:

New territories

A good 5 weeks into Medical Oncology. It has been a tough posting. Starting early every day, ending late, steep learning curve with respect to specialist only knowledge, new environments and people. Mixed feelings. Medicine still excites me the way it does the first time I cardioverted a patient with SVT. And in every discipline there will always be that group of patient whom you spend more time figuring out their social situation than dealing with their medical problems. The past month was made particularly more difficult with the father of a friend under my direct care. Cancer certainly is undiscriminating. I don't think I've yet had that feeling of discharging someone with ease that that person is better than he was coming in. There will always be that lingering feeling of what next? More chemotherapy? Best supportive care? The cancer will grow, recur and spread like wild fire.

That said, seniors have been excellent. I had a good month in my first team, and am now rotating through my second. Despite late nights and long ward lists, they never fail to press on with doing the best they can, sorting out what they need to, and conducting family conferences on weekends.

Being in a different hospital gives new dimension to my experience as a doctor. Having been through 3 different hospitals in the past year, I feel that I now have a better understanding of hospital operations, why things are run the way they are, what ways there are to improve and improvise. Interesting how the decision high up can make such a great difference to the lives of doctors, outcomes of patients. Some decisions are tough to make, and can have dire consequences if foolishly made.

Calls in this hospital have been of a different kind. On average we do about 1-2 full calls a month, compared to the 4-5 full calls I was doing back in my previous hospital. There is different sort of pressure though, being in a centre of medical oncology and hematology where there is an abundance of the weird and wonderful. I discover medical conditions that I could have never possibly imagined existed in the middle of the night, and need to get help and advice on what to do from seniors. Learning goes on forever.

Post call now and in a little bit of a stupor. Thankful for a long suffering husband who cooks yummy food for me all the time. Dinner time!

Brain mets

Within 30 seconds of hearing him speak.

Impressive.

Adding life to days

Mr J did get married after all. :D

Elective at the National Cancer Centre

“So…are you afraid?”

The candor of my mentor’s question stunned me.

Before me was an elderly Chinese woman who had been diagnosed with advanced colorectal cancer, suffered complications that caused her kidneys to fail, was experiencing metastatic bone pain and was now on palliative care. Her prognosis was not good.

In medical school we learn a lot about communication. We learn about the time, place and setting that is important for breaking bad news. We learn about body language, tone, volume and choice of words. We learn that we need to ask if they stay on a floor with a lift landing, whether they have financial difficulties and whether they were able to perform their activities of daily living independently. Yet, nothing had quite prepared me for this moment between doctor and his patient, where Death took centre stage.

It was like saying “So, let’s talk about you dying…right now.”

It was a full twenty minutes between doctor and patient, by the bedside without any writing, blood taking or COWs in the way. The conversation revolved around the patient’s hobbies, family, likes and dislikes, in between scattered laughs and periods of silence. This was exactly as Dr Simon Ong had taught his students – “exploring your patient’s psychosocial status means asking them about their fears, hopes, concerns and wants.” At the end of the conversation, Death no longer had the limelight. Talk was about spending meaningful days, finishing unfinished business and enjoying every breath that comes our way.

"It's okay," she said, "Thank for for all that you have done for me."

I chose to do an elective in Medical Oncology for various reasons, but largely because it had a stark absence in our entire medical curriculum. Four weeks at the National Cancer Centre saw me rotating through the various disciplines in oncology. From the usual morning hospital ward rounds to an extended morning round in the community hospital, followed by rotations through Surgical Oncology, Palliative Medicine, Ambulatory Treatment Unit and Radiation Oncology. Afternoons were spent seeing patients in the clinics of various subspecialties and attending didactic teaching sessions. Although I was at times unable to fully appreciate the medicine and science behind clinical decisions, I was greatly inspired by the way Medical Oncologists spent time pondering and deliberating over each case. It seemed to me that the more complex and challenging the medical dilemmas, the more intriguing it became to debate and discuss management options in the patient’s best interest. Notably, withholding treatment was often placed on the discussion table as an option. As my mentor never fails to reminds me, as doctors we are quick to give ourselves a pat on the back for treating a patient, but fail to see the value of not doing so.

In the first week of my posting, I was flatly rejected by a patient after I approached him to ask him “a few questions about his illness”. Little did I know that my "approach" in wanting to clerk him would have triggered unhappy thoughts and feelings in him. I was a lot more mindful of my words after that incident, with a good friend of mine keeping me in check. Over the weeks as I became more comfortable talking to patients on palliative treatment about death, I was surprised to discover my own underlying assumptions in thinking that all cancer patients were depressed and needed some sort of “uplifting”. (My own mother had assumed that I would become depressed by the end of the 4 weeks.) While the notion of cancer often comes as an apparent “death sentence” to most people, I encountered an entire spectrum of people ranging from those who were completely oblivious to the fact that the cancer in their body would eventually lead to their demise, to those who very willingly accepted it as a natural process of life and also those who were completely devastated. As much as I am left speechless in response to patients who question their suffering, I encounter a similar speechlessness when the laugh of a patient with end stage-disease resonates through the ward corridor, “What to do? I’ll take it as it comes!”

Some patients inspire me in their resilience in fighting the disease, persevering through debilitating treatment for reasons beyond themselves, and yet still find time and energy to speak to us students. One particular patient had been willingly clerked and examined by over 100 final year medical students over his multiple admissions to the hospital, and every time with a smile! Surely this is more than enough to spur us on to become the best doctors that we can, for those who have “suffered” under our inexperienced hands!

Cancer hits anyone and everyone, and will continue to do so. In oncology, it is through Death that we discover Life. It seems to me that the prospect of imminent death reminds us daily that each day is indeed a gift that we often take for granted. Oncologists have the privilege of walking through perhaps life’s final journey with their patients, a role that is precious and intimate. I guess this explains why all the Oncologists that I’ve encountered at NCC are always so affable and sensitive to patient’s needs, a trait possibly more commonplace in this department than in others.

It was a fantastic elective, thanks to possibly the best doctor I've ever seen in my entire clinical experience. At the end of my posting, what have I learnt? I make my own mental check list. Approach to oncological symptoms? Check. Oncological emergencies? Check. Treatment modalities? Check. Life? Maybe. Being human? Certainly.