I spent the last six weeks doing my internal medicine rotation at Los Angeles County Hospital. Often the hospital is at 100% capacity, leading to intense pressure from the hospital administration to churn through patients as quickly as possible. I agree with the underlying idea: we want to provide the most help to the greatest number of people in need, so patients who are stable enough to be discharged should be released quickly to make room. In other words, the only way to remain hospitalized for more than a day or two at County is to be very, very sick. Many of the patients are dying.
Until this point in medical school, I had not been confronted with the task of talking so openly with a patient about his impending death. I had never been asked before, “Alexa, am I dying?”
Mr. Smith is a 50-year-old man with metastatic colorectal adenocarcinoma. His cancer had spread throughout his abdomen, and at the time that I met him the cancer had paralyzed his intestines so that he could no longer keep food down. He came to the hospital with intractable nausea and vomiting. We stuck a tube down his nose all the way through to his stomach, to suction out any food or secretions and to let his bowels rest. I performed my first paracentesis on him, sticking a large needle into his abdomen and withdrawing five liters of fluid that had accumulated because his liver was no longer functioning well. His prognosis was dismal, but it seemed as though no one had directly told him this.
Soon enough, it became clear that his situation was not improving. Tumors in his abdomen were growing so big that they were obstructing his bowels. His cancer had continued to spread despite two rounds of chemotherapy. It was proposed as a possibility that a tube could be inserted through the skin of the abdomen directly into his intestine so that he could feed himself through the tube, but because of the extent of the cancer there was a good chance that the surgical site would not heal well, or that he still would not be able to pass the liquid through the rest of his intestines.
“Alexa, am I dying?” he asked me one morning. I took a deep breath and looked back at him.
Well it certainly looks that way to me, I thought. But dying is relative. Aren’t we all dying at least a little? Perhaps the more accurate question is, how fast am I dying?
“Well, you have cancer, cancer that is not getting better. It’s actually getting worse. You are not dying today, but there is nothing we can do to fix this cancer. And this problem with your intestines is a very tough one. I don’t think you are going to be able to eat food through your mouth anymore.”
“And what about the surgery?” he asked. “Would you try to have this surgery, even though it’s risky, if you were me?”
I sat on the edge of his hospital bed. “I’ve been thinking about that all day,” I replied. It occurred to me in that moment how much power I had. He was treating me as his doctor, asking me for advice on this critical decision. I was the one who had spent the most time with him in the hospital. I had brought him a collection of tea bags from my house when he had been unable to eat food, but was wishing for good cup of tea. He trusted me. The opinion of my attending was that the surgery was more trouble than it was worth—that if successful it would not buy him much more time, and that the risks of complication were very significant. My gut feeling from the beginning had been that he should turn down the surgery too. But I wonder if things would be different if I were actually in his situation, actually the one dying, actually the one having to tell my family that I was done fighting.
“So how will I get nutrients if I can’t eat?” he asked.
“Well, you’ll keep doing what you are doing now. I think it’s the best we can do. Fifteen teaspoons of Ensure per day, spaced out throughout the day,” I answered.
15 teaspoons of Ensure per day until you die…
Then, since there was nothing else we were doing for him medically, and the hospital was full, the emergency department full of sick people waiting to come upstairs, we sent him home. I gave him a hug and wished him luck.
For the record, I understand why we sent him home. It was true, there was nothing more we were doing for him medically. Drinking Ensure at home is undoubtedly much more enjoyable than having it at the hospital. Still though, it felt grim and unfinished.
And speaking of dying, I really feel like I’m dying too. Not as quickly as the patients, but not as slowly as I was before. The days are grueling. 11 or 12 hour work days, 6 days per week, with about a half-hour break per day, plus studying on the side for a really tough exam. There is no time to think about anything else. I barely go to the gym. Groceries and cooking? Forget it. I go days and days on end without ever stepping outside when it’s light out. Sitting down for breakfast is a thing of the past, because I decided that it is actually more painful to force myself to eat breakfast before work than to be hungry for a few hours until I can eat lunch.
And the thing is, doctor culture normalizes this. By the standards of all of the doctors, the “internal medicine schedule really isn’t bad. You get nights off and a weekend day every week!” I get deemed a wimp for complaining about this schedule. My attending chuckled when I told him I felt like there wasn’t much time for studying, replying, “Oh, you think it’s bad now? You just wait until you are a resident, or until you are me.”
The thing that upsets me most is that being on rotations has forced me to make sacrifices to my own health. I am a person who has spent my whole life sleeping well, eating right, and exercising. It’s what I tell the patients to do. Do I not deserve the same?
Still, my experience in internal medicine was pivotal in my professional and personal development. I have never learned so much in a six-week period, and I am full of admiration and respect for my team of interns, residents, and attending. They work so hard every minute of every day, and know so much. Again, I am left humbled by the stories of the patients and appreciative of the incredible fortune that is my good health.
Next is family medicine. I wonder my rate of dying will decrease.