Thursday, August 26, 2010

My Little Shadow

For first years, shadowing is a basic part of our clinical experience. I recently had the pleasure of shadowing an oncologist one-on-one in an inpatient setting. He was fairly high up on the totem pole, and after two hours and five patients, I could see why.
From my observations:
  • The oncologist rarely used numbers. A treatment didn't have x percent chance of success, and a patient didn't have x weeks or x years. His words qualified, not quantified.
  • He was frank with patients. Seeing a white coating inside a patient's mouth, he suspected the horse (thrush, a side effect of treatment) but did not hesitate to mention the zebra (oral cancer). Again, instead of tossing around numbers, he simply said, "It's probably okay, but I still have to check."
  • He was franker with me regarding his expectations and frustrations. He mentioned that "I can get most patients to do what I want them to do, as long as I phrase it the right way or draw them the right pictures." But he expressed exasperation with intransient paients. Regarding a lady who, for inexplicable reasons, was willing to undergo an invasive bone marrow transplant but not a routine vaccination: "I'm working hard to save her life from cancer and she's going to **** it up and die because of something like that?" Another man's leukemia spread dramatically. With the patient, he was all business, making plans for treatment and not giving an explicit prognosis. When I asked more specifically about the prognosis, he predicted that he would probably die within the year.
  • He strongly believed that a physician, with vastly more knowledge and experience than a patient, should not remain neutral on treatment options. "Never say to a patient, 'Here are your two options. You decide what you want to do.' Tell them what you would recommend and why."
  • He never assigned blame. When I asked if a patient's cancer had spread because of his refusal to get treatment initially, he told me that it was dangerous to think that way and it's almost impossible to pin down murky causes like that.
  • He said "I don't know" once but had a clear plan. Even if that plan was just waiting and watching.
  • He was meticulous about details and trends. He continuously analyzed minor changes in blood cell count and cancer cell count (and informed the patients about these), and he did not jump to potentially unnecessary treatment without waiting a few weeks to gain a better handle on the bigger picture.
  • He was a brilliant and compassionate physician, and it was an honor to shadow him.


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